Abstracts from the 2023 Annual Meeting of the Society of General Internal Medicine

Scientific Abstract - Acute Disease Management

ADMISSION VITAL SIGNS AND LABORATORY CHARACTERISTICS AS PREDICTORS OF DISPOSITION STATUS IN A DIVERSE COHORT OF HOSPITALIZED COVID-19 PATIENTS IN NEW MEXICO

Dominic Lundquist³; Alexandra Do⁸; Jordan West³; Molly Biggs⁴; Gaelan Montoya⁹; Clinton Onyango⁶; Samuel Bonuke⁵; Ivy Hurwitz¹; Douglas Perkins²; Jens Langsjoen⁷

¹Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM; ²Global Health, University of New Mexico Health Sciences Center, Albuquerque, NM; ³School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM; ⁴School of Medicine, University of New Mexico School of Medicine, Albuquerque, NM; ⁵Center for Global Health, University of New Mexico Health Sciences Center, Albuquerque, NM; ⁶Biomedical Sciences and Technology, Maseno University, Maseno, Nyanza, Kenya;⁷internal medicine, The University of New Mexico, Albuquerque, NM; ⁸Medical School, University of New Mexico School of Medicine, Albuquerque, NM; ⁹School of Medicine , University of New Mexico Health Sciences Center, Albuquerque, NM. (Control ID #3874848)

BACKGROUND: There is limited data on the admission vital signs and clinical laboratory values that are associated with patient discharge status [i.e., home, skilled nursing facility (SNF), or death]. Such information is particularly important in diverse ethnic/racial groups since data for the United States and the State of New Mexico illustrate substantially higher rates of hospitalization in American Indians/Alaska Natives (AI/AN). To foster improved preemptive care for future patients, we determined the impact of admission characteristics on disposition status in three hospitalized groups [AI/AN, Hispanic, and Non- Hispanic Whites (NHW)] at the University of New Mexico Hospital (UNMH).

METHODS: A retrospective observational study was conducted on COVID-19 patients (n=1,309) admitted to UNMH between March 2020 and July 2021. Self-reported race/ethnicity, vital signs, and clinical laboratory measures were captured within 48 hours of admission. Disposition status was determined upon discharge and was categorized as (a) home, defined as discharged home, COVID isolation shelters, correctional facilities without the need for nursing care, and nursing homes; (b) skilled-nursing facility (SNF), defined as discharge to any facility that provided additional care; or (c) death, defined as mortality during hospitalization. Univariate analyses for categorical and continuous variables were determined using Chi-Square analysis and Kruskal-Wallis analysis. Multinomial logistic regression analyses were performed using disposition status as the dependent variable with race/ethnicity (reference=NHW), age, sex at birth, vital signs, and clinical laboratory parameters as the predictor variables. Due to a large number of predictor variables, separate models were generated for vital signs, complete blood count, kidney and liver function, and others (i.e., coagulation, HgbA1C, and procalcitonin) with race/ethnicity, age, sex at birth, and admission to the intensive care unit (ICU) in all models.

RESULTS: Of the 1,309 patients included in the study, 777 (59.4%) patients were discharged home, 304 (23.2%) transitioned to SNF, and 228 (17.4%) died during hospitalization. Factors associated with adverse disposition (i.e., SNF or mortality) included increased age, admission to ICU, and AI/AN ancestry. Higher levels of mean arterial pressure, platelets, hemoglobin, Ca²⁺, Cl^-, CO₂, albumin, and HbA1C were associated with protective effects. Conversely, predictors of adverse disposition status were elevated BUN, K⁺, Na⁺, and alkaline phosphatase.

CONCLUSIONS: Admission characteristics for hospitalized COVID-19 patients, as well as race/ethnicity and age are important predictors of disposition destination. These factors should be taken into consideration by physicians when prognosticating patient care plans. Identification of such variables can help physicians take precautionary measures to try and achieve the best patient outcomes.

AN ASSOCIATION BETWEEN THE INPATIENT USE OF EXTENDED-RELEASE OPIOIDS AND INCREASED LENGTH OF HOSPITALIZATION FOR ACUTE PAIN EPISODES IN SICKLE CELL DISEASE

Madison Canning, John T. Menchaca, Morgan McLemore, Fuad El Rassi

Internal Medicine, Emory University, Atlanta, GA. (Control ID #3873560)

BACKGROUND: The intermittent acute pain syndrome associated with sickle cell disease is a poorly understood phenomenon with a complex pathophysiology mechanism. Given the broad spectrum of opioid analgesic formulations, including immediate-release (IR) and extended-release (ER) opioids, it can be challenging for physicians to decide on the most optimal combination of therapies for inpatient treatment of pain episodes. Notably, the American Society of Hematology 2020 guidelines do not comment on the preferred use of IR vs. ER monotherapy or combination regimens for inpatient treatment of sickle cell pain crisis. Based on a thorough literature review, no large-scale randomized trials have been conducted to evaluate the role of ER opioid formulations in improving pain control and decreasing the length of stay for hospitalized sickle cell patients. Therefore, the benefit of IR monotherapy vs. ER-incorporated regimens is largely unknown.

METHODS: This was a retrospective chart review (n=200) of patients with known sickle cell disease requiring hospitalization for acute pain secondary to vaso-occlusive crisis without an alternative secondary etiology for pain source. The review included patients aged 18-67 years old with 43.5% males and 56.5% females hospitalized from 2/1/2022 to 5/6/2022. The hospital course was evaluated for several factors including daily outpatient regimen of morphine milligram equivalents (MME), highest daily inpatient MME, choice of inpatient opioid agents, and length of stay. Specifically, the use of an ER opioid-incorporated regimen was compared against the length of hospital stay and evaluated using a Wilcoxon Rank Summary analysis model.

RESULTS: Out of the 200 patient cohort, n=128 were started or continued on an ER opioid (including Morphine Sulfate CR, Oxycontin, Xtampza ER, Methadone, etc.) as compared to n=72 on an IR monotherapy opioid regimen for the duration of their hospital course. The highest inpatient daily MME averaged 279 [156.0, 361.2] for the IR monotherapy cohort as compared to 380 [300.0, 470.0] for the patients treated with an ER opioid-incorporated regimen with a p-value of <0.01. The average length of stay was 5.0 days [3.0, 7.0] and 6.0 days [4.0, 9.0] for the IR monotherapy group and for the ER-incorporated regimen group, respectively, with a significant p-value of <0.01.

CONCLUSIONS: This study found that inpatient analgesia regimens which included an ER opioid were associated with a statistically significant higher daily inpatient MME and a longer length of hospitalization as compared to an IR monotherapy opioid regimen. A potentially confounding factor is that patients on home ER formulations were more likely to have failed IR opioid monotherapy due to opioid tolerance and therefore have a predisposed risk of prolonged hospital stay. Even with consideration of this factor, these results show that further research is needed to determine the benefit of ER opioids in regard to shortening the hospital course and minimizing inpatient MME escalation.

ASSESSING THE RISK OF CENTRAL PONTINE MYELINOLYSIS IN PATIENTS WITH DIABETIC KETOACIDOSIS AND HYPEROSMOLAR HYPERGLYCEMIC SYNDROME. Falah I. Abu Hassan, Sadia A. Tanami, Mustafa Al-Bayati, Md Rockyb Hasan, Kelly Mcmaster

Internal Medicine, Texas Tech University Health Sciences Center School of Medicine, Amarillo, TX. (Control ID #3852333)

BACKGROUND: Central pontine myelinolysis (CPM) is a dangerous complication of overcorrection of hyponatremia. Several cases have been described in the literature with CPM complicating hyperosmolar hyperglycemic syndrome (HHS), however, the exact risk is unknown.

METHODS: All adult cases with documented ICD-10 codes diagnostic of diabetic ketoacidosis (DKA), HHS, and sepsis were selected from the National Inpatient Sample (NIS) between the years 2016 and 2020. 1:1 propensity score matching without replacement was performed. The Greedy nearest neighbor algorithm was used to match DKA and HHS cases with sepsis cases based on CPM risk factors of hyponatremia, liver disease, malnutrition, and alcohol abuse. SPSS v25.0 fuzzy matching extension was used to perform the matching and the statistical analysis. Sample size was reduced from 2,651,553 to 685,764 following the matching procedure. Subgroup analysis with multivariate binary logistic regression was performed to assess the odds ratio of developing CPM in HHS, DKA and sepsis patients.

RESULTS: A sample of n = 685,764 weighted patients were included in the analysis. 47,762 patients had either DKA or HHS with sepsis, and thus the sepsis control group will refer here to patients with sepsis bu without DKA or HHS. Mean ages for the DKA, HHS, and sepsis were 46, 60, and 65 years respectively 50.8%, 55.3%, 52.2% of the DKA, HHS, and sepsis groups were males respectively. Hyponatremia was present in 23.7% of the DKA group, 32.2% of the HHS group, and 21.7% of the sepsis group. The controlled variables using the propensity score matching were comparable except for the prevalence of liver disease which was higher in the sepsis control group. Odds Ratio (OR) of developing CPM in HHS was 2.683 ± 1.314 (CI 95%, 1.369 - 5.258, p = 0.004), and 0.840 ± 0.341 (CI 95%, 0.499 - 1.415, p = 0.513) for DKA.

CONCLUSIONS: It seems that HHS is associated with increased odds of developing CPM. It is hypothesized that the extreme fluctuations of osmolarity associated with the treatment of HHS and hyperglycemia are responsible for the subsequent development of CPM. Our study matched controls to adjust for the presence of hyponatremia and the presence of other risk factors that can increase the risk of developing CPM, and despite correction, HHS patients had significantly higher odds to develop CPM. This effect was not observed with DKA patients. Unfortunately, our study was not designed to determine the exact etiology of CPM in the setting of HHS, but it may suggest that rapid correction of the high osmolarity and the associated pseudohyponatremia can be dangerous.

ASSOCIATIONS BETWEEN VOLUME OF INTRAVENOUS FLUID AND MORTALITY IN SEPTIC PATIENTS WITH AND WITHOUT HEART FAILURE

Alexander J. Beagle²; Priya A. Prasad¹; Margaret Fang²; Sandra Martinez-Oreper³; Yumiko Abe-Jones⁴; Kirsten Kangelaris⁴

¹Division of General Internal Medicine, Department of Epidemiology and Biostatistics, UCSF, San Francisco, CA; ²Medicine, University of California, San Francisco, San Francisco, CA; ³Hospital Medicine , University of California San Francisco, San Francisco, CA; ⁴Medicine, Division of Hospital Medicine, University of California at San Francisco, San Francisco, CA. (Control ID #3874537)

BACKGROUND: Surviving Sepsis guidelines recommend 30cc/kg intravenous fluid (IVF) resuscitation, but as a recent randomized controlled trial underscored, optimal volume goals are unclear. Some uncertainty may stem from comorbidities like heart failure (HF), a population that typically receives less fluid and in which volume-mortality associations are not well characterized. We sought to evaluate this association.

METHODS: Retrospective analysis of electronic health record (EHR) data from adult academic medical center patients (2012-2021) who met EHR-based Sepsis-III criteria. We excluded patients who presented hypervolemic (required intravenous diuretics). Logistic regression using restricted cubic splines (RCS) was used to model the fluid-mortality relationship, given the non-linearity of the volume-mortality relationship. Exposure: IVF received over the first six hours after patients met Sequential Organ Failure Assessment (SOFA) criteria for sepsis. Outcome: death in-hospital or discharge to hospice. We stratified this analysis by HF status, and adjusted for age and presenting SOFA score as potential confounders.

RESULTS: There were 9,149 patients; 1,375 had HF identified by ICD codes. HF patients received a median of 15 cc/kg of fluid (IQR 7-27), whereas those without HF received 23 cc/kg (IQR 13-37). Across all patients, the unadjusted relationship between volume and probability of death/hospice was U-shaped (Figure A). It was not U-shaped after adjustment for confounders in patients with HF (Figure B). In those without HF, receiving 0-5 cc/kg was associated with increased odds of death vs receiving 25-30 cc/kg (OR= 1.30, 95% CI 1.09-1.55).

CONCLUSIONS: Receiving 25-30 cc/kg was associated with reduced mortality in patients without HF. Nearly 75% of HF patients received less than this, but there was no association between IVF volume and mortality in this group in an adjusted RCS analysis. Large prospective studies could help identify ideal fluid resuscitation strategies in septic patients with HF.

A SURVEY OF PERCEPTIONS OF INPATIENT PAIN MANAGEMENT AMONG HOSPITALIZED PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Ariel Jordan¹; Mehwish Ahmed²; Queen Saunyama²; Jami Kinnucan³; Megan Riehl²; Jeffrey Berinstein²

¹Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI; ²Gastroenterology, University of Michigan Michigan Medicine, Ann Arbor, MI; ³Gastroenterology, Mayo Clinic in Florida, Jacksonville, FL. (Control ID #3863586)

BACKGROUND: Patients with inflammatory bowel disease (IBD) are at risk for chronic pain, particularly during disease exacerbations, which can negatively impact quality of life. Providers often face challenges controlling pain due to limited safe pain management options, leaving IBD patients feeling their pain is not being addressed or treated. There has been limited data focusing on inpatient perceptions of screening and management of pain during IBD relapses. We aim to understand patients with IBD perception of pain during hospitalization in order to optimize pain management in the acute care setting.

METHODS: This was a prospective survey study in adult patients with IBD hospitalized at a single tertiary center for the indication of IBD-related relapse between December 2021- November 2022. Patients completed a survey focused on screening for pain level, inpatient interventions, and outpatient follow-up plan. Descriptive statistics were reported as means and standard deviations for continuous variables and as frequency and percentages for categorical variables.

RESULTS: Among the 40 respondents, 60.5% were female with a mean age of 45.2y (SD 17.1y). The majority were Caucasian (95.0%), 60.0% had Crohn’s disease, 37.5% had ulcerative colitis, and 2.5% had indeterminate colitis with a mean age of diagnosis of 32.2y (SD 20.0y). 67.5% of patients were on an immunosuppressive agent, 52.5% had extraintestinal manifestations, and 67.6% required steroids during admission.

The average pain score prior to admission ranged from 1-9, 27% rating their pain as 1-3, 27% rating their pain as 4-6, and 24.3% rating their pain as 7-9. Most common home pain medications were acetaminophen (38.7%), gabapentin (12.9%), and nonsteroidal anti-inflammatory drugs (12.9%). During the admission, 43.2% of respondents reported an average pain level of 4-6. The majority (71.1%) noted a discussion about pain during admission. 51.4% of respondents were started on new pain medications during admission, most commonly oxycodone (32.4%), acetaminophen (27%), and tramadol (10.8%). The most recommended non- pharmacologic interventions were exercise (25.6%), breathing techniques (15.4%), and dietary adjustments (15.4%). 55.3% of respondents felt offered inpatient interventions improved their pain during admission 23.1% felt they did not have an adequate pain management plan prior to discharge.

CONCLUSIONS: Our data shows inpatient pain management is adequate, though with significant room for improvement. Hospitalized patients at our center utilize a combination of pharmacologic and non- pharmacologic interventions to address their pain. Unfortunately, many patients received opioids during admission, which can increase risk of disease relapse and mortality. We encourage inpatient providers to maximize use of non-opioid medications and non-pharmacologic interventions.

CHANGES IN HOSPITALIZATION OUTCOMES AMONG PRIVATE EQUITY AND NON- PRIVATE EQUITY HOSPITALS DURING THE COVID-19 PANDEMIC

Zirui Song^1,2; Joseph D. Bruch³; Xiaoran Zhang⁴; Derek A. Haas⁴

¹Health Care Policy, Harvard Medical School, Boston, MA; ²Massachusetts General Hospital Department of Medicine, Boston, MA; ³University of Chicago Division of the Biological Sciences, Chicago, IL; ⁴Avant-garde Health, Boston, MA. (Control ID #3875446)

BACKGROUND: Hospitals are increasingly owned by private equity (PE) firms. To date, however, evidence relating hospital quality of care to PE remains scant. In particular, how patient outcomes differed between PE and non-PE hospitals during the COVID-19 pandemic, a time when hospital resources were stressed, is unknown. Using nationwide Medicare data, we examined the relationship between PE hospital ownership and changes in outcomes among COVID-19 and non-COVID-19 hospitalizations, focusing on mortality, before and during the COVID-19 pandemic.

METHODS: We used 100% traditional Medicare inpatient claims from January 2019 to February 2021. We identified hospitals acquired by PE before the study period (treatment group) using data from S&P Global Market Intelligence software, Irving Levin Associates, Securities and Exchange Commission, official press releases, and hospital websites. The control group comprised non-PE hospitals in the same markets (CBSAs) as PE hospitals.

We identified COVID-19 admissions using the COVID-19 diagnosis, with all others defined as non- COVID-19 hospitalizations. Primary outcomes included: in-hospital mortality, 30-day all-cause mortality, and mortality inclusive of discharges to hospice or of deaths during 30-day readmissions. Secondary outcomes included discharges to hospice and discharges to post-acute care.

Analyses of COVID-19 hospitalizations were cross-sectional comparisons between PE and non-PE hospitals, given the lack of COVID-19 prepandemic. Analyses of non-COVID-19 hospitalizations used an OLS difference-in-differences model (pre and post periods before and after March 2020, respectively), adjusted for age, sex, race, CMS-HCC risk score, share of admissions with ESRD, share with disability, CBSA-level COVID-19 infection rate, month fixed effects (FEs), admitting diagnosis group FEs, and hospital FEs, with standard errors clustered by hospital. We further assessed differential changes in outcomes by race and ethnicity.

RESULTS: We identified 187,382 and 114,166 hospitalizations before and during the pandemic respectively, among 122 PE hospitals, along with 2,287,717 and 1,454,353 hospitalizations before and during the pandemic, respectively, among 1,060 non-PE hospitals.

For COVID-19 hospitalizations, 30-day all-cause mortality was 2.3 percentage points higher among PE hospitals relative to their non-PE counterparts (p=0.02, control group mean 29.0%). Among non-COVID-19 hospitalizations, PE hospitals exhibited a differential increase in 30-day all-cause mortality of 0.90 percentage points relative to non-PE hospitals (p<0.001, control group mean pre-COVID 8.1%).

No differential gaps or changes in mortality by race or ethnicity were found among PE relative to non-PE hospitals.

CONCLUSIONS: All-cause mortality after COVID-19 hospitalizations was higher, and that after non- COVID-19 hospitalizations differentially increased, among PE relative to non-PE hospitals in Medicare. These findings stress the importance of understanding the impact of PE on care delivery.

CHARACTERIZING INTUBATION IN SEVERE COVID-19 INFECTION

Ogheneyoma Akpoviroro¹; Nathan Sauers³; Myriam Castagne²; Wasique Mirza¹; Jameson Woodard¹

¹Internal Medicine, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA; ²Clinical and Translational Science Institute, Boston University, Boston, MA; ³Department of Engineering, Pennsylvania State University, State College, PA. (Control ID #3871770)

BACKGROUND: We sought to characterize the group of severe COVID-19(SC19) patients who required intubation and mechanical ventilation(IMV)

METHODS: Retrospective review of admissions with SC19. SC19 was defined as requiring admission to the progressive care unit(PCU). Other inclusion criteria: aged 18-85 years, at least a 10-day course of high- dose dexamethasone and 10 days of remdesivir, admission between 01/01/2021-12/31/2021, intubated during admission.

RESULTS: The study sample included 40 patients. Median age was 60 years; interquartile range(IQR):15.5. Males comprised 57.5%(23/40), 42.5%(17/40) were female. Caucasian patients comprised 95%(38/40), 5%(2/40) were Black. Non-Hispanic patients comprised 82.5%(33/40),10.0%(4/40) were Hispanic; 7.5%(3/40) had unknown ethnicity. While 65% had government-funded insurance, 35% had private insurance. Median BMI was 35.5(IQR:10.6). Median Charlson Comorbidity Index(CCI) was 4(IQR:4). Prevalence of comorbid conditions was as follows: chronic kidney disease:5.0%, diabetes:47.5%, hypertension:75.0%, congestive heart failure:12.5%, chronic lung disease(CLD):50% and of these, 45%(9/20) had COPD and 55%(11/20), obstructive sleep apnea. Patients with an ever-smoker status comprised 65.0%, and of these, 15.4%(4/26) were current smokers and 84.6%(22/26), former smokers. Bacterial pneumonia occurred in 65%(26/40), and AKI in 12.5%(5/40). Azithromycin was administered in 37.5%, hydroxychloroquine in 5%, baricitinib in 22.5%, tocilizumab in 37.5%, anti-diabetic medication in 65%(compared to prior-to-admission use in 15%), and statin medications in 40%. Fully vaccinated patients comprised 5%(2/40). Average admission duration was 22.5 days(standard deviation(SD):10.0 days). Non- invasive ventilation occurred in 90%(36/40). Average admission-to-IMV interval was 108.1 hours(SD:134.9). Average duration of ICU stay was 14.4 days(SD:8.7). Average laboratory values were as follows:albumin(2.9, SD:0.4), ALT(85.7, SD:185.4), AST(70.7, SD:75.9), total bilirubin(0.5, SD:0.2), creatinine(0.8,

SD:0.4), CRP(85.3, SD:58.6), ESR(31.3, SD:32.3), lactate(2.7, SD:3.1), ferritin(1139.0, SD:966.7), D-Dimer(5.1, SD:5.2), troponins(31.1, SD:57.8), WBC count(14.0, SD:4.2), PaCO2(45.4, SD:12.7), pH(7.37, SD:0.06), bicarbonate(25.4, SD:5.0), and respiratory rate(22.8, SD:3.5). In-hospital mortality occurred in 52.5%(21/40). Patients received an average of 14.7 days(SD:4.5) of dexamethasone, and 10.1 days(SD:0) of remdesivir. An average of 0.3 days(SD:0.7) elapsed between starting dexamethasone and remdesivir. CONCLUSIONS: More intubated patients with SC19 infection were male. Racial and ethnicity distribution were like the regional population. Most patients had government-funded insurance, moderate comorbidity- level per the CCI, obesity, hypertension, a smoking history, and half had CLD. Bacterial pneumonia occurred in more patients than not. Only 5% were fully vaccinated. Liver function labs and markers of inflammation were elevated. Over half(52.5%) experienced in-hospital mortality.

CHARACTERIZING THE DISTRIBUTION OF UNDERLYING ETIOLOGIES IN HOSPITALIZED ANEMIA PATIENTS

Christian Carrier¹; David O. Meltzer^1,2; Stephanie Cardenas¹; Micah T. Prochaska^1,2

¹Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; ²Section of Hospital Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL. (Control ID #3874801)

BACKGROUND: Anemia is an acute and/or chronic condition with a range of underlying etiologies present in 40-70% of hospitalized patients. Diagnostic algorithms for anemia exist, but they are rarely used in the inpatient setting because they were derived in ambulatory patients where acute anemia is less common, and a comprehensive outpatient derived workup may be inappropriate in patients who are acutely sick with other conditions. Therefore, the workup of anemia in the inpatient setting varies by provider. As a result, a hospital-based diagnostic and treatment algorithm would improve identification of the etiology of anemia and allow for intervention if appropriate. However, data on the clinically relevant incidence of anemia etiologies in an inpatient setting is needed to develop such algorithms. Therefore, the purpose of this study was to quantify the distribution of anemia etiologies in hospitalized patients into categories clinically relevant to inpatient providers.

METHODS: Any hospitalized general medicine patient with a hemoglobin (Hb)<10 g/dL during hospitalization was eligible. Anemia categories were derived from laboratory data in consenting patients that was abstracted from the electronic health record (EHR) during the index admission and included: 1) Anemia due to nutritional deficiency defined by a ferritin level <50 ng/mL or Vitamin B12 level <20 pg/mL or B12 <300 pg/mL with a corresponding methylmalonic acid >0.4 mmol/L or a serum folate level <3.4 ng/mL or a red blood cell folate <316 ng/mL. 2) Chronic anemia defined by a glomerular filtration rate <30 mL/min/body surface area or a ferritin >50 ng/mL. 3) Acute blood loss anemia defined by an admission Hb >11.5 g/dL. 4) Sickle cell anemia based on a documented history in the EHR and/or an International Classification of Disease 10 code. 5) Undiagnosed anemia defined by patients without laboratory values available or meeting criteria for any of the above anemia etiologies. Patients meeting criteria for more than one etiology were categorized as 6) multiple etiologies of anemia.

RESULTS: There were 945 participants. The mean age was 58, 57% were female and 72% were African American. The mean admission Hb level was 9.5 g/dL, and the mean nadir Hb was 7.7 g/dL. Chronic anemia was the most common etiology (532 patients, 56%), followed by undiagnosed anemia (250 patients, 26%), acute blood loss anemia (141 patients, 15%), anemia due to nutritional deficiency (83 patients, 9%), and sickle cell anemia (74 patients, 8%). 132 patients (14%) were found to have more than one etiology of anemia.

CONCLUSIONS: Chronic anemia is the most common etiology of anemia, but a substantial portion of hospitalized adults with anemia have undiagnosed anemia. The distribution of the underlying anemia etiologies in hospitalized patients differs from the outpatient setting, and this data can be used to develop an optimal standardized approach to anemia diagnosis and treatment in hospitalized patients.

CLINICAL CHARACTERISTICS, RISK FACTORS, AND OUTCOMES OF PATIENTS WITH COMMUNITY-ASSOCIATED CLOSTRIDIOIDES DIFFICILE INFECTION

Nicole Winchester¹; Curtis J. Donskey³; Amy S. Nowacki²; Abhishek Deshpande⁴

¹Lerner College of Medicine, Cleveland Clinic, Cleveland, OH; ²Quantitative Health Science, Cleveland Clinic, Cleveland, OH; ³Cleveland VAMC, Cleveland, OH; ⁴Center for Value Based Care Research, Cleveland Clinic, Cleveland, OH. (Control ID #3875277)

BACKGROUND: Clostridioides difficile results in half a million new infections and 15-30,000 deaths in the US each year. Half of patients are diagnosed as outpatients and one third have no recent hospital exposures and are defined as community-associated infections. Most studies of community-associated C. difficile infection (CDI) were conducted when standalone nucleic acid amplification tests (NAAT) were the diagnostic test of choice. However, standalone NAAT runs the risk of over diagnosis as the test cannot differentiate between symptomatic infection and asymptomatic carriage, and may therefore underestimate disease severity in this population.

METHODS: We conducted a retrospective cohort analysis of patients (ages >18) with an initial diagnosis of CDI at the Cleveland Clinic between January 1, 2018 and March 1, 2020, and no overnight stay in a healthcare facility within the preceding 90 days. CDI was defined as diarrhea plus a positive toxin B NAAT and toxin enzyme immunoassay (EIA). Patients with white blood cell count greater than 15,000 and creatinine greater than 1.5 mg/dl or 1.5 times their baseline level were classified as severe disease, according to IDSA/SHEA guidelines. Numeric and categorical variables were assessed for association with disease severity utilizing t-tests/Wilcoxon rank-sum tests and chi-square tests/Fisher’s exact tests respectively. P < 0.003 was considered statistically significant to adjust for 17 comparisons.

RESULTS: 340 patients met inclusion criteria for community associated CDI. The median age was 68.79. 63.8% of patients were female, 84.1% identified as white, 9.1% as black, 2.1% as multiracial, 0.6% as Asian, and 0.3% as American Indian or Alaskan Native. The median BMI was 26.58 (IQR- 8). 18.3% of patients had inflammatory bowel disease at baseline, 20.6% had diabetes, and 21.6% had chronic kidney disease. During the 90 days prior to CDI diagnosis, 30% of patients were taking a gastric acid suppressant, only 34.0% received antibiotics prior, and half of patients had no healthcare exposures of any kind within the 90 days prior to CDI diagnosis. 85% of patients were hospitalized, 17.4% had severe disease, and 11.2% developed sepsis. Older age (p=0.002), diabetes(p,0.001), chronic kidney disease (p<0.0001), and no prior antibiotic exposure (p=0.001) were strongly associated with severity.

CONCLUSIONS: In our facility, patients with community-associated CDI had low rates of outpatient healthcare exposure and antibiotic use preceding diagnosis. 17.4% of patients developed severe disease and older age, diabetes, CKD, and lack of prior antibiotic exposure were all strongly associated with severe disease.

CLINICAL CHARACTERISTICS AND OUTCOMES OF VETERANS HOSPITALIZED WITH ALCOHOL WITHDRAWAL

Matthew Ronan^1,3; Kirsha S. Gordon²; Michael F. Krug¹¹; Patrick O. Godwin¹²; Dan Heppe¹³; Matthew Hoegh¹³; Joel C. Boggan⁴; Jeydith Gutierrez⁵; Micah Pescetto²³; Peter J. Kaboli⁵; Michelle Guidry¹⁴; Peter Caldwell¹⁴; Christine A. Mitchell¹⁵; Erik Ehlers¹⁵; Nazima Allaudeen⁶; Jessica E. Cyr⁷; Andrea Smeraglio¹⁶; Yarbrough Peter⁸; Richard Rose^17,8; Anand Jagannath¹⁸; Jaclyn Vargas¹⁸; Paul B. Cornia⁹; Meghna Shah⁹; Matthew Tuck¹⁰; Cherinne Arundel¹⁰; James D. Laudate¹⁹; Joel Elzweig¹⁹; Benjamin A. Rodwin²⁰; Joyce Akwe²¹; Meredith Trubitt²¹; Mary K. Charles²²; Craig Gunderson²⁰

¹Medicine, VA Boston Healthcare System, West Roxbury, MA; ²School of Medicine, Yale Univesity, New Haven, CT; ³Harvard Medical School, Boston, MA; ⁴Medicine, Duke Medicine, Durham, NC; ⁵Internal Medicine, Iowa City VAMC, Iowa City, IA; ⁶Internal Medicine, VA Palo Alto Health Care System, Palo Alto , CA; ⁷Internal Medicine, VA Pittsburgh Healthcare System, Pittsburgh, PA; ⁸Internal Medicine, University of Utah, Salt Lake City, UT; ⁹Medicine, VA Puget Sound HCS & University of Washington SOM, Seattle, WA; ¹⁰Medical Service, Washington DC VA Medical Center, Washington, DC; ¹¹Medicine, Boise VA Medical Center, Boise, ID; ¹²Jesse Brown VA Chicago Healthcare System, Chicago, IL; ¹³VA Eastern Colorado Health Care System, Aurora, CO; ¹⁴Southeast Louisiana Veterans Health Care System, New Orleans, LA; ¹⁵VA Nebraska-Western Iowa Health Care System, Omaha, NE; ¹⁶Portland VA Medical Center, Portland, OR; ¹⁷VA Salt Lake City Health Care System, Salt Lake City, UT; ¹⁸VA San Diego Healthcare System, San Diego, CA; ¹⁹White River Junction VA Medical Center, White River Junction, VT; ²⁰VA Connecticut Healthcare System, West Haven, CT; ²¹VA Medical Center Atlanta, Decatur, GA; ²²Durham VA Medical Center, Durham, NC; ²³Kansas City VA Medical Center, Kansas City, MO. (Control ID #3855393)

BACKGROUND: Alcohol withdrawal (AW) is common in hospitalized patients, yet few studies describe current management in hospitalized settings or compare practices to the American Society of Addiction Medicine (ASAM) guideline. We sought to describe patient characteristics and determine factors associated with complicated withdrawal (CW) and treatment duration in hospitalized patients with AW.

METHODS: A cohort of hospitalized patients with AW from 19 Veterans Affairs (VA) hospitals across the US was used. Demographic and comorbidity data were obtained from the VA’s corporate data warehouse. Inpatient management and hospital outcomes were obtained by chart review. Treatment duration was the total number days of treatment (last date minus first date of receiving AW medication). CW was a composite of delirium and seizure. Using a Poisson model, factors associated with treatment duration were examined.

Logistic regression was used to examine factors associated with CW. Both models were adjusted for demographic, clinical characteristics, treatment type, and medications.

RESULTS: There were 594 patients with AW. Most were male (96%), white (74%) and unemployed (60%). More than half had an AW admission in the prior year, 28% had prior alcohol withdrawal delirium, and 33% had a prior withdrawal seizure. Fifty Six percent were managed with symptom triggered therapy (STT) alone, 28% with fixed dose plus STT, 13% with front load regimens plus STT, and 6% with fixed dose alone. The medication given most was lorazepam (87%) followed by chlordiazepoxide (33%), diazepam (14%), and phenobarbital (6%). Median duration of treatment was 3 days. Thirteen percent of patients developed delirium, 5% seizure, and 1% died. Factors associated with treatment duration included prior delirium, acute medical reason for admission, and prior intensive care unit admissions. STT alone and STT with front loads were associated with reduced treatment duration. Lorazepam, gabapentin and phenobarbital were associated with increased treatment duration. Factors associated with CW included race (Black compared to White, AOR 3.1, 95% CI 1.5-6.4), prior delirium (AOR 2.3, 95% CI 1.2-4.4), prior seizure (AOR 2.1, 1.1-3.9), admission alcohol level (AOR 1.0, 95% CI 1.0-1.0) and thrombocytopenia (AOR 2.2, 1.2-3.8). Neither treatment mode nor choice of medication were associated with CW.

CONCLUSIONS: Our results support recommendations by ASAM to manage patients with long-acting benzodiazepines using STT alone or with front-loaded medications. The most popular medication used was the intermediate-acting lorazepam, which was associated with increased treatment duration. Fixed-dose regimens were commonly used and were associated with increased treatment duration. Symptom triggered regimens were preferable to fixed dose regimens for preventing complicated withdrawal in univariate analysis, but the difference was non-significant in adjusted models.

CLINICAL OUTCOMES ASSOCIATED WITH RACE AND GENDER AMONG COVID-19 PATIENTS HOSPITALIZED IN 2020 IN THE USA

Joseph-Kevin Igwe^1,2; Bilen Kassu²; Kelechi Weze²; Precious Ogbonna²; Nicolas Bakinde²

¹Cardiovascular Research, Stanford University School of Medicine, Stanford, CA; ²Morehouse School of Medicine, Atlanta, GA. (Control ID #3875514)

BACKGROUND: COVID-19 disease (COVID-19) has been associated with significantly increased mortality and morbidity. However, the association between race and gender in COVID-19-related mortality has not been evaluated using a national inpatient sample. To determine these associations, we analyzed mortality and related outcomes associated with race and gender for COVID-19 patients hospitalized in the U.S. during the COVID-19 Pandemic using the 2020 National Inpatient Sample (NIS).

METHODS: We identified adults (≥18 years-old) from the 2020 (NIS) database with and without ICD-10- CM codes indicating COVID-19 disease. Pearson χ2 analysis, Analysis of variance (ANOVA), multivariable regression, and propensity-score matched analyses (PSM) of independent variables were conducted to analyze significant associations between variables. Propensity-score matching used age, primary insurance type, length of stay, hospital characteristics, comorbid conditions, medications, and population median- Elixhauser-sum to determine primary outcome: death; and secondary outcomes: acute pulmonary embolism (PE), cardiogenic shock, mechanical ventilation (MV), and ECMO (Extracorporeal Membrane Oxygenation) utilization. STATA/MP software (StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC)) was used for all analyses.

RESULTS: We identified 1,698,560 patients with COVID-19 disease (6.31% of all admissions) with a mean age 63.19±0.09 years and predominance of males 885,110 (52.11%). Mortality in COVID-19 females (11.63%) was significantly lower than COVID-19 males (15.10%, p≤0.01).

The PSM of 339,719 COVID-19 observations demonstrated that female gender was associated with significantly lower odds of mortality (aOR: 0.83, [0.81-.85], p≤0.01), acute PE (aOR:.70, [0.65-.76], p≤0.01), MV (aOR: 0.82, [0.80-0.84], p≤0.01), and cardiogenic shock (aOR:0.76, [.69-0.84], p≤0.01); but no significant difference in ECMO utilization compared to male patients. However, within the matched female subpopulation, African American and Asian race was associated with higher odds of cardiogenic shock (1.41, [1.18-1.69] p≤0.01; 1.72, [1.28-2.31], p≤0.01, respectively) and ECMO utilization (aOR:2.10, [1.30-3.38], p≤0.01); (aOR:2.94, [1.48-5.85], p≤0.01, respectively) compared to white race COVID-19 patients.

The odds of death for females were significantly different between younger age groups compared to that of older age patients (Subpopulation Age 18-49: aOR: 0.72, [0.65-0.80], p≤0.01; Subpopulation Age≥50: aOR: 0.84, [0.82-0.87], p≤0.01).

CONCLUSIONS: In our study, COVID-19 outcomes among female patients were significantly better than male patients; and race or a race-related confounder plays a role in disease severity in COVID-19. The negative trend in odds of death associated with age was concordant with menopausal age among the female population. The anti-inflammatory effects of estrogen play a modulating role in COVID-19 disease. Additional studies are needed to expand on these findings.

CORONARY ARTERY DISEASE TESTING AMONG PATIENTS HOSPITALIZED WITH NEW- ONSET HEART FAILURE

Siamak Kohan³; Janet Lee¹; Huong Q. Nguyen¹; In-Lu Amy Liu¹; Mingsum Lee²; Cheng-wei Huang⁴. ¹Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA; ²Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA; ³Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA; ⁴Hospital Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA. (Control ID #3875255)

BACKGROUND: Coronary artery disease (CAD) testing may be underutilized in patients with heart failure with reduced ejection fraction (HFrEF). We aimed to identify factors associated with CAD testing among patients with new-onset HFrEF.

METHODS: We retrospectively studied adults (≥18 years) hospitalized with new-onset HFrEF between 2016-2021 within Kaiser Permanente. Heart transplant, hospice, pregnant, expired, and non-member patients were excluded. We evaluated the association between sociodemographic and clinical factors with CAD testing within 90 days of index hospitalization with multivariable logistic regression. Odds ratio (OR [95% confidence interval]) were estimated.

RESULTS: Among 2,908 patients, the median age was 70 (interquartile range: 58-80) and 61% were male. White, Hispanic, Black and Asian patients comprised 42%, 28%, 19%, and 10% of patients, respectively. CAD testing was performed in 54% of patients. Patients with ages 60-69 (1.35 [1.03-1.77]), reference: ages 50-59), ages 70-79 (1.43 [1.02-2.01], reference: ages 50-59), and valvular disease (1.26 [1.05-1.51], reference: absence) had higher odds of CAD testing. Patients with ages ≥80 (0.69 [0.48-0.98], reference: ages 50-59), atrial fibrillation (0.70 [0.58-0.84], reference: absence), and do-not-resuscitate order (0.41 [0.32-0.54], reference: full code) had lower odds of CAD testing.

CONCLUSIONS: Differences in CAD testing among patients with new-onset HFrEF may be explained by clinical judgment factoring in the perceived etiology of the HFrEF and goals of care. A universal CAD testing approach may not be appropriate.

DERIVATION AND VALIDATION OF A MODEL TO PREDICT BLEEDING IN MEDICAL INPATIENTS

Benjamin G. Mittman^2,3; Megan Sheehan^1,2; Lisa Kojima^1,2; Michael B. Rothberg²

¹Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; ²Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; ³Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH. (Control ID #3874718).

BACKGROUND: Venous thromboembolism (VTE) is the leading cause of preventable hospital death in the US. The 2018 American Society for Hematology guidelines recommend providing pharmacological VTE prophylaxis to acutely or critically ill medical patients at acceptable bleeding risk, but there are few validated risk assessment models (RAMs) for estimating bleeding risk in such patients. We developed a RAM and compared it with the IMPROVE model.

METHODS: We identified all medical patients admitted to one health system from 2017-2020. Bleeding events were identified by a combination of diagnostic and administrative codes and validated through chart review. Predictors included risk factors identified from previous studies and medications with known bleeding risk. Data were split into training (70%) and validation (30%) sets with pseudo-randomization of bleeding events to ensure proportional event rates in each set. Multiple logistic regression was used to generate and validate the model with all predictors retained. We also validated the IMPROVE model and compared its performance to our RAM in the validation set on the basis of calibration and discrimination. Finally, we compared models on bleed detection rates and the number of patients categorized as low vs. high risk using chi-squared tests.

RESULTS: Our training set included 22,351 patients, 86 (0.39%) of whom developed a bleed while in the hospital. Our final RAM included 15 variables: age, sex, race, platelet count, INR, PTT, GFR, bleeding event <3 months prior to admission, rheumatic disease, sepsis, ICU or CCU admission, central line, peptic ulcer, current cancer, and in-hospital receipt of antiplatelet medications (aspirin, clopidogrel, ticagrelor, or prasrugrel). The strongest predictors were peptic ulcer (OR = 7.2, 95% CI [3.7, 13.0]), central line (5.6, [3.4, 9.2]), and sepsis (4.3, [2.7, 7.0]). The validation set included 9,580 patients; 37 (0.39%) had an in-hospital bleed and individual predicted risks ranged from 0.006% to 28% (median = 0.12%), with good calibration. The C-statistic for our model was 0.77 (95% CI, 0.68-0.86) compared with 0.70 (95% CI, 0.61-0.79) for the IMPROVE model (p = .31). At a treatment threshold of 1.1% (equivalent to an IMPROVE score of 7), our model detected a similar percentage of bleeds as IMPROVE (32% vs 35%, p = .81), but categorized significantly fewer patients as high-risk (7.2% vs 9.0%; p < .001). Additionally, 69% of patients categorized as high-risk in our model nevertheless received in-hospital VTE prophylaxis.

CONCLUSIONS: Most hospitalized patients are at low risk of bleeding, although some are at very high risk. Our RAM had good calibration and similar discrimination to the IMPROVE model. Our RAM detected a similar number of bleeds as the IMPROVE model but identified significantly fewer patients as high-risk. Use of this RAM could help physicians accurately balance risks of bleeding against VTE when considering prophylaxis.

DEVELOPING A TOOL TO ASSESS THE RISK FOR THROMBOEMBOLISM IN PATIENTS HOSPITALIZED WITH SARS-COV-2

Zeina Kayali^1,2; Sarah Paglialonga^1,2; Wilhelmine Wiese-Rometsch³; Ke Ning⁴

¹Internal Medicine Residency Program, Florida State University College of Medicine, Tallahassee, FL; ²Sarasota Memorial Health Care System, Sarasota, FL; ³Graduate Medical Education, Florida State University, Sarasota, FL; ⁴Florida Cancer Specialists & Research Institute LLC, Sarasota, FL. (Control ID #3874205)

BACKGROUND: SARS-CoV-2 infection is thrombogenic. A standardized risk prediction tool to identify thromboembolic risk on admission has not been developed.

METHODS: Patient demographics and clinical and administrative data were extracted from electronic medical records under IRB exemption. Generalized regression with adaptive LASSO modeling and response surface was used to identify (p < 0.05) traits putatively associated with embolism, retaining those that optimized generalized RSquared for aggregated features. Univariate logistic regression for each retained trait created a receiver operating characteristic (ROC) curve with Youden Index estimating cut-point optimizing sensitivity and specificity associated with embolism. An analysis was performed using Boosted Tree (BT) computed at each vascular site thromboembolism percentage for the patient traits while differentiating between present on admission vs. delayed. The area under the ROC was optimized to represent the predictive synergy of the model.

RESULTS: Among 5724 patients hospitalized with SARS-CoV-2 and consecutively discharged from index hospitalization between March 14, 2020, and June 30, 2022, 424 (7.4%) experienced an embolism, including arterial embolism (AE, 3.4%), deep venous thrombosis (DVT, 1.8%), and pulmonary embolism (PE, 2.2%). The BT model identified 13 patient traits and their cutoff points and demonstrated that thromboembolic event signatures differed across embolism sites.

CONCLUSIONS: This single-institution study demonstrates a descriptive tool model to stratify the risk of developing thromboembolic events in patients hospitalized with SARS-CoV-2. We identified 13 different patient traits on hospital admission while establishing the proportion each trait contributes to thromboembolic sites. Future research with a larger sample size is needed to create a predictive tool to guide patient-centric treatment in this population.

DEVELOPMENT AND VALIDATION OF A MODEL TO PREDICT TRANSFUSION REQUIREMENT DURING ELECTIVE SURGERY

Matthew A. Pappas^1,2; Lisa Kojima⁵; Moises Auron³; Deborah Tolich⁷; Daniel I. Sessler⁶; Michael B. Rothberg⁴

¹Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH; ²Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH; ³Hospital Medicine, Cleveland Clinic, Cleveland, OH; ⁴Internal Medicine, Cleveland Clinic, Cleveland, OH; ⁵Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; ⁶Department of Outcomes Research, Cleveland Clinic, Cleveland, OH; ⁷Patient Blood Management, Cleveland Clinic, Cleveland, OH. (Control ID #3869236)

BACKGROUND: Patients completing surgery are often transfused at thresholds higher than supported by available evidence. Preoperative hemoglobin is related to transfusion requirements, but the system used to predict transfusion needs during elective surgery, the Maximum Surgical Blood Order Schedule (MSBOS), does not incorporate preoperative hemoglobin.

METHODS: We assembled a cohort of patients who visited a preoperative risk assessment clinic from 2008 through 2018. We used preoperative hemoglobin and scheduled Current Procedure Terminology (CPT) code to predict the lowest hemoglobin (dichotomized at 7 mg/dL) in the three days after surgery. When patients received intraoperative transfusion, we adjusted the nadir hemoglobin for transfusion volume received using the Lopez-Picado formula. We imputed preoperative hemoglobin when not measured on the morning of surgery.

We split the dataset into derivation (80%) and validation (20%) cohorts, stratified by CPT code. We then fit a multilevel logistic regression in the development set, clustered by CPT code and with preoperative hemoglobin as a restricted cubic spline. Then, in the validation set, we assessed discrimination using the area under the receiver-operator curve (AUROC) and calibration using the Brier score.

RESULTS: We identified 109,794 visits that were followed by major noncardiac surgery within 30 days; 104,267 had one or more preoperative hemoglobin measures. After imputation, our analytic sample included 107,003 surgeries of 2,363 types (87,998 for development, 19,005 for validation). The adjusted nadir hemoglobin was below 7 mg/dL in 5,967 (5.4%). The model's AUROC was 0.92 (95% CI: 0.91-0.93) and its Brier score was 0.04. A calibration plot is shown in the Figure.

CONCLUSIONS: A model using planned CPT and preoperative hemoglobin predicted whether a patient's nadir hemoglobin would fall below 7 mg/dL with excellent discrimination and calibration. This model could allow more efficient preoperative crossmatching compared to MSBOS guidance based on CPT code alone.

DIRECT ORAL ANTICOAGULANT FOR MANAGEMENT OF INTRA-CARDIAC THROMBI: A RETROSPECTIVE COHORT STUDY

Agara Srinivasa Gagan Kumar¹; Omar Hegazy¹; Niranjana Chellappa²; Ola Al-Sous¹

¹Internal Medicine, St Joseph Mercy Health System, Ann Arbor, MI; ²Pulmonary and Critical Care Medicine, Albert Einstein Healthcare Network, Philadelphia, PA. (Control ID #3875310)

BACKGROUND: Intracardiac thrombus (ICT) is a major risk for systemic embolization. Risk has been reported to be as high as 4-5% with left atrial thrombus and 10-15% with left ventricular thrombus in patients who are not anticoagulated. While strong evidence supports the use of direct oral anticoagulants (DOAC) over vitamin K antagonists (VKA) for thrombosis and embolization prevention, data for the management of established ICT has not been as concise. Current data have not only shown that DOAC have at least similar efficacy to VKA for the management of venous and arterial thromboembolic events but also have similar or fewer bleeding events. Given DOAC’s convenience, this data was extrapolated to manage ICT. VKA, however, remains the mainstay of treatment. This study aims to compare the effectiveness of DOAC vs. VKA for ICT management.

METHODS: This was a retrospective descriptive study. The primary outcome was a complete resolution of ICT after six months of treatment. Secondary outcome was serious complications, including major bleeding and cerebrovascular accidents (CVA). Data between January 1, 2015, and December 31, 2019, was obtained electronically from EMR, followed by manual extraction. Inclusion criteria were new diagnosis of ICT confirmed by echocardiogram. Exclusion criteria were loss to follow-up and no available follow-up echocardiogram. Unadjusted t-tests and Chi-square tests were used to assess for differences in baseline characteristics. Regression analysis controlled for baseline characteristics followed, assessing differences in ICT resolution in the first follow-up echo.

RESULTS: Out of 287 patients diagnosed with ICT, 38 patients were included. The VKA and DOAC arms included 22 and 16 patients, respectively. For the primary outcome, the unadjusted comparison revealed greater ICT resolution in the DOAC group vs. the VKA group (81.25% versus 40.91%, p-value = 0.027).

This effect was maintained after adjusting for co-variates, and regression analysis revealed lower odds of ICT resolution with VKA (OR = 0.13, p-value = 0.044). The composite secondary endpoint occurred in 13.16% and 7.89% in the VKA vs the DOAC arms, respectively (p-value =0.249).

CONCLUSIONS: Our study shows 87% decreased odds of ICT resolution with VKA compared to DOAC. Moreover, we did not observe a difference between the two treatment modalities in major bleeding and CVA. Our study’s main limitation is being underpowered due to the small sample size. Nevertheless, our results are consistent with recent evidence supporting DOAC as an alternative to VKA for the treatment of ICT. Large clinical trials are, hence, warranted to confirm these findings. Meanwhile, this study adds to the growing body of evidence, and we hope it contributes to future meta-analyses.

EFFECT OF EMPIRIC ANTIBIOTICS FOR METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS ON MORTALITY FOR PATIENTS HOSPITALIZED WITH BACTERIAL INFECTIONS George B. Carey^1,2; Jurgen Holleck^2,1; Samer Ein Alshaeba²; Ritujith Jayakrishnan¹; Kirsha Gordon^3,2; Alyssa Grimshaw⁴; Craig Gunderson^5,2

¹Medicine, Yale School of Medicine, New Haven, CT; ²Medicine, VACT Healthcare, Yale School of Medicine, WestHaven, CT; ³Internal Medicine, Yale University School of Medicine, New Haven, CT; ⁴Cushing/Whitney Medical Library, Yale University, New Haven, CT; ⁵Internal Medicine, Yale School of Medicine, New Haven, CT. (Control ID #3873740)

BACKGROUND: Many hospitalized patients are treated empirically for methicillin-resistant Staphylococcus aureus (MRSA), though most do not have MRSA. The benefit of this practice is unclear. We performed a systematic review and meta-analysis to estimate the effect on mortality of initial empiric MRSA coverage, both in patients admitted with MRSA infection and in patients admitted with common infectious syndromes, for whom the causative pathogen may not be MRSA.

METHODS: A systematic literature search was conducted using 7 databases from database inception through April 2022. Studies were included if they reported mortality with active and inactive empiric antibiotics in hospitalized patients with culture-proven MRSA infection. The primary outcome was adjusted odds ratio of mortality with active empiric antibiotics. We used adjusted odds ratios from our meta-analysis with MRSA prevalence and base mortality rates from the literature to estimate the absolute mortality reduction with initial empiric MRSA coverage for common infectious syndromes.

RESULTS: Of 2136 titles, 37 studies (11661 participants) were included. Fifteen studies (6066 participants) reported adjusted odds ratios of mortality, mostly in bacteremia (11 studies, 4266 participants). The pooled adjusted odds ratio was 0.64 (95% confidence interval, 0.48-0.84), favoring active empiric antibiotics in patients with MRSA infection. We found no evidence of benefit in MRSA pneumonia (2 studies, 295 participants; adjusted odds ratio 1.56; 95% confidence interval, 0.74-3.27). We estimate an absolute mortality reduction of 0.1% or less with initial empiric treatment for MRSA for non-critically ill patients admitted with the 3 most common infectious syndromes (community-acquired pneumonia, skin and soft tissue infection, urinary tract infection). Higher absolute risk reductions were estimated in other conditions, such as septic shock (0.6; 95% confidence interval, 0.2-1.0).

CONCLUSIONS: We estimate that for most hospitalized patients, the absolute mortality benefit of initial empiric antibiotics for MRSA is likely 0.1% or less. Meaningful benefit may be seen in conditions with higher prevalence of MRSA and baseline mortality, such as septic shock.

EFFECT OF WEEKEND VS. WEEKDAY ADMISSION ON ENDOCRINE EMERGENCIES RESULTS FROM NATIONAL INPATIENT SAMPLE DATABASE 2016-2019

Bidhya Poudel¹; Biraj Shrestha²

¹Internal medicine, AMITA Health Saint Francis Hospital Evanston, Evanston, IL; ²internal medicine, Tower Health, Reading, PA. (Control ID #3875473)

BACKGROUND: Limited studies exist to understand the effect of weekend vs. weekday admission on Endocrine emergencies.

METHODS: We queried the National Inpatient Sample database from 2016-2019 for hospitalizations with a primary diagnosis of Endocrine emergencies (Diabetic Ketoacidosis (DKA), Hyperosmolar Hyperglycemic State (HHS), Thyrotoxicosis, Myxedema coma and Addison's Crisis). We used NIS-predefined admission days to find whether the admission was on weekends or weekdays. We assessed the two groups' demographics, in-hospital mortality, length of stay, and cost of hospital admission. In-hospital mortality was adjusted for potential confounders using multivariable logistic regression analysis adjusting for baseline characteristics significantly different in univariate analysis (liberal threshold of p<0.20).

RESULTS: From 2016 to 2019, we found 934,685 patients admitted for endocrine emergencies, of which 85.03% were for DKA, 9.63% were for HHS, 3.80% were for thyrotoxicosis, 1.12% were for Adrenal Crisis, and 0.41% were for Myxedema coma. Patients in the Weekday admission were older (43.76 vs. 43.25 years, p<0.001) with higher comorbidities like heart failure, obesity, valvular heart disease, and a higher Elixhauser comorbidity index (-3.09 vs. -3.19, p<0.001). In-hospital mortality was not statistically different in univariate analysis between weekend admission vs. weekday admission (0.55% vs. 0.49%, OR: 1.11, 95% CI: 0.97-1.28, p=0.136); however, when adjusted for the difference in comorbidities, we found slightly higher mortality in weekend admission compared to weekday admission (adjusted OR: 1.16, 95% CI: 1.01-1.34, p=0.039). We didn't find any cost difference between weekend and weekday admission ($8,043.50 vs. $8080.67 USD, p=0.437). We also didn't find any differences in length of stay between weekend and weekday admissions (3.38 days vs. 3.42 days, p=0.052).

On Subgroup analysis of endocrine emergencies, we found a higher unadjusted (unadjusted OR: 1.82, 95% CI: 1.05-3.14, p=0.03) and adjusted (adjusted OR: 1.80, 95% CI: 1.02-3.16, p=0.042) in-hospital mortality in weekend admission vs. weekday admission for Myxedema Coma. We also found a higher adjusted in- hospital mortality (adjusted OR: 1.88, 95% CI: 1.02-3.50, p=0.044) in weekend admission vs. weekday admission in patients admitted for thyrotoxicosis. We didn't find any difference in adjusted or unadjusted in- hospital mortality in weekend vs. weekday admission in patients admitted for DKA, HHS, and adrenal Crisis. For hospital cost and length of stay, we didn't find any differences in subgroup analysis for the various endocrine emergencies.

CONCLUSIONS: Weekend admission for endocrine emergencies was associated with a higher in-hospital mortality than weekday admission, primarily driven by myxedema coma and thyrotoxicosis. Further study is needed to understand the hospital, administrative and physician factors contributing to poorer outcomes in endocrine emergencies, especially in myxedema coma and thyrotoxicosis.

EXPLORING THE CHARACTERISTICS OF THE HOSPITALIZED PATIENTS ADMITTED FOR ACUTE PANCREATITIS WHO DEVELOP ABDOMINAL COMPARTMENT SYNDROME IN THE US HOSPITALS

Falah I. Abu Hassan, Andrea J. Zapata, Md Rockyb Hasan, Sadia A. Tanami, James ". Walker

Internal Medicine, Texas Tech University Health Sciences Center School of Medicine, Amarillo, TX. (Control ID #3872719)

BACKGROUND: Abdominal compartment syndrome (ACS) is a documented complication of acute pancreatitis and is thought to be secondary to aggressive fluid resuscitation. Recent studies advocated for moderate over large volume resuscitation in acute pancreatitis due to the high risk of fluid overload and lack of added benefit.

METHODS: All the cases admitted with a diagnosis of acute pancreatitis between the years 2016 - 2020 were selected by using the relevant ICD-10 codes from the national inpatient sample (NIS). ICD-10 code “M79A3” was used to determine the patients who developed ACS. Multivariate binary logistic regression was used to assess the odds of developing ACS in the presence of biliary pancreatitis, alcoholic pancreatitis, pancreatic necrosis, active alcohol withdrawal, malnutrition, liver disease (hepatitis, cirrhosis, or liver failure), Malignancy, and sepsis. Results were reported as the odds ratio (OR) with confidence intervals (CI) of 95%. Significant results had a p value < 0.05.

RESULTS: 371,729 patients with pancreatitis were found. 0.12% (n = 455) of the patients admitted with pancreatitis developed ACS. 52.7% of all pancreatitis admissions were males. 75.6% of patients with ACS were males. The average age of patients who developed ACS was 48 years as compared to 53 years in those who did not. Significantly higher odds to develop ACS were seen with the presence of sepsis OR = 11.32 (CI

9.16 – 13.99), pancreatic necrosis OR = 10.66 (CI 8.73 – 13.00), active alcohol withdrawal OR = 1.78 (CI 1.377 – 2.32), liver disease OR = 1.72 (CI 1.441 – 2.09), malnutrition OR = 1.57 (CI 1.27 – 2.93), and alcoholic pancreatitis OR = 1.48 (CI 1.1 – 1.88). Biliary pancreatitis, however, is associated with significantly lower odds of OR = 0.62 (CI 0.46 – 0.85). The presence of a malignant comorbidity was not significantly associated with the odds of developing ACS.

CONCLUSIONS: To our knowledge, specific risk factors associated with developing ACS in pancreatitis patients have not been previously reported. In pancreatitis, development of diffuse abdominal edema and fluid sequestration frequently occur, eventually leading to the evolution of ACS (>20mmHg) in rare cases. This leads to a cascade of decreased visceral perfusion and multiple organ dysfunction. Our results suggest that necrosis and sepsis play a major role in the progression of ACS and we hypothesize that the increased permeability and fluid sequestration associated with necrosis, and the larger volume resuscitation in septic patients are to blame. Interestingly, alcoholic pancreatitis and alcohol withdrawals during hospitalization are correlated with higher odds of ACS. We also hypothesize that this is related to the direct toxic damage induced by alcohol on the pancreatic tissue. Clinicians should be vigilant when treating such patients as further studies are needed to unveil unexplored risk factors associated with ACS in pancreatitis, such as necrosis.

IMPACT OF CORTICOSTEROIDS, ANTICOAGULATION, BOTH OR NONE ON PATIENT IN- HOSPITAL OUTCOMES FROM COVID-19 INFECTION

Alison Leslie¹; Katelyn Tessier⁴; Christopher Tignanelli⁵; Scott A. Chapman³; Sameh Hozayen²

¹University of Minnesota Medical School Twin Cities, Minneapolis, MN; ²Department of Medicine, Division of Hospital Medicine, M Health Fairview University of Minnesota Medical Center East Bank, Minneapolis, MN; ³Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN; ⁴Biostatistics Core, University of Minnesota Masonic Cancer Center, Minneapolis, MN; ⁵Department of Surgery, Division of Critical Care/Acute Care Surgery, M Health Fairview University of Minnesota Medical Center East Bank, Minneapolis, MN. (Control ID #3876157)

BACKGROUND: There has been increased research evaluating corticosteroids (CCS) and anticoagulants (AC) on clinical outcomes in patients hospitalized with Covid-19. CCS may reduce mortality and ventilation needs in patients hospitalized with Covid-19, but data are sparse outside clinical trials. Similarly, Covid- induced hypercoagulability and the need for AC in SARS-CoV-2 patients may need more practice-driven data in an area of possibly conflicting clinical trial results. This study includes patients hospitalized with Covid-19 who received AC and/or CCS and to evaluate the impact of these pharmacologic interventions on patients’ real life clinical outcomes.

METHODS: This retrospective cohort study included adult patients hospitalized with Covid-19 from March 1st, 2020 to April 30th, 2022 at Fairview, a United States Midwest health system. Included patients were grouped into four cohorts: received AC only, CCS only, both AC + CCS, or neither. In-hospital outcomes included mortality and thromboembolic events. Baseline demographics and in-hospital outcomes were summarized and compared by medication group. Unadjusted and adjusted logistic regression models were performed.

RESULTS: 5420 patients were included: AC only (N=2332), CCS only (N=129), both AC + CCS (N=1857), or neither (N=1102). There were statistically significant differences in baseline characteristics by medication group, some likely driven by sample size. Results are in the table below. For the unadjusted model, AC only was associated with significant reduction in mortality while CCS only and AC + CCS were associated with a significant increase in mortality. AC only remained significant in its mortality reduction when adjusting for comorbidities, while the increased mortality with CCS only was no longer seen. CCS only was associated with increased thromboembolism risk in both adjusted and unadjusted models.

CONCLUSIONS: AC only decreased the risk of mortality while CCS only increased the risk of thromboembolism in hospitalized patients with Covid-19. Increased risk with CCS only group may reflect a higher risk group at baseline that had more comorbidities and higher acuity presentation.

IMPLICATIONS OF USING LOCALLY VALIDATED RISK FACTORS FOR RESISTANCE WHEN CHOOSING ANTIBIOTICS FOR COMMUNITY-ACQUIRED PNEUMONIA

Benjamin G. Mittman^1,2; Hamlet Gasoyan¹; Abhishek Deshpande¹; Peter B. Imrey³; Ning Guo³; Michael B. Rothberg¹

¹Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; ²Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH; ³Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH. (Control ID #3874709)

BACKGROUND: The 2019 ATS/IDSA community-acquired pneumonia (CAP) guidelines recommend prescribing empiric extended-spectrum antibiotics (ESA) for MRSA or P aeruginosa only if locally validated risk factors are present, but the implications of this recommendation are unknown. We determined the percentage of US hospitals that had enough resistant infections to identify local risk factors and, among hospitals that did, compared theoretical use of ESA based on local risk factors or generic risk factors against observed use of ESA.

METHODS: We identified 177 hospitals in the Premier Healthcare Database and quantified resistant infections among adult patients hospitalized for CAP from 2010-2015. We assumed that hospitals with ≥80 patients with resistant infections could identify local risk factors. Among these hospitals, we compared the performance of local risk factors with 2 generic risk factors recommended by the guidelines (recent intravenous antibiotics or previous infection with or MRSA or P aeruginosa). Local risk factors were those associated with resistant infections at p < 0.05 in standard two-group comparisons. We then compared the percentage of all patients and those with resistant infections who would receive ESA with each approach. Finally, we determined actual rates of ESA use in each hospital.

RESULTS: Over 5 years, 11/177 (6%) hospitals had enough resistant infections to derive their own risk factors. Physicians covered 60-80% of patients with resistant infections by prescribing ESA to 37-58% of all patients (Figure). Using local risk factors, these hospitals would improve coverage of resistant infections to 81%-98.8%, but this would require using ESA for 54-93% of all patients with CAP. Using the 2 generic risk factors would reduce the use of ESA to <13% of all patients, but would cover only 11-28% of resistant infections.

CONCLUSIONS: Most US hospitals did not have enough patients with resistant infections to derive local risk factors. For those that did, choosing ESA based on local risk factors would increase rates of ESA, whereas basing it on the two generic risk factors would decrease use of ESA. Guidance is needed regarding the appropriate tradeoff between treating patients with resistant infections and those without.

IN-HOSPITAL MORTALITY IN PATIENTS WITH PULMONARY EMBOLISM MANAGED WITH ULTRASOUND-ASSISTED CATHETER-DIRECTED THROMBOLYSIS COMPARED TO SYSTEMIC THROMBOLYSIS

Kristina D. Menchaca¹; Catherine A. Ostos¹; Nemanja Draguljevic²; Virginia Velez Quinones¹; Erika Ostos¹; Robert Chait¹

¹Internal Medicine, University of Miami School of Medicine, Miami, FL; ²Internal Medicine, Univerzitet u Beogradu, Beograd, Beograd, Serbia. (Control ID #3875383)

BACKGROUND: Patients with high-risk or intermediate-risk pulmonary embolism (PE) require more aggressive therapy, such as systemic thrombolysis. Although parenteral systemic thrombolysis leads to faster clot resolution, it is associated with a high risk for significant bleeding and its complications. The use of catheter-directed thrombolysis (CDT) decreases systemic exposure to thrombolytics and reduces the risk of complications and mortality. Adding ultrasound to CDT can potentially decrease the dosing of local thrombolytics and make it even safer for the patients.

METHODS: This retrospective cohort study identified 1,007 patients diagnosed with pulmonary embolism (PE) across several facilities. Patients were stratified into two groups based on the treatment they received, a group that received systemic thrombolysis (ST), 432 (42.9 %), and a group that received ultrasound-assisted catheter-directed thrombolysis (EKOS), 575 (57.1 %). The aim was to explore immediate mortality from direct and indirect complications arising from PE and its management in patients treated with systemic thrombolysis vs. EKOS. We used logistic regression to analyze data.

RESULTS: The patients with PE and who were managed with ST were more likely to expire than those treated with EKOS (OR 2.893, CI 1.766~5.041, p<0.001). Patients who passed were more likely to experience tachycardia (OR 2.432, CI 1,299~4.556, p<0.001) and use of vasopressors (OR 13.331, CI 8.075~22.006, p<0.001). There were 70 (6.95 %) deaths in the ST group vs. 26 (2.58 %) in the EKOS group.

CONCLUSIONS: Patients with PE managed with ST are more likely to die than those with EKOS. This illustrates better outcomes of using EKOS vs. systemic thrombolysis for PE. However, a limitation of this study was the small sample of patients and possible cofounders, which warrants future studies.

IRON INFUSIONS, THEIR REACTIONS AND EFFICACY RELATED TO DOSING – A SINGLE CENTER RETROSPECTIVE STUDY

Tejaswi Venigalla¹; Manasa Anipindi²; Madiha Gilani³; David Ezdon⁴; Jermine Mousa⁴; Mitchell Goldstein³; Minal Dhamankar³

¹Internal Medicine, Albert Einstein Medical Center, Philadelphia, PA; ²Internal Medicine, Einstein Medical Center Montgomery, East Norriton, PA; ³Hematology Oncology, Einstein Medical Center Montgomery, East Norriton, PA; ⁴Pharmacy, Einstein Medical Center Montgomery, East Norriton, PA. (Control ID #3855016)

BACKGROUND: Intravenous (IV) iron infusions are associated with a variety of adverse drug reactions (ADRs). The Commonly used IV iron formulations are Iron sucrose (Venofer), Ferric carboxymaltose (Injectafer), Sodium ferric gluconate complex (Ferrlecit), and others.

We aim to study:

1. If altering the dose of Venofer will result in a lesser incidence of allergic reactions.

2. To determine if one preparation of IV iron has a higher incidence of adverse events than another.

3. To evaluate the efficacy after 6 to 8 weeks of completion of iron infusions, by comparing the response to various dosages and formulations.

METHODS: This is a retrospective chart review of 274 patients ages 18-92 who received Intravenous Iron in our Infusion Center. Patients were divided into two groups based on the Venofer dosing schedule. Group D1 patients received any of the above-mentioned IV iron formulations from January to May 2021. In this group, Venofer dosing was 400mg x 1 followed by 300mg x2. Group D2 patients received any of the above- mentioned IV iron formulations from June to October 2021, where Venofer dosing was changed to 300mg x 3 doses or 300mg x 2 followed by 400mg. We collected data on age, gender, race, preparation, strength, total doses received, pregnancy status, prior history of allergies and transfusion reactions, adverse drug reactions, the timing of reaction, pre/post-medications, outcomes of reaction, hemoglobin, iron studies before and after the infusions.

RESULTS: Out of 120 patients in group D1, 59.2% of the patients received Injectafer. Out of these, 17% had ADRs. Responders in this group were 39.4%. 14.1% were lost to follow-up. 40% of the patients received Venofer, out of which 22.9% had ADRs. Responders to the infusion in this group were 22.9% with 20% lost to follow-up. 0.8% received ferumoxytol, with no ADRs.

In the D2 group of 154 patients, 49.3% of the patients received Injectafer, out of which 18.4% had ADRs. Responders in this group were 38.1% and 13.2% were lost to follow-up. 50% of the patients received Venofer, out of which 11.7% had ADRs. Responders to the infusion in this group were 46.8% and 11.7% were lost to follow-up. 0.6% received Ferumoxytol with no ADRs [Table No.1]

CONCLUSIONS: Injectafer was overall associated with more ADRs when compared to Venofer, including anaphylactic reactions. The most common ADR was hypotension with Injectafer, and back pain with Venofer. We found that Venofer dosing with 400mg x 1 followed by 300mg x2 was associated with the highest incidence of ADRs. Both strategies of Venofer dose modification with 300mg x 3 and schedule modification, 300x 2 followed by 400mg had greater efficacy and lesser frequency of ADRs as compared to Venofer 400mg followed by 300mg x2. Other studies have shown the benefit of Venofer in non-renal disease patients with iron deficiency. Although our study was not planned to demonstrate this outcome, our data may suggest that Venofer is beneficial for this group of patients. This should be looked into with further studies.

ISCHEMIC STROKE OUTCOMES AFTER STRESS-INDUCED HYPERGLYCEMIA IN DIABETIC VERSUS NON-DIABETIC PATIENTS

Honglian Duan²; Ho Jun Yun¹; Gary Rajah¹; Yanna Tong²; Zhe Cheng²; Lipeng Cai²; Xiaokun Geng^1,2; Yuchuan Ding¹

¹School of Medicine, Wayne State University School of Medicine, Detroit, MI; ²Department of Neurology, Beijing Luhe Hospital, Beijing, China. (Control ID #3857779).

BACKGROUND: Approximately one-third of patients with acute ischemic stroke (AIS) develop hyperglycemia regardless of pre-existing history of diabetes. Hyperglycemia is associated with increased risk of hemorrhagic transformation and can be considered as a predictor of poor functional outcome after intravenous thrombolysis (IVT) and mechanical thrombectomy (MT). Additionally, risk of death, hemorrhagic complications, and functional dependency are found to increase with stress-induced hyperglycemia especially in those without history of diabetes mellitus. This study assesses whether stress- induced hyperglycemia is a predictor of poor outcome for patients with AIS treated by endovascular treatment (EVT) and they are impacted by previous blood glucose status.

METHODS: This retrospective study collected data from 576 patients with AIS of large vessel occlusion (LVO) treated by EVT from March 2019 to June 2022. The sample was composed of 230 and 346 patients with and without diabetes mellitus (DM), respectively, based on their premorbid diabetic status. Prognosis was assessed with modified Rankin Scale (mRS) score at 3-month after diagnosis of AIS. Poor prognosis was defined as mRS>2. Stress-induced hyperglycemia was assessed by fasting glucose-to-glycated hemoglobin ratio (GAR). Each group was stratified into 4 quartiles of GAR (Q1–Q4). Any significant association between stress-induced hyperglycemia and poor outcomes in both the DM and non-DM groups was assessed. Multivariate logistic regression analysis was used to identify any relationship between different GAR quartiles and clinical outcome after EVT.

RESULTS: In DM group, GAR level was measured to be 1.27±0.44 and poor prognosis was seen in 122 (53%) patients. These variables were higher than non-DM group and the differences were statistically significant (p<0.05, respectively). Patients with more severe stress-induced hyperglycemia showed greater occurrence of poor prognosis at 3 months (in DM, Q1=39.7%, Q2=45.6%, Q3=58.6%, Q4=68.4%, p=0.009; in non-DM, Q1=31%, Q2=32.6%, Q3=42.5%, Q4=64%, p<0.01). After logistic regression, the highest quartile of GAR was independently associated with 3-month poor outcome (OR 0.34, 95%CI 0.16-0.70, p=0.004).

CONCLUSIONS: The outcome of patients with LVO stroke treated with EVT appears to be influenced by premorbid diabetes status. However, the poor prognosis in diabetic patients is not independently associated with stress-induced hyperglycemia. This could be due to the long-term damage resulted from persistent hyperglycemia and/or the adaptive alterations of diabetic patients responding to stress-induced hepatic glucose metabolism after acute ischemic damage to the brain.

IS HIGHER BMI A RISK FACTOR FOR WORSE OUTCOMES IN COVID-19?

Hossny Alaws¹; Gagan Kumar²

¹Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA; ²Critical care, Northeast Georgia Health System Inc, Gainesville, GA. (Control ID #3874843)

BACKGROUND: Obesity is a growing epidemic in the United States and has been described as a risk factor for severe COVID-19. Most studies, however, have used discreet cut-off points on BMI as their covariates and report poorer outcomes in patients with higher BMI categories. We used restricted cubic splines to examine BMI as a continuous variable to examine its association with COVID-19 outcomes.

METHODS: We performed a retrospective analysis of adult COVID-19 patients aged ≥ 18 years admitted to a large community hospital in northeast Georgia between March 1, 2020, and April 5, 2022.

Outcomes studied were - in-hospital mortality, the rate of intensive care unit (ICU) admissions, invasive mechanical ventilation (IMV), acute kidney injury (AKI), and the use of vasopressors. The Chi-square and the Wilcoxon rank tests were used for categorical and continuous variables, respectively. For all analyses, statistical significance was deemed as a p-value ≤ 0.05.

Restricted cubic splines with 5 knots were used for our analysis. Logistic regression was used to examine the probability of outcomes. All statistical analyses were performed using STATA MP 16.0 (Stata-Corp, College Station, Tx).

RESULTS: Of the 9698 patients admitted in the study period, BMI data were available for 9327 patients. Of these, 2056 had BMI < 25, 5936 had BMI between 25 and 39, and 1335 had a BMI≥40. The severity of COVID-19, as determined by the 4C score, decreased as BMI increased. There was a non-linear relationship between BMI and the outcomes studied. The probability of in-hospital mortality decreased with increasing levels of BMI until a BMI of 30 and then did not change with BMI after that (figure 1). Thus, the odds for in- hospital mortality were 0.55, 0.34, 0.31, and 0,30 at a BMI of 20, 30, 40, and 50, respectively, when compared to a BMI of 14.

Rates of AKI and pressor use increased till a BMI of 30, then flattened out; however, the rates of ICU admission and IMV increased with BMI without any elbow.

CONCLUSIONS: ICU admission and IMV increased with BMI, while rates of vasopressor use, and AKI did not change significantly once BMI was > 30.

The probability of in-hospital mortality decreased with increasing levels of BMI till BMI of 30.

IS UNCONTROLLED DIABETES PRIOR TO HOSPITALIZATION A RISK FACTOR FOR WORSE OUTCOMES IN COVID-19?

Hossny Alaws¹; Gagan Kumar²

¹Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA; ²Critical care, Northeast Georgia Health System Inc, Gainesville, GA. (Control ID #3874011)

BACKGROUND: Diabetes Mellitus (DM) is a well-described risk factor for hospitalization with COVID-19. However, its unknown whether poor diabetes control prior to admission results in poorer outcomes. We examined whether higher levels of HbA1c prior to admission were associated with poorer COVID-19 outcomes.

METHODS: We performed a retrospective analysis of adult COVID-19 patients (age ≥18 years) admitted to a large community hospital in Northeast Georgia between March 1, 2020, to April 1, 2022.

Outcomes were in-hospital mortality, the severity of COVID-19, the rate of intensive care unit (ICU) admissions, invasive mechanical ventilation (IMV), the use of vasopressors, the rate of hospital-acquired infections (HAI), and rates of readmission. We used the chi-square test and the Wilcoxon rank test for categorical and continuous variables, respectively. For all analyses, we deemed statistical significance a p-value < 0.05.

We used restricted cubic splines with 5 knots for our analysis. Logistic regression was used to examine the probability of outcomes. We performed all statistical analysis using STATA MP 16.0 (Stata-Corp, College Station, Tx).

RESULTS: Of the 9698 patients admitted during the study period, 3894 (40.2%) had diabetes mellitus. Of these, HbA1c data were available for 2672 patients. The severity of COVID-19, as determined by the 4C score, was higher in those with DM (mean 8.6 ± 4.3 vs. 10.9 ± 3.6, p < 0.001). There was non-linear relationship of HbA1c levels and outcomes studied. The rates of ICU admission, mechanical ventilation, HAI, or vasopressor use did not change significantly with higher levels of HbA1c. The probability of in- hospital mortality decreased with increasing levels of HbA1c (figure 1). Thus, the odds for in-hospital mortality were 0.43 (95% confidence interval (CI), 0.29-0.66) at an HbA1c level of 13 when compared to 7. The rates of readmission and AKI decreased with increasing levels of HbA1c.

CONCLUSIONS: HbA1c levels, prior to admission, were not associated with increased severity of COVID-19 as judged by ICU admission, vasopressor use, or rates of invasive mechanical ventilation. Higher HbA1c levels were negatively associated with in-hospital mortality and readmissions.

MEDIUM-TERM MORTALITY IN PATIENTS PULMONARY EMBOLISM MANAGED WITH ULTRASOUND-ASSISTED CATHETER-DIRECTED THROMBOLYSIS COMPARED TO SYSTEMIC THROMBOLYSIS

Catherine A. Ostos¹; Kristina D. Menchaca¹; Virginia Velez Quinones¹; Can Jones¹; Erika Ostos²; Nemanja Draguljevic³; Robert Chait¹

¹Internal Medicine, University of Miami School of Medicine, Miami, FL; ²St Petersburg College - Clearwater Campus, Clearwater, FL; ³Univerzitet u Beogradu Medicinski fakultet, Beograd, Beograd, Serbia. (Control ID #3875021)

BACKGROUND: Pulmonary embolism is one of the leading causes of morbidity and mortality in the United States^1-2. PE is classically treated with anticoagulation and systemic thrombolysis (ST)³. Over the last few decades, there have been important advances in therapeutic options for PE management such as catheter- directed thrombolysis (CDT) with or without addition of ultrasound assistance². However, the use of this devices is still controversial, given the lack of long-term evidence for its outcomes^2-3. We conducted a retrospective study to assess medium-term mortality comparing patients who received treatment with EKOS® Ultrasound-Assisted Catheter-Directed Thrombolysis (US-CDT) compared to Systemic Thrombolysis.

METHODS: This retrospective cohort study identified 1007 patients across several facilities diagnosed with Pulmonary Embolism (PE). Patient were stratified into groups based on the treatment they received. Patients were excluded if they had pregnancy, stroke, or history of recent bleeding. We observed 575 (57.1%) patients treated with EKOS® Ultrasound-Catheter-Directed Thrombolysis (US-CDT) and 432 (42.9%) patients treated with Systemic Thrombolysis (ST). The aim was to assess characteristics of patients and 60-day mortality after treatment, comparing patients who received US-CDT vs ST. Logistic regression was used to predict the 60-day mortality.

RESULTS: Patients’ characteristics were analyzed with 54.22% being male and 45.78% were female. Baseline comorbidities (hypertension, coronary artery disease, chronic obstructive pulmonary disease) were similar among both groups of treatment The patients with PE who were managed ST were more likely to expire within 60 days of the event compared to the ones managed with US-CDT (OR= 3.037, p<0.001, CI 1.856~4.971). Patients who expired were also more likely to experience tachycardia (OR= 2.432, p<0.001, CI 1.299~4.556), and use of vasopressors (OR= 13.331 p<0.001, CI 8.075~22.06) during their hospitalization. A total number of 70 deaths (6.95 %) were identified in the ST group vs. 26 (2.58 %) in the US-CDT group

CONCLUSIONS: Ultrasound-Assisted Catheter-Directed Thrombolysis is an option for treatment that provides less dose of anticoagulation, potentially reducing side effects among other outcomes in patients with PE². Although there has been not enough evidence to differentiate standard CDT vs US-CDT^1-3, our study demonstrated that patients with PE who were managed with ST were more likely to expire within 60 days of the event compared to the ones who had US-CDT (OR= 3.037, p<0.001, CI 1.856~4.971), making US-CDT a safer option for patients with PE. Limitation to our study includes small patient sample. More research is needed to assess their differences.

METFORMIN FOR TREATMENT OF COVID-19: SYSTEMATIC REVIEW OF CLINICAL TRIAL DATA AGAINST SARS-COV-2

Spencer Erickson¹; Sarah Fenno²; Carolyn Bramante³; Jenna Bartley⁴; George Kuchel⁴

¹University of Minnesota Medical School Twin Cities, Minneapolis, MN; ²University of Minnesota Medical School, University of Minnesota Medical School Twin Cities, Minneapolis, MN; ³Medicine, University of Minnesota Twin Cities, Minneapolis, MN; ⁴UConn Health, Farmington, CT. (Control ID #3876554)

BACKGROUND: Observational and preclinical data suggest metformin may prevent severe COVID-19 outcomes. We conducted a systematic review of randomized clinical trials of metformin treatment for COVID-19 to determine whether metformin affects clinical or laboratory outcomes in individuals infected with SARS-CoV-2 and a structured summary of pre-clinical data.

METHODS: Two independent reviewers searched PubMed on September 11, 2022 from 2020-2022 for randomized controlled trials which randomized adults with COVID-19 to metformin versus control and assessed clinical and/or laboratory outcomes of interest. The Cochrane Risk of Bias 2 tool was used to assess bias. The synthesis plan was developed a priori and was guided by SWiM guidelines. Summary tables and narrative synthesis were used.

RESULTS: Three randomized trials met inclusion criteria and were included. Each study utilized a different formulation of metformin; 2 of the trials found metformin improved clinical outcomes, and the 3^rd had a different sample population but did have a direction of benefit in the per-protocol group. The largest of the trials enrolled during the delta and omicron waves, but did not exclude vaccinated individuals. Many preclinical studies have found metformin to be effective against SARS-CoV-2. No safety concerns were identified in any of the trials.

CONCLUSIONS: The certainty of evidence that metformin improves clinical outcomes in patients with SARS-CoV-2 infection was moderate per GRADE criteria and is consistent with preclinical data. Future trials will help define the role of metformin in COVID-19 treatment guidelines.

OUTCOMES AMONG HOSPITALIZED CORONAVIRUS DISEASE 2019 (COVID-19) PATIENTS WITH RHABDOMYOLYSIS: A NATIONWIDE ANALYSIS

Bruce Adrian Casipit¹; Hussein Al-Sudani²

¹Internal Medicine, Albert Einstein Medical Center, Philadelphia, PA; ²Einstein Medical Center Montgomery, East Norriton, PA. (Control ID #3871799)

BACKGROUND: Rhabdomyolysis is a significant cause of morbidity among hospitalized patients. Previous studies suggest that patients with rhabdomyolysis have a higher risk of in-hospital complications including acute kidney injury (AKI), which if severe could lead to renal failure requiring renal replacement therapy (RRT) and maybe even death. However, there are limited data exploring the influence of Coronavirus Disease (COVID-19) infection in this population. We aim to investigate the impact of COVID-19 infection among hospitalized patients with rhabdomyolysis in terms of risk for in-hospital mortality, AKI, and requirement for RRT.

METHODS: We conducted a retrospective cohort study utilizing the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) 2020 database which represents 20% of all payer admissions to hospitals in the United States in 2020. Univariate logistic regression analysis was used to calculate unadjusted odds ratios (ORs) for the primary and secondary outcomes. Multivariate logistic regression analysis was used to adjust for potential patient and hospital level confounders. Proportions were compared using the Chi Square test, and a Student t test was used to compare continuous variables. A p value <0.05 was considered statistically significant.

RESULTS: A total of 1,058,815 admissions for COVID-19 infection were identified in 2020, of which, 1.13% (n=11,995) had rhabdomyolysis. Of the total sample, 11,695 met our inclusion criteria. Overall, the inpatient mortality rate among COVID-19 patients with rhabdomyolysis is 23.98% (n=2804/11695). Using a stepwise regression model that adjusted for patient and hospital level confounders, hospitalized COVID-19 patients with concomitant rhabdomyolysis had higher adjusted in-hospital mortality rates (odds ratio [OR] 2.62; 95% confidence interval [CI], 2.34-2.93), risk for AKI (odds ratio [OR] 4.14; 95% confidence interval [CI], 3.75-4.56), renal replacement therapy utilization rates (odds ratio [OR] 3.19; 95% confidence interval [CI], 2.56-3.98), hospital length of stay (p value 0.00) and total hospitalization charges (p value 0.00).

CONCLUSIONS: In our analysis, we concluded that among hospitalized COVID-19 patients with concomitant rhabdomyolysis, there is a higher risk for in-hospital mortality as well as complications including the development of AKI requiring RRT leading to a longer hospital length of stay as well as higher hospitalization charges. This concurs with previous studies suggesting that COVID-19 increases the risk for the development of rhabdomyolysis and AKI possibly through direct cytopathic effects and cytokine storm leading to muscle injury and subsequent renal impairment by means of the nephrotoxic effects of the byproducts of muscle destruction. With this, attention should be focused on mitigating the effects of rhabdomyolysis among hospitalized COVID-19 patients by employing strategies for early recognition and treatment in order to prevent further complications and poor outcomes.

OUTCOMES OF FEBRILE NEUTROPENIA IN CIRRHOTIC VERSUS NONCIRRHOTIC PATIENTS

Reem Dimachkie¹; Zakaria Alameddine¹; Ahmad Mustafa¹; Mira Alsheikh¹; Chapman Wei¹; John Afif¹; Suzanne El-Sayegh¹; Liliane Deeb²

¹Internal Medicine, Staten Island University Hospital, Staten Island, NY; ²Gastroenterology, Staten Island University Hospital, Staten Island, NY. (Control ID #3875138)

BACKGROUND: Liver cirrhosis is associated with high mortality and morbidity due to the resulting portal hypertension. However, it is also well known that patients with liver cirrhosis are at increased risk for serious infections. Febrile neutropenia is defined as fever in a patient with an absolute neutrophil count <1500 cells/microliter. The impact of febrile neutropenia in cirrhotic patients is not well studied. The aim of this study is to highlight the outcome of febrile neutropenia in cirrhotic versus noncirrhotic patients.

METHODS: National Inpatient Sample (NIS) Database 2016-2018 was used to sample individuals presenting with febrile neutropenia, and baseline demographics and comorbidities were collected using ICD-10-DM codes. Patients with missing data were excluded. Individuals were stratified into two cohorts based on the presence or absence of liver cirrhosis. Logistic regression analysis was performed to analyze the outcomes between the two groups.

RESULTS: Out of 116,142 patients admitted with febrile neutropenia, 1418 had cirrhosis. Baseline characteristics and outcomes are summarized in the Table 1. On logistic regression analysis, cirrhotic patients with febrile neutropenia had higher mortality (adjusted OR: 1.3 [1.1-1.6]; p=0.013), gastrointestinal bleed (adjusted OR: 3.8 [3.2-4.6]; p<0.001), sepsis (adjusted OR: 1.2 [1.02-1.40]; p=0.02) and acute renal failure (adjusted OR: 1.4 [1.2-1.6]; p<0.001).

CONCLUSIONS: This study highlights that the presence of liver cirrhosis in patients with febrile neutropenia was associated with higher mortality, gastrointestinal bleed, sepsis, and renal failure. Thus, special care should be taken when managing patients with febrile neutropenia with an underlying diagnosis of cirrhosis. Further studies are needed to establish management strategies for this vulnerable population.

PNEUMOCOCCAL URINARY ANTIGEN TESTING IN PATIENTS WITH SEVERE COMMUNITY-ACQUIRED PNEUMONIA: AN OVERLAP PROPENSITY SCORE-WEIGHTED ANALYSIS

Priscilla Kim^2,1; Michael B. Rothberg⁴; Amy S. Nowacki³; David Gugliotti¹; Abhishek Deshpande¹

¹Medicine, Cleveland Clinic, Cleveland, OH; ²Education, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; ³Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; ⁴Internal Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #3871788)

BACKGROUND: Pneumococcal urinary antigen tests (pUATs) facilitate early diagnosis of pneumococcal pneumonia, enabling clinicians to administer targeted therapy and improve antimicrobial stewardship. Current ATS/IDSA guidelines make a weak recommendation to perform pUAT only in patients with severe community-acquired pneumonia (CAP), but few studies have investigated this association. Our objective was to evaluate the association between severe CAP and pUAT positivity.

METHODS: We conducted a retrospective cohort study of adults (>18 years) who were hospitalized with CAP to the Cleveland Clinic Health System from 2010-2019 and were tested with pUAT. Patients were classified by CAP severity (severe vs. non-severe) using three definitions for severe CAP: a CURB-65 score of ≥3, pneumonia severity index (PSI) risk class IV/V, or need for vasopressors, invasive mechanical ventilation, or ICU admission in the first 48 hours of hospitalization (“proxy” definition). Because patients with severe CAP are more likely to have underlying comorbidities, overlap propensity score weighting was performed to address potential confounding. Three separate analyses were performed using each definition for severe CAP, where the primary predictor was CAP severity, and the primary outcome was a positive pUAT result.

RESULTS: A total of 19,282 patients were admitted with CAP and underwent pUAT. The median (IQR) age was 69.1 (57.4-79.9) years, 49.8% were female, and 176.5% were white. Among all patients who underwent pUAT, 51% had a CURB-65 score of ≥3; 68.6% were in PSI risk class IV/V; and 39.6% required vasopressors, IMV, or ICU admission in first 48 hours of hospitalization. A positive pUAT result was observed in 394 (2%) of patients. Overlap propensity score weighting showed no significant association between severe CAP and pUAT positivity by the CURB-65 definition (adjusted OR, 1.11; 95%CI, 0.89-1.37), PSI definition (adjusted OR, 0.99; 95%CI, 0.88-1.23), or proxy definition (adjusted OR, 0.90; 95%CI, 0.72-1.13).

CONCLUSIONS: In this large multi-center sample of patients, severe CAP was not associated with pUAT positivity by any definition for severe CAP. Patients with severe CAP alone may not represent the ideal population for patients who should undergo pUAT. Additional predictors of pUAT positivity should be identified to improve test efficiency.

POST-ACUTE SEQUELAE OF COVID-19 (PASC) AMONG OLDER ADULTS: AN OBSERVATIONAL STUDY

Nancy Haff²; Brandon T. Suehs¹; Richard Sheer¹; Stuart Cowburn¹; Gauri Bhatkhande²; Julie Lauffenburger²; Brian Powers³; Katherine Goodrich³; Niteesh K. Choudhry⁴

¹Humana Healthcare Research, Humana, Louisville, KY; ²Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; ³Humana Inc, Louisville, KY; ⁴Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School, Boston, MA. (Control ID #3873726)

BACKGROUND: Many individuals experience prolonged or new symptoms weeks to months after acute infection with COVID, a syndrome now known as post-acute sequelae of COVID (PASC). There is significant heterogeneity in findings that describe the prevalence and trajectory of PASC, likely due to different research methodologies used and populations studied. Additionally, less is known about the prevalence of PASC in older adults.

METHODS: We conducted a cohort study of individuals age ≥65 enrolled in Medicare Advantage plans offered by a large US insurer. We used medical claims, supplemented by COVID test result data, to construct separate cohorts of ambulatory and hospitalized cases of COVID between Apr 1, 2020 and Jun 30, 2021. These case sets were each propensity-score (PS) matched to two comparison groups: 1) contemporary controls with a non-COVID ambulatory visit or negative COVID test, or a non-COVID hospitalization, and 2) ambulatory or hospitalized influenza cases between Jan 1, 2015 and Dec 31, 2018. Patients were followed until disenrollment, death, or end of the study period (Aug 31, 2021). A set of conditions that could represent PASC were identified from existing reports and clinical knowledge and mapped to ICD-9 and -10 diagnosis codes. Conditions observed beginning 28 days after cohort entry, with no codes for the condition prior to cohort entry, were counted as potential post-acute sequelae. In additional analyses we required the presence of two codes to count a condition. Incidence rates were calculated for each potential PASC condition and used to generate incidence rate differences (IRDs) between matched groups.

RESULTS: We identified 107,189 ambulatory and 50,143 hospitalized COVID cases resulting in 88,554 ambulatory and 30,210 hospitalized contemporary non-COVID matched pairs and 28,497 ambulatory and 8,343 hospitalized historical influenza matched pairs. The most common condition was dyspnea, with a cumulative incidence of 10.1% (95% CI 9.8-10.4%) among ambulatory and 20.8% (95% CI 19.9-21.6%) among hospitalized patients in the COVID cohort matched to contemporary non-COVID controls. Fourteen conditions were consistently more common among COVID cases regardless of comparison: dyspnea, fatigue/malaise, diabetic ketoacidosis/hyperglycemia, deep vein thrombosis/pulmonary embolism, pulmonary fibrosis/interstitial lung disease, malnutrition, alopecia, coagulopathy, sleep dysregulation, myopathy, post- traumatic stress disorder (PTSD), thrombocytopenia, olfactory/gustatory dysfunction, and pulmonary function abnormalities.

CONCLUSIONS: In this analysis of older adults with COVID and their PS-matched controls, 14 conditions were consistently associated with COVID, regardless of the comparison group, and likely represent true PASC. Many of these conditions have been observed in prior studies of PASC and are supported by mechanistic data. These results can help inform the care of older adults with PASC and guide further studies of mechanisms and treatments.

PREVALENCE OF POORLY CONTROLLED CHRONIC DISEASES IN RECENTLY HOSPITALIZED PATIENTS

Alexander Chaitoff¹; Stephanie Mueller²; Nancy Haff²; Julie Lauffenburger³; Niteesh K. Choudhry⁴

¹Medicine, Brigham and Women's Hospital, Boston, MA; ²Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA; ³Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; ⁴Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School, Boston, MA. (Control ID #3875506)

BACKGROUND: Evidence suggests that significantly disruptive health events, such as hospitalizations, may increase patients’ receptiveness to interventions that lead to healthier lifestyle choices and medication adherence. Opportunities may exist to harness hospitalizations to address a broad array of chronic diseases, but the scope of those opportunities is not well-described. This study aimed to characterize the prevalence of poorly controlled hypertension, hyperlipidemia, and diabetes among recently hospitalized community- dwelling adults.

METHODS: We conducted an analysis using the National Health and Nutrition Examination Survey (NHANES), which is a survey that samples non-institutionalized civilians to provide nationally representative estimates. We included adults enrolled in NHANES between January 2017 to March 2020 who reported an overnight hospitalization in the preceding year. Respondents were considered to have a potential opportunity for a chronic disease intervention if they had poorly controlled hypertension, hyperlipidemia, or diabetes at the time of being surveyed. Poorly controlled chronic diseases were defined as: 1) hypertension: self-reported diagnosis of hypertension and a blood pressure reading >140/90 mmHg during the exam portion of the survey, and on 1 or more anti-hypertensive medications; 2) hyperlipidemia: aged 40-70, ASCVD risk score >7.5%, and not on lipid lowering therapy; and 3) diabetes: hemoglobin a1c>7% and age <65 years. Frequencies and counts were used to describe the combined population of patients with a potential opportunity for chronic disease intervention during hospitalization. Chi-square and t-tests were used to assess for respondent characteristics associated with a potential opportunity for chronic disease intervention. Percentages are weighted while counts are unweighted unless otherwise specified.

RESULTS: Of all surveyed adults, 935 had a hospitalization in the previous year. Among those with a hospitalization, 23.6% (95%CI: 20.5%-26.8%, n=282), corresponding to a weighted count of 5,563,810 individuals (95%CI: 4,394,885-6,732,735), had poorly controlled hypertension, hyperlipidemia, or diabetes at the time of their survey and therefore could be potentially eligible for intervention. Those who were potentially eligible for intervention were on average older (63.6 vs 51.6 years, p<0.001), more likely to be male (29.1% versus 20.1%, p=0.003), and more likely to not have a high school degree (18.4% versus 11.8%, P<0.001), but there were no differences by race/ethnicity or family income-to-poverty ratio (both p>0.05)

CONCLUSIONS: We found a high prevalence of poorly controlled chronic diseases in the year following discharge. This supports a potential opportunity for hospital-based chronic disease management efforts, especially non-pharmacologic ones, which should be further studied using data sources that can clarify temporal associations between disease control and hospitalization.

SYMPTOMS CONSISTENT WITH POST-ACUTE SEQUELAE OF COVID (PASC) IN TWO HEALTH SYSTEMS

Ingrid A. Binswanger¹; Jason M. Glanz¹; Jennifer Barrow¹; Courtney Kraus¹; Komal J. Narwaney¹; Katia J. Bruxvoort³; Jason A. Lyons¹; Jessica A. Lam²; Darryl Palmer-Toy²

¹Institute for Health Research, Kaiser Permanente Colorado, Denver, CO; ²Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, CA; ³School of Public Health, The University of Alabama at Birmingham, Birmingham, AL. (Control ID #3875455)

BACKGROUND: The understanding of post-acute sequelae of COVID (PASC) is rapidly evolving. The objectives of this study were to (1) estimate the prevalence of symptoms consistent with PASC, including persistent, recurrent, and new symptoms in a population-based sample, and (2) among people with a history of documented COVID, assess the association between SARS-CoV-2 seropositivity and symptoms twelve or more weeks later.

METHODS: We recruited English and Spanish-speaking members ≥18 years old from Kaiser Permanente (KP) Colorado and KP Southern California who had viral and serological (nucleocapsid or spike protein- based) testing as of August 2021. Between October 2021 and April 2022, participants completed an online or mailed survey assessing socio-demographics, prior COVID infection and testing, and potential PASC symptoms using PROMIS items for physical health, mental health, cognitive function, anxiety, and depression. Survey results were linked to electronic health record data on lab results. We conducted descriptive analyses and generated T-scores standardized to the (pre-COVID) US population (T-score 50.0; higher score=worse function) by prior antibody and viral testing results (+/+, +/-, -/+, -/-). T-scores were adjusted by study site, age, race, ethnicity, and time since the serology test date and survey date.

RESULTS: Across the two regions, 3947 members consented, completed the survey, and were included in the analysis (25% response rate). The mean respondent age was 52 years old (SD 15.6), the majority were female (68%), and 28% identified as Hispanic. Among participants who reported having had COVID, 49.8% reported having at least one or more symptoms that lasted over 12 weeks, with the most common being fatigue (56.6%), brain fog or focus issues (48.3%), and shortness of breath (41.6%). Fifty percent of respondents who reported having had COVID reported persistent symptoms, 29% recurrent, and 23% new symptoms after the initial infection. After a median of 15 months after serology testing, self-reported physical health and cognitive function were significantly worse among people with prior infection and positive serology (+Ab/+PCR) compared to those who did not have prior infection and had negative serology (-Ab/-PCR) but overall close to the US population norms pre-COVID. There were no significant differences in mental health, anxiety, and depression observed.

CONCLUSIONS: High proportions of patients reported they had persistent, recurrent, and new symptoms after COVID. After a median of 15 months, differences between groups based on prior viral and serologic testing demonstrated small but significant differences in physical and cognitive health, but no differences in several domains of mental health and overall values similar to the general population pre-COVID.

THE ASSOCIATION BETWEEN ANTIBODIES TO SARS-COV-2 AND REINFECTION IN COLORADO A PROSPECTIVE COHORT STUDY

Ingrid A. Binswanger, Jennifer Barrow, Komal J. Narwaney, Courtney Kraus, Jo Ann Shoup, Claudia Steiner, Jason M. Glanz

Institute for Health Research, Kaiser Permanente, Colorado, Denver, CO. (Control ID

#3872604)

BACKGROUND: In April 2020, antibody tests to detect SARS-CoV-2 immunoglobulins were approved under FDA Emergency Use Authorization. However, the association between antibody test results and SARS-CoV-2 reinfection risk in community-based samples and spanning the Omicron phase has not been well quantified, and the CDC cautions against using the tests to influence vaccine decisions or other preventive behaviors. Within a population-based cohort of Kaiser Permanente Colorado members, we conducted a nested case-control study to examine the association between antibody test results and the incidence of reinfection.

METHODS: Participants were recruited between June 2020 and March 2021, surveyed, and encouraged to complete viral and antibody laboratory testing every 28 days for 10 months. Participants with reinfections (positive SARS-CoV-2 viral test ≥90 days after the first positive viral test) were matched to control participants without reinfections by age, sex, first date of a positive viral test, last antibody test date, and antibody test type (nucleocapsid or one of 3 spike tests). Using conditional logistic regression, we compared the odds of a seronegative antibody test result between case and control participants, adjusted for demographic and clinical covariates. To account for vaccination status, we used an interaction term to assess the association between seronegativity and reinfection by the timing of antibody test relative to vaccination: not vaccinated, antibody test on the same date/after the first vaccine, and antibody test before the first vaccine.

RESULTS: The cohort (n=4235) included 2033 participants with ≥1 positive viral test, 120 of whom had a reinfection (0.52/100 person-months). Among 80 case patients who could be matched, the last antibody test was negative in 12 cases (15.0%) whereas the last antibody test was negative in 77 of 1043 (7.5%) of control participants. Seronegativity (aOR, 2.73; CI, 1.34-5.54), Hispanic ethnicity (aOR. 1.86; CI, 1.13-3.08), and household size (aOR, 1.14; CI, 1.01-1.28 for each additional household member) were associated with reinfection. When stratifying by vaccination status, the association between seronegativity and reinfection was stronger among those who were not vaccinated (aOR 4.19; 95% CI 1.28, 13.76) and among who had a vaccination on the same day or before the antibody test (aOR 6.30; 95% CI 1.66, 23.94) than among those who were vaccinated after the antibody test (aOR 1.08; 95% CI 0.21, 5.48).

CONCLUSIONS: Seronegative antibody status was associated with a greater than two-fold risk of COVID reinfection, suggesting serological testing may be useful to assess the risk of reinfection. Given the morbidity and mortality associated with reinfection, leveraging serology to support preventive efforts should be considered.

THE EFFECT OF RESTRICTIVE RED BLOOD CELL TRANSFUSION ON COGNITIVE FUNCTION IN HOSPITALIZED PATIENTS

Stephanie Cardenas¹; Christian Carrier¹; David O. Meltzer²; Micah T. Prochaska²

¹Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; ²Medicine, The University of Chicago, Chicago, IL. (Control ID #3876664)

BACKGROUND: Anemia is a risk factor for cognitive impairment as a result of the reduced delivery of oxygen to the brain from low hemoglobin (Hb) levels. In ambulatory patients even mild anemia has been associated with reductions in patients’ cognitive function (CF). However, in hospitalized patients it is standard of care to maintain Hb levels far lower, around 7g/dL, as a result of restrictive transfusion practices. This raises the possibility that the lower Hb levels tolerated in hospitalized patients may have a deleterious effect on patients’ CF. This is important because reduced CF negatively effects patients’ self-efficacy and functioning, can increase the risk of delirium and length of stay, and may ultimately impact discharge destination and recovery after hospital discharge. While transfusion trials in hospitalized patients have shown no difference in outcomes between restrictive vs. liberal transfusion thresholds, these RCTs did not examine the effect that lower Hb levels may have on patient’s CF. Therefore, the purpose of this study was to test for an association between Hb levels during hospitalization and patient’s CF.

METHODS: Hospitalized general medicine patients at an urban academic medical center with a Hb <10g/dL were approached for an interview. CF was measured using the Short Portable Mental Status Questionnaire (SPMSQ), which has a range from 0-10 with higher scores indicating worse CF. Patients’ Hb values and clinical data were abstracted from hospital administrative databases. Patients with a diagnosis of dementia were excluded from the analysis. Linear regression was used to test the association between CF (SPMSQ) as the dependent variable and patients’ nadir Hb and age as the predictor variables of interest, controlling for race, gender, Charlson Comorbidity Index, a diagnosis of depression, and receipt of transfusion. An interaction between patient’s nadir Hb and age was also included to test for changes.

RESULTS: A total of 4,418 patients had a Hb<10g/dL and completed the SPMSQ questionnaire. The average age was 56, 58% were female, and 74% were Black. In the regression models, lower nadir Hb levels were associated with reduced cognition (higher SPMSQ) (β=-0.22, p<0.01) overall. Additionally, the effect of lower Hb level on reduced cognition was greater within each decreasing Hb strata compared to patients whose Hb was between 9-10g/dL during their hospitalization (Hb: 8-9g/dL, β=0.03, p<0.01; Hb: 7-8g/dL, β=0.27, p<0.01; Hb: 6-7g/dL, β=0.55, p<0.01; Hb<6g/dL, β=0.78, p<0.01). The interaction between a patient’s nadir Hb and their age was also associated with significant reductions in CF (β=-0.004, p<0.01).

CONCLUSIONS: Lower Hb levels during hospitalization, particularly the Hb levels tolerated as a result of restrictive transfusion policies, are associated with significant decreases in CF. Clinicians should be aware of and attentive to the effect of anemia on CF, and should consider screening for and monitoring high risk patients with anemia for decreased CF.

TRENDS OF VITAMIN C IN ADULT PATIENTS

Hannah Hoang, Isabella Kelly, Adil Mohyudin, Pradeep Bathina

Internal Medicine, The University of Mississippi Medical Center, Jackson, MS. (Control ID #3871958)

BACKGROUND: Vitamin C deficiency (VCD), rare in developed countries, still affects patients, making it an important diagnosis to recognize. Manifestations of VCD cause collagen synthesis impairment due to vitamin C-dependent hydroxylases which form stable triple helices in collagen. Deficiency leads to fragile connective tissue which presents as mucosal bleeding, bruising, impaired healing, anemia, and poor immune response. VCD occur in people on diets deficient in fruits and vegetables. Diagnosis is largely based on history and physical examination. Serum testing of the vitamin C (<0.4 mg/dL) is consistent with deficiency. This study will evaluate the trends of vitamin C levels at UMMC.

METHODS: Cross Sectional Observational study was performed on adult patients (age >18) who received a Serum Vitamin C level at UMMC from January 1, 2013 to December, 2021. Patient Cohort Explorer was used to obtain de-identified patient data from EPIC. We obtained the data for patients on whom the serum Vitamin C level was ordered and used Microsoft Excel, Stata 17.0 for calculations.

RESULTS: Serum Vitamin C level was ordered 439 times on 371 patients. 262 (59.68%) tests were done in females and 177 (40.32%) in males. 187 (42.69%) tests were done in African Americans and 238 (54.34%) tests in Caucasians.

Of the 439 tests, 199 tests were abnormal. 196 (44.65%) came back low with level <0.4 mg/dl, the lower cut off value. Only 3 tests (0.68%) came back high with level >2 mg/dl, the maximum cut off value. Of the 196 tests that came back low, 89 (20.27%) tests came back with level <0.1 mg/dl, the minimum detectable level 106 of 262 tests (40.45%) in females resulted low while 90 of 177 tests (50.84%) resulted low in males. For African Americans 86 of 187 tests (45.98%) resulted low. In Caucasians 105 of 238 tests (44.11%) resulted low 140 tests were done on 128 patients while admitted in the hospital, while the rest were done as outpatient. Of the 140 tests done as inpatient, 72 tests were abnormal. 70 (50%) tests came back low with level <0.4 mg/dl. 2 tests (1.48%) came back high with level >2 mg/dl. Of the 70 tests that came back low 35 (25%) tests came back with level <0.1 mg/dl, the minimum detectable level.

Alcoholic cirrhosis with Ascites is a commonly listed primary diagnosis at 2.73%.

CONCLUSIONS: This is the largest known data sample at a university medical center. One in two serum Vitamin C sample levels was lower than the minimum cut off value, and one in four samples had undetectable levels. Though patients may not reflect the deficiency in the general population, the prevalence of VCD in tested patients was alarming. More studies are needed to study risk factors of VCD especially with chronic wounds.

YIELD OF BIDIRECTIONAL ENDOSCOPY FOR ASYMPTOMATIC IRON DEFICIENCY ANEMIA IN AN INNER CITY POPULATION

Arielle Greenberg¹; Lawrence J. Brandt²

¹Internal Medicine, Montefiore Medical Center, Bronx, NY; ²Montefiore Medical Center, Bronx, NY. (Control ID #3869811)

BACKGROUND: Internists are often faced with evaluating patients with iron deficiency anemia (IDA) and the decision to refer to Gastroenterology (GI) for endoscopic evaluation of occult bleeding. Current GI national guidelines recommend bidirectional endoscopy (BDE) for the evaluation of IDA. The prevalence of anemia is 1.8 billion people worldwide and is 3 times more common in African Americans than Whites. Iron deficiency is the most common cause of anemia. Our institution is a Mid-Atlantic academic medical center located in an inner-city. Among our population, greater than 43% of residents are Black and greater than 54% are Hispanic. The diagnostic yield of BDE in IDA without gross GI bleeding in an inner-city patient population like ours is unknown.

METHODS: The study was conducted retrospectively with IRB approval. Inclusion criteria included adults with IDA based on hemoglobin, ferritin, and percent saturation. Patients with frank GI bleeding were excluded. Data from 2020-2021 were reviewed and patients were grouped into 4 source categories: (1) likely/definitive source of IDA identified; (2) possible source identified; (3) no source identified; and (X) source identified by pathology alone with no endoscopic lesions.

RESULTS: 102 patients (35.3% Black, 42.2% Hispanic) underwent BDE. 42.2% of patients were in source categories 1 and 2 (definitive or possible source found). Among esophagogastroduodenoscopies (EGDs) 27.5%, 5.9%, 53.9%, and 12.7% of patients were in source categories 1, 2, 3, and X respectively. Among colonoscopies 8.8%, 0%, 91.2%, and 0% of patients were in categories 1, 2, 3, and X respectively. No source categories had significantly different hemoglobin, ferritin, or percent saturation values from our overall sample. Sources identified with EGD included erosive gastropathy, duodenal erosions, polyps, angiodysplasias, atrophic gastritis, and malignancy. Patients in category X had biopsy proven H. pylori, which can impair iron absorption. Sources of IDA identified with colonoscopy included angiodysplasias and large polyps.

CONCLUSIONS: In our inner-city population, 49% had a possible or definitive GI cause for their IDA. 46.1% had sources found on EGD and 8.8% on colonoscopy. There are limitations to this study. Our patients often underwent colonoscopy before EGD. Some patients with sources of IDA on colonoscopy might not have gone on to EGD or been included in our sample. Including such patients would have resulted in a higher yield. 6 patients had sources found on both EGD and colonoscopy, so despite findings on unidirectional endoscopy, BDE should be completed for a complete evaluation.

Scientific Abstract - Adolescent Medicine and Transitioning to Adult Care

IMPROVING THE TRANSITIONAL CARE PROCESS FOR ADOLESCENT PATIENTS WITHIN THE PRIMARY CARE SETTING

Esha M. Kapania, Gianna Bosco, Suwon Nopachai

Medicine/Pediatrics, Rush University Medical Center, Chicago, IL. (Control ID #3857032)

BACKGROUND: The transition from pediatric to adult-oriented care can be a challenging time for both patients and providers. While it is well recognized that a successful transition is critical for improving health outcomes and costs, there continues to be limited infrastructure and education for healthcare providers to aid with this process. The objective of this study was to identify what providers felt are barriers to providing successful transitions of care and implement subsequent interventions to improve the process. Our hypothesis is that by increasing education and support around transitions of care, that providers would feel more empowered and comfortable conducting this process. Our goal was that through this process, there would be an increase in the number of providers who address transitional care readiness and participate in coordinating care between pediatric and adult practices.

METHODS: We sent out a survey to the pediatric department at Rush University Medical Center assessing their current level of comfort with healthcare transition (HCT) and identifying potential barriers to successfully transitioning a patient to adult providers. Based on the results, the following four interventions were completed: education sessions were held with providers regarding key aspects of HCT, a formal list of adult sub-specialists was compiled and distributed to pediatric providers, an educational packet was created for patients, and the EMR template for adolescent healthcare visits was revised to prompt providers to discuss age appropriate aspects of transitions of care. After 6 months with the above interventions, the same survey was sent back out to providers to assess if the interventions impacted provider comfort level with HCT. A Chi-squared test was used to conduct statistical analysis of the pre-and post intervention data.

RESULTS: The results of the pre and post intervention surveys showed significant improvement in perceived familiarity with the transition of care process, as well as increased comfort level when discussing HCT with patients. Additionally, more providers expressed that they were addressing transitional care readiness with their patients and participating in coordination of care between pediatric and adult practices. There was however, no significant difference noted in the comfort level that providers had working with adolescents with chronic diseases of childhood onset.

CONCLUSIONS: Providing education and support influenced more providers to address transitional care readiness and participate in coordination of care between pediatric and adult practices

MASCULINITY AND TOXINS: EXPLORING CONNECTIONS BETWEEN ADOLESCENT MALE GENDER EXPRESSION, SOCIAL NETWORKS, AND ADULT SUBSTANCE USE

Nathaniel J. Glasser¹; Jacob Jameson²; Elizabeth L. Tung¹; Stacy T. Lindau^3,4; Harold A. Pollack^5,6

¹Section of General Internal Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ²Harvard University T H Chan School of Public Health, Boston, MA; ³Ob/Gyn and Geriatics and Palliative Care, University of Chicago, Chicago, IL; ⁴Department of Medicine -- Geriatrics and Palliative Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ⁵University of Chicago Crown School of Social Work, Policy, and Practice, Chicago, IL; ⁶Public Health Sciences, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #3872099)

BACKGROUND: Endorsement of stereotypically male gender identity through behavioral gender expression (GE) is associated with risk-taking behaviors in adolescence and adulthood. We examine associations between adolescent social network characteristics, adolescent-to-adult changes in male GE, and adult substance use.

METHODS: This prospective cohort study uses 1994-95 (Wave I) and 2016-18 (Wave IV) data from the National Longitudinal Study of Adolescent to Adult Health (Add Health). Participants are a nationally representative sample of adolescents (ages 11-18), followed longitudinally to young adulthood (ages 24-32). Associations between GE, social network variables, and substance use are modeled using multivariable regression, adjusting for participant- and neighborhood-level covariates. Primary exposures are population- standardized male GE, calculated in both waves; adolescent friendship network characteristics; and school- standardized adolescent GE. Primary outcomes are self-reported young adult prescription drug misuse, recreational drug use, marijuana use, smoking, and heavy drinking.

RESULTS: 4,882 (48%) of 10,263 males enrolled in Wave I completed both Wave I and IV surveys and were eligible for inclusion. Higher adolescent male GE was associated with greater young adult cigarette use (β=0.10, p<0.05), marijuana use (β=-0.12, p <0.01), and recreational brug use (β=0.11, p<0.05). Adult male GE and adolescent-to-adult increases in male GE were significantly associated with all adult substance use behaviors. Significant adolescent-to-adult changes in GE were predicted by school-standardized GE. Adolescents whose GE scores were above or below their school’s average GE were significantly more likely to change GE between waves in the direction of their school’s average (β=-0.80, p<0.01), relative to the overall population of males in each wave.

CONCLUSIONS: Adolescent GE, adult GE, and increased adolescent-to-adult GE are associated with greater adult substance misuse among men. An adolescent male’s positioning in apposition to his high school social milieu is associated with change in GE over time, with marked regression to the school mean. Interventions that influence adolescent group gender norms may be valuable and unexplored pathways to reduce substance misuse across the life course.

REPRESENTATION OF GIRLS IN ATTENTION-DEFICIT HYPERACTIVITY DISORDER RESEARCH

Mary Rozelle¹; Bradley Peterson²; Joey Trampush³; Maria Bolshakova¹; Aneesa Motala⁴; Susanne Hempel¹

¹Population and Health Sciences, University of Southern California, Los Angeles, CA; ²Psychiatry, Children's Hospital Los Angeles Division of Adolescent and Young Adult Medicine, Los Angeles, CA; ³Psychiatry and Behavioral Sciences, Keck Hospital of USC, Los Angeles, CA; ⁴Keck Hospital of USC, Los Angeles, CA. (Control ID #3834322)

BACKGROUND: Girls are underrepresented in the diagnosis and treatment of attention-deficit hyperactivity disorder (ADHD). Girls also present ADHD differently than boys in symptoms, functions, and associated comorbidities. The less disruptive behaviors of girls with ADHD may account for lower diagnostic rates and referrals. Impulsivity and risk-taking behaviors place girls at increased risk of self-harm, early- sexual debut, perceived sexual exhibitionism, and vulnerability to stigmatized behaviors. We studied the extent to which ADHD intervention research studies included girls.

METHODS: The American Academy of Pediatrics nominated an Agency for Quality and Research (AHRQ) evidence report update on ADHD in children and adolescents to support new clinical guidance, addressing multiple questions regarding the diagnosis, treatment (pharmacologic and nonpharmacologic), and monitoring. The review identified 18,055 citations and involved searches in eleven databases. Interventions included medication, behavioral therapy, supplements and others, published since 1980. Two independent reviewers screened publications against prespecified eligibility criteria to identify studies in children and adolescents up to 18 years old diagnosed with ADHD with or without concomitant conditions. From 5,498 full-text publications screened, data were abstracted on the proportion of girls from 263 identified intervention studies. We evaluated data using descriptive analysis and random-effects meta-analysis.

RESULTS: The number of girls studied overall was small, and several identified studies were conducted exclusively on boys. The percentage of girls in the studies ranged from 0% to 64%. Most studies included less than a third of girls (median 24.3%, IQR 17.6-30.0), a pooled result of 23.7% girls (95% CI 22.5%, 24.9%). Compared to the population's prevalence of ADHD, girls in the research studies were underrepresented.

CONCLUSIONS: Intervention research in ADHD predominately includes boys. Interventions do not target girls, and the small proportion of girls hinders analyses of potential differential treatment effects for boys and girls. Clinicians should consider interventions that meet the interests and needs of girls diagnosed with ADHD, as their psychosocial needs differ from boys. However, current research practice does not support high-quality evidence about the appropriateness of interventions for girls.

THE CLINICAL AND ECONOMIC IMPACT OF CHILD AND ADOLESCENT FIREARM INJURIES ON SURVIVORS AND FAMILY MEMBERS

Zirui Song^1,2; Jose Zubizarreta^1,3; Mia Giuriato¹; Katherine Koh^4,5; Chana A. Sacks²

¹Health Care Policy, Harvard Medical School, Boston, MA; ²Massachusetts General Hospital Department of Medicine, Boston, MA; ³Statistics, Harvard University, Cambridge, MA; ⁴Massachusetts General Hospital Department of Psychiatry, Boston, MA; ⁵Boston Health Care for the Homeless Program, Boston, MA. (Control ID #3875581)

BACKGROUND: More US children and adolescents today die from guns than any other cause. Yet often forgotten is many more of their peers who are shot but survive. Even larger is the number of family members —parents and siblings—of these victims. To date, evidence on the health and economic impact of firearm injuries on children/adolescents and their family members remains scant. Existing literature is limited by small samples, lack of claims data, or lack of control groups. Indeed, most studies on guns exclude children.

METHODS: Using 2007-2020 Marketscan commercial claims, we defined 2 exposed groups: (1) people under age 20 with a firearm injury, and (2) their family members. Each exposed subject was matched to 5 control subjects without replacement using risk set (cardinality) matching—exact matched on year, month, sex, plan attributes, and MSA, while balanced on mean age and DxCG risk score.

We used an event study, difference-in-differences model to examine changes in spending, utilization, and morbidity from 1 year before through 1 year after firearm injury, with covariate adjustment to improve precision.

Sensitivity analyses used randomization tests and inverted the permutational t-test on the effect estimates. We tested sensitivity to unmeasured confounding using Rosenbaum bounds to calculate how large a confounder would need to be to explain away the effects.

We further conducted subgroup analyses by the type and severity of firearm injury, as well as the subgroup of family members of children/adolescents whose firearm injuries were fatal.

RESULTS: We identified 2,002 child/adolescent survivors and 9,931 matched controls, along with 6,040 family members of survivors matched to 29,963 controls, balanced on age, sex, risk score, plan attributes, and MSA (standardized mean differences 0 to 0.02).

Survivors had an increase in medical spending of $2,661 per survivor per month relative to control in year 1—a 6.2-fold increase from baseline (p<0.001). They also experienced a 112% increase in pain syndromes, 59% increase in psychiatric disorders, and 96% increase in substance use disorders relative to control (p<0.001). Family members of survivors had a 13.5% increase in psychiatric disorders in year 1 (p=0.008) with a 10.8% increase in ER visits (p=0.04) and 4.3% increase in office visits (p=0.007), relative to control. Family members of children/adolescents killed by guns experienced a larger 3.3-fold increase in psychiatric disorders and 72% increase in psychiatric medication days relative to control (p<0.001).

Intentional and more severe (ICU) firearm injuries drove the results. Estimates were robust to sensitivity analyses.

CONCLUSIONS: Firearm injuries in child and adolescent survivors increased their mental and physical disease burden as well as societal spending on their care. Family members also saw increased psychiatric illness, especially those of children/adolescents killed by guns. This illustrates the ripple effects of gun violence from young victims, through families, and to society.

Scientific Abstract - Career Development, Professionalism, and Wellness

APPLYING A POSITIVE DEVIANCE APPROACH: ANALYZING AAMC STANDPOINT SURVEY DATA TO ADDRESS FACULTY BURNOUT THROUGH SHARED ORGANIZATIONAL LEARNING

Robert G. Badgett¹; Jon A. Courand²; Jennifer L. Hartwell³; Catherine F. Pipas⁴; Valerie Dandar⁵

¹Internal Medicine, University of Kansas School of Medicine Wichita, Wichita, KS; ²Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ³Surgery, University of Kansas School of Medicine, Kansas City, KS; ⁴Community & Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH; ⁵Medical School Operations, Association of American Medical Colleges, Washington, DC. (Control ID #3875072)

BACKGROUND: Workforce burnout and engagement are associated with organizational performance outcomes. The AAMC StandPoint Engagement Survey uniquely allows the measurement of differences (or heterogeneity) of burnout rates of academic departments within and across schools. If heterogeneity is found, then appreciative inquiry or positive deviance assessment of “bright spots” can guide organizational improvement efforts and ultimately, well-being and engagement outcomes. The importance of the organization was shown by Shanafelt’s finding that 47% and 11% of the variation in physician satisfaction and burnout, respectively, at an organization can be explained by the leadership score of their immediate supervisor.

METHODS: This study measures heterogeneity in rates of burnout across departments and schools and factors associated with low departmental rates of burnout. We studied AAMC StandPoint data from 22 academic medical centers (AMCs) surveyed from 2020-2022, which included 359 unique academic units containing 27 disciplines. Burnout was defined with the single-item Mini-Z.

RESULTS: 54% of full and part-time faculty completed the survey (11,044/20,584). Of those, 9,873 (2867 (29%) reported being burned out (estimated Maslach rate: 42%) and 81% reported dedication. Three of the 22 AMCs had lower-quartile burnout and upper-quartile dedication. Regarding burnout, there was "substantial" heterogeneity (I² = 75%; range 18% to 41%) across AMCs and "moderate" heterogeneity (I² = 48%; range 18% to 38%) across disciplines.

Regarding the variation in rates of burnout across departments, 15% was explained by the rates of burnout in the AMC and discipline (10% and 5%, respectively).

The variance in burnout scores within individuals was significantly explained by the mean burnout score in the respondent's department (R² = 6%) with no additional explanation provided by the medical center or discipline. After accounting for the department, identifying as a woman (R2 = 2%) and junior rank (R² < 1%) were significant, albeit lesser risk factors.

As an example, within an AMC selected for moderate heterogeneity (I² = 32%) in rates of burnout across departments, the strongest predictor of burnout was a lack of a sense of accomplishment (R² = 10%), followed by lack of a sense of autonomy (R² = 5%) and sense of belonging in a department (R² = 4%).

CONCLUSIONS: There is heterogeneity in the rates of burnout across organizations and disciplines. The strongest predictor of burnout in the individual is the mean burnout score in their department. The strongest predictor of burnout in a department was rates of burnout in the AMC, more than the discipline. Thus, we conclude that “local factors” dominate in driving burnout and should be the focus of proposed interventions.

The finding of heterogeneity in burnout rates can guide improvement via a positive deviance strategy. We invite schools to participate in this AAMC project.

A QUALITATIVE STUDY OF PROFESSIONAL IDENTITY FORMATION AMONG FEMALE INTERNAL MEDICINE TRAINEES

Samantha J. Cheng¹; Scheherazade Elkeshk³; Tamara Goldberg²

¹Neurology, Montefiore Medical Center, Bronx, NY; ²Internal Medicine, Mount Sinai Morningside Hospital, New York, NY; ³Psychiatry, Hackensack Meridian Hackensack University Medical Center, Hackensack, NJ. (Control ID #3873624)

BACKGROUND: Postgraduate medical training represents a crucial period in professional identity formation (PIF) for physician trainees. The ease of transition from medical student to physician can be challenging, particularly for those with pre-existing identities that have historically been marginalized within the profession. This study seeks to understand how gender informs the professional identity formation of female internal medicine residents over the course of residency training.

METHODS: Using a qualitative approach based in grounded theory framework, we pursued a nuanced understanding of the adaptive process of PIF among internal medicine trainees. All self-identified females at a single internal medicine residency program in New York City were invited via email to participate in a focus group session. Using a semi-structured moderator guide, PGY-specific focus groups were conducted among 11 total participants in December 2021. Focus groups were transcribed, and an iterative 3-phase coding process was employed to identify central themes for each focus group.

RESULTS: Based on focus-group dialogue, PIF for female resident participants was a 3-phase process impacted by peer support and mentorship. PGY-1 participants described “identity dissonance,” which was characterized by frequent tensions between personal ideals of inhabiting the physician role and the reality of how they are treated by others and what is expected of them. They expended much time cognitively processing dismissive and negative interactions, which impacted their professional confidence. PGY-2 women described “playing the role,” a performative trial-and-error approach towards internalizing their role and responsibility as leaders. PGY-2 participants were attuned to how they were treated compared to male peers, and were conscientious to provide support to other women. By PGY-3 year, participants had learned to “inhabit the role,” demonstrating internalization of their professional competence, but increased clarity and frustration towards gender power dynamics. Peer support and mentorship bolstered their confidence, encouraging them to confront biases.

CONCLUSIONS: Among female internal medicine residents at a single institution, professional identity formation encompasses a 3-phase process, aligned with postgraduate year, which is bolstered by peer support and mentorship. By elucidating this process, we hope educators and program directors can better tailor strategies to create inclusive learning environments for their trainees that support PIF.

A SYSTEMATIC REVIEW AND META-ANALYSIS OF GENDER DISPARITY IN ACADEMIC MEDICINE PROMOTION

Elizabeth Marhoffer^2,1; Samer Ein Alshaeba^2,1; Alyssa Grimshaw⁴; Jurgen Holleck^2,1; Benjamin Rudikoff¹; Lori Bastian^3,1; Craig Gunderson^2,1

¹VA-Connecticut, West Haven, CT; ²Internal Medicine, Yale School of Medicine, New Haven, CT; ³Internal Medicine, Yale University School of Medicine, West Haven, CT; ⁴Cushing/Whitney Medical Library, Yale University, New Haven, CT. (Control ID #3873101)

BACKGROUND: It is well established that there is a persistent gender gap in promotion in academic medicine despite an equal number of male and female medical students for the past 20 years. Possible mediators of this gender gap include differences between men and women in years on faculty, measures of productivity such as number of publications and grants, leadership positions and direct gender bias. We performed a systematic review of studies that report rates of promotion to full professor between men and women adjusted for potential mediators.

METHODS: A systematic search of Academic Search Premier, Business Source Complete, Cochrane Library, ERIC, Google Scholar, Ovid Embase, Ovid MEDLINE, PubMed Scopus, and Web of Science Core Collection was conducted from inception through August 18, 2022. Gender was treated as binary given the limitations of the literature. All studies were included that reported the proportion of faculty who were full professors by gender. The primary outcome was adjusted odds ratio for promotion to full professor stratified by area of medicine (Internal Medicine, Surgery, and other). Risk of bias was assessed using the Risk of Bias in Non-randomized Studies of Exposures (ROBINS-E) tool.

RESULTS: Three hundred and twelve studies met inclusion criteria. The unadjusted odds ratio for promotion to full professor was 0.38 (95% CI, 0.35-0.40). Fourteen studies reported adjusted analyses. The overall adjusted odds ratio for promotion of women to full professor was 0.60 (95% CI, 0.45-0.80). The adjusted odds ratio for promotion to full professor in Surgery was 0.55 (95% CI, 0.34-0.88) and 0.89 (95% CI, 0.65-1.21) for studies limited to Internal Medicine. Overall risk of bias was high due to lack of inclusion of important confounders. Statistical heterogeneity was high (I² = 83%, p<0.001). On meta-regression, 84% of the heterogeneity was due to whether the study was from the United States, which reported lower disparity (OR 0.75, 95% CI, 0.61-0.92).

CONCLUSIONS: Most studies continue to find a lower rate of promotion to full professor of women compared to men, even after adjustment for potential mediators such as number of publications, grants, or years on faculty. Gender disparity is particularly notable in Surgery and in studies from outside the United States. Studies limited to Internal Medicine did not find an adjusted difference in promotion. Our results suggest that differences in promotion are due both to differences in mediators of promotion and possible direct bias. Efforts to improve equity need to address both direct bias as well as the disparity in academic productivity.

A WORKSHOP ON SHAME IN MEDICINE AND ITS EFFECT ON BURNOUT AND HELP- SEEKING BEHAVIORS IN INTERNAL MEDICINE INTERNS

Lauren G. Navitsky, Brielle Spataro. Division of General Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #3875803)

BACKGROUND: Burnout prevalence among US physicians continues to increase with the most recent national data suggesting that nearly two-thirds of doctors are experiencing symptoms of this psychological syndrome. Burnout has wide-ranging consequences on physician health, including impairment, stress, mood disorders, substance use disorders, and suicidal ideation, and therefore, efforts to minimize burnout and promote well-being have been prioritized. This has been operationalized in many ways, and one unique method is by examining shame in medicine. Shame, a self-conscious emotion, is thought to lead to diminished psychological and physical wellness in resident physicians. Bynum et al. found that providing training in the understanding and recognition of the self-conscious emotions and creating safe environments for discussing shame experiences might promote well-being among learners. However, this study did not assess for behavioral change. Our study evaluates whether attendance at a one-time workshop on shame in medicine leads to differences in burnout scores and help-seeking behaviors in internal medicine (IM) interns.

METHODS: Based on prior work by Bynum et al., we developed a three-part workshop on shame in medicine. The workshop included a didactic on the self-conscious emotions, a storytelling session during which IM residents and faculty shared their own shame experiences, and faculty-led small group discussions. At a single academic institution, half of the incoming IM interns were randomized to attend the workshop during intern orientation. All interns were invited to complete a survey assessing burnout scores and help- seeking behaviors at orientation and again at the end of the year. A single item was used to measure burnout on a 5-point Likert scale where higher scores indicated more severe burnout. Interns were asked whether or not they had reached out to peers, mentors, family members/friends, and therapists in the last six months. We compared burnout scores using a two-tailed t-test and help-seeking behaviors using chi-squared tests.

RESULTS: Overall, 30/50 (60%) and 37/52 (71%) interns completed the orientation and year-end surveys, respectively. The average burnout scores were 1.9 at orientation and 2.7 at the end of the year. We found no statistical difference in year-end burnout scores between the intervention and control groups (p=0.95). Overall, 31/37 (84%) interns reached out to someone for support in the preceding six months on the year-end survey. We found the acts of reaching out to peers, mentors, family members/friends, and therapists to all be independent of workshop attendance (p=0.55, p=0.48, p=0.97, and p=0.54, respectively).

CONCLUSIONS: While average burnout scores increase over the course of intern year, attendance at a one-time workshop on shame in medicine neither minimizes burnout scores nor promotes help-seeking behaviors in the long-term in IM interns. The impact of a longitudinal curriculum is unknown and remains a potential area of future study.

CURRENT PARENTAL LEAVE POLICIES FOR MEDICAL STUDENTS AND INTERNAL MEDICINE RESIDENTS IN ILLINOIS NEW YORK AND CALIFORNIA A COMPARATIVE STUDY

Stephanie Erickson¹; Savina Sahgal³; Usama Ahmad²; Caspian K. Folmsbee^1,2

¹Internal Medicine, Rush University Rush Medical College, Chicago, IL; ²Internal Medicine, Rush University Medical Center, Chicago, IL; ³Rush Medical College, Rush University Medical Center, Chicago, IL. (Control ID #3868798)

BACKGROUND: Medical training coincides with childbearing years, with the average matriculant into medical school reported as 24 years old. Consequently, medical students and residents must make difficult decisions regarding family planning that may impact health later in life. Programs may use a combination of medical leave, vacation and short-term disability as a form of parental leave. This propagates the archaic belief of pregnancy and child rearing as a pathologic state, dehumanizing trainees and undermining gender equity in the long term. Ideally, parental leave guidelines should adhere to the national guidance from the American Board of Medical Specialties4 and American Board of Internal Medicine; however, this has yet to be well-examined. This study sought to determine the state of parental leave policies in Illinois, New York, and California for medical trainees ranging from medical school to internal medicine (IM) residency.

METHODS: In October 2022, two independent researchers reviewed websites of the Accreditation Council for Graduate Medical Education’s 141 accredited IM residencies and 42 MD- or DO-granting medical schools in Illinois, New York, and California. These states were selected for their high number of medical training programs and geographic diversity. For residency programs, webpages, sample house staff contracts, and handbooks were searched using the following keywords: “pregnant” OR “pregnancy” OR “maternity” OR “paternity” OR “parent” OR “parental OR “family” OR “child” OR “birth.” The same keywords were utilized to search online student handbooks and school webpages. Information regarding medical leave, without inclusion of these keywords was not considered a parental leave policy. Data were analyzed using descriptive statistics.

RESULTS: Forty-two medical school programs and 141 IM residencies were evaluated. Of the medical schools, 57% (n=24) of programs discussed parental leave on their materials. 17% of programs (n=7) have specific parental leave policies not discussed under a pre-existing leave of absence or Title IX policy. Four policies referred to “maternity” only. Of the IM residency programs, 44% (n=62) have publicly available policies regarding parental leave discussed. Only 11% of residency programs (n=16) offer their residents dedicated paid time off for parental leave. Four programs offer dedicated paid time off for parental leave specific for “maternity”.

CONCLUSIONS: Navigating the complexities of family building during medical training requires institutional support. Parental leave policies are only available via public web search at approximately half of medical schools and IM residencies. Medical training programs should improve transparency of policies that clearly communicate the institution’s support and approach to its trainees building families. This could improve gender inequity and trainee well-being, while also serving as a recruiting tool for the institutions.

DEVELOPMENT OF A SHARED MENTAL MODEL FOR SUPPORT OF FACULTY, STAFF, AND TRAINEES WITH FAMILIES IN A DEPARTMENT OF MEDICINE

Whitney Harper, Lia M. Barros, Elizabeth K. Vig, Samantha Caldwell, Ryan Clodfelter, Susan E. Merel

Medicine, University of Washington, Seattle, WA. (Control ID #3865851)

BACKGROUND: Working caregivers in medicine balance the needs of their families, patients, and other responsibilities with limited resources. The context and climate of academic medicine reinforce gender inequities and lead to increased burnout, gender pay inequities, and decreased opportunities for career advancement for working caregivers. Stressors associated with work-life integration are highest in women with children and have been exacerbated by the COVID-19 pandemic. We sought the perspectives of faculty and staff to understand the barriers to supporting employees with families and to explore what an ideal model of support for faculty, staff and trainees with families might look like.

METHODS: We conducted five focus group interviews by videoconference in an academic medical center in the Northwest Region. Facilitators led participants in discussions about perceived barriers to achieving work-life integration, childcare needs, and ways to better support employees with families. Audio recordings were transcribed verbatim and analyzed using conventional content analysis.

RESULTS: 24 employees took part in focus groups. 17% were staff, 79% faculty, and 4% APP; 13% identify as male and 88% as female. See table for domains, themes, and subthemes identified in the qualitative analysis.

CONCLUSIONS: Participants identified barriers at home and work to feeling that they and their family life are supported as employees in the Department of Medicine. Systemic challenges identified within the Department included cultural and structural changes as well as perpetuation of societal inequities. In rich focus group discussions, participants were able to propose a number of solutions including aspects of necessary culture change. We plan to use these results to inform future discussions in our division of GIM as well as in the larger Department of Medicine.

IMPACT OF A NEAR PEER COACHING PROGRAM FOR NEW HOSPITALIST FACULTY AT A LARGE AND GROWING ACADEMIC MEDICAL CENTER

Zuzanna Czernik. Medicine, University of Colorado Denver School of Medicine, Aurora, CO. (Control ID #3873113)

BACKGROUND: Hospital medicine is a rapidly growing field and faces many challenges in academic medicine. One of those challenges is a lack of available senior mentors. The benefits of mentoring to success in academic medicine such as retention of faculty and faculty satisfaction have been shown. Coaching has been widely used in the corporate environment and is starting to be adopted as a tool in academic medicine as well, with early data showing benefits for decreasing emotional exhaustion, increasing well-being and increasing job satisfaction. In order to address the needs of a growing hospital the University of Colorado Division of Hospital Medicine has been hiring more than 10 new faculty members each year over the past 5 years. In an effort to develop systems to support all these new faculty a Near Peer Coaching Program was developed and deployed.

METHODS: This Near Peer Faculty Coaching Program was developed with the aims of: (1) creating professional connections within a large and growing group, (2) providing space for reflection, goals setting and future planning for new faculty and (3) providing structured support for addressing challenges and problems faced by new faculty. The program paired interested new faculty hires (“coachees”) with interested current faculty (“coaches”) for the duration of the new faculty’s first 12 months of employment. Coaches received basic training in coaching principles along with structured materials throughout the year on how to guide coaching sessions. Faculty pairs were prompted via e-mail to meet quarterly for coaching sessions. Participants were surveyed about their experiences upon completion of the year long program.

RESULTS: Between 2019 and 2022, fifty-four faculty members participated in the Near Peer Faculty

Coaching Program. Survey response rate across 3 years of data collection was 72%. Eighty-three percent of coaches and coachees reported that this program helped create a personal connection between faculty. Seventy-eight percent of coaches and coachees reported that this program provided an effective space for reflecting, goal setting, future planning and addressing challenges. Eight-five percent of coachees reported that this program eased their transition into their new role. One hundred percent of coaches and coachees recommended the program for other faculty.

CONCLUSIONS: This Near Peer Faculty Coaching Program has been well received by participants at our institution. Similar models could be used by other groups experiencing growth in order to make connection between their faculty, or by programs hoping to provide structured support to new faculty when there may be a lack of senior mentors.

PARENTAL LEAVE IN HOSPITAL MEDICINE: WE CAN DO BETTER

Angela Keniston³; Natalie Schwatka¹¹; Shradha A. Kulkarni⁷; Gopi Astik⁴; Anne S. Linker⁵; Matthew Sakumoto⁶; Marisha Burden²; Andrew Auerbach⁷; Kirsten Kangelaris⁷; Gregory Bowling⁸; Nila Radhakrishnan⁹; Benji Mathews¹⁰; Areeba Kara¹

¹Department of Medicine, Indiana University School of Medicine, Indianapolis, IN; ²Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ³Division of Hospital Medicine, University of Colorado, Aurora, CO; ⁴Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ⁵Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ⁶Medicine, University of California San Francisco, San Francisco, CA; ⁷Department of Medicine , University of California, San Francisco, San Francisco, CA; ⁸Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ⁹Medicine, University of Florida, Gainesville, FL; ¹⁰University of Minnesota, Minneapolis, MN; ¹¹Colorado School of Public Health, Aurora, CO. (Control ID #3872130)

BACKGROUND: Parenting as a clinician is challenged by parental leave (PL) policies. Taking PL may negatively affect clinicians’ income, career, and relationships with colleagues. We describe PL experiences in hospital medicine.

METHODS: The Hospital Medicine Reengineering Network national collaborative supports research and improved care. We conducted virtual, semi-structured focus groups through the Network and described the data using rapid qualitative analysis.

RESULTS: There were 21 participants from 15 unique sites, 13 (61%) were women. Four themes emerged.

Preparing

PL was described as evolving towards more inclusion. An emphasis on better planning was noted- by staffing to needs and by facilitating earlier disclosure of pregnancy. Challenges included support for anticipatory budgeting, the complexity of hospitalists’ work affiliations and schedules. Hospitalists described having to self-advocate in the face of opaque policies.

Taking leave

PL was described as ‘disappointing’ with variations across sites. Many described continuing to work in their non-clinical roles during PL juggling parenting and academic expectations. Decreased resiliency by those covering for colleagues on PL was noted.

Returning

Upon return, support systems commonly support lactation including lactation credits and census reductions for lactating women. Childcare was described as increasingly challenging. Returning from PL was felt to disproportionately negatively impact women, with women reducing or altering their roles.

The way forward

As participants envisioned a way forward, the role of how our culture values parenting and shapes expectations emerged. Improving the workday of a hospitalist was identified as a powerful tool to support hospitalists at all stages of their life-cycle.

CONCLUSIONS: PL in hospital medicine poses unique and consequential challenges which disproportionately impact women. Concerted efforts to address our policies, procedures, staffing, culture and expectations that span preparing, taking and returning from leave are needed.

PEER COACHING IN ACADEMIC MEDICINE: BENEFITS AND PROFESSIONAL DEVELOPMENT FOR PEER COACHES

Kenzie A. Cameron¹; Adeboye B. Ogunseitan²; Kiran Nimmagadda³; Cybele Ghossein⁴; Gopi Astik⁵

¹Medicine/General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ²Medicine/Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ³Medicine/Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL; ⁴Medicine/Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL; ⁵Medicine/Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #3872666)

BACKGROUND: We implemented a peer coaching program for first-year faculty in a Department of

Medicine (DOM) and investigated the impact of the program on the coaches.

METHODS: In 2019-2021, we assigned all new DOM faculty a trained peer faculty coach. Coaches logged session details and voluntarily evaluated the program annually on 5-point Likert scales (Strongly Disagree – Strongly Agree), assessing program satisfaction, connectivity and career path, and confidence in coaching skills. Coaches participated in focus groups exploring their experiences and the impact of the program on themselves.

RESULTS: In 2019, 9 faculty were selected as coaches; an additional 5 faculty joined in 2020. All coaches were DOM clinician educator faculty at the rank of Assistant (n=6), Associate (n=1), or Full Professor (n=7); 64% were female. Coaches logged 109 meetings with 45 unique new faculty between September 2019-July 2021; meetings lasted 5-90 minutes (M = 46.8, sd = 18.3). Coaches reported high program satisfaction and perceived it to be a valuable career experience; their confidence in their coaching skills significantly increased from baseline to one year (p<.01), with an additional increase after two years. Although not statistically significant, coach perspectives of connectivity to and support from the institution were high at baseline and increased after 1 and 2 years in the program (Table 1). Anticipated benefits identified via focus groups included (1) opportunity to give back to the medical community, (2) developing useful skills, and (3) assisting others in their career development. Unanticipated benefits included: (1) increased connectivity through participation in a developing coaching community; (2) increased self-awareness, agency, and introspection, and 3) recognition of the applicability of coaching skills to professional and personal domains beyond the scope of the program.

CONCLUSIONS: A peer coaching program has unintended but powerful benefits for faculty coaches including increasing self-awareness and agency, personal growth, and an enhanced sense of community.

PREVALENCE OF WOMEN IN MEDICINE PROGRAMS AT UNIVERSITY-BASED INTERNAL MEDICINE RESIDENCY PROGRAM

Shinji Rho, Alyssa Rust, Koeun Lee, Lydia Zhong, Abby Spencer, Maria Q. Baggstrom, Rakhee Bhayani

Internal Medicine, Washington University in St Louis, St Louis, MO. (Control ID #3834888)

BACKGROUND: Gender disparity remains an unresolved issue in medicine. Women physicians face various forms of inequities during their training process that inhibit them from reaching their full potential. As a response, several academic institutions have established Women in Medicine (WIM) programs as a support system. Our objective was to investigate the prevalence of Women in Medicine (WIM) programs at university-based internal medicine residency programs as of December 2021.

METHODS: Four independent reviewers searched the websites of 145 university-based internal medicine residency programs for evidence of a WIM program. If a webpage for a WIM program was found, the reviewers assessed the site to determine if the program was specific to the department of medicine and if the program was targeted toward trainees. The proportions of programs that had a WIM program, had a Department of Medicine-specific WIM program, and had a trainee-specific WIM program were analyzed. RESULTS: Out of the 145 programs searched, 58 (40%) had a WIM program. Only 16 (11%) were specific to trainees (11 specific to internal medicine trainees and 5 for trainees in all programs). The remaining 42 programs were for faculty and trainees (5 specific to the Department of Medicine and 37 for all departments)

CONCLUSIONS: Few university-affiliated Internal Medicine residency programs have a WIM program specific to trainees. Given the paucity of women leaders at the highest of academic medical centers and evidence that supports early development of leadership skills and support networks, our findings highlight a possible gap in the residency training program infrastructure.

SHARED LEADERSHIP FOR SAFETY & HEALTH AT WORK

Natalie Schwatka^1,7; Angela Keniston²; Marisha Burden³; Gopi Astik⁴; Anne S. Linker⁵; Matthew Sakumoto⁶

¹Environmental and Occupational Health, University of Colorado, Aurora, CO; ²Division of Hospital Medicine, University of Colorado, Aurora, CO; ³Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ⁴Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ⁵Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ⁶Medicine, University of California San Francisco, San Francisco, CA; ⁷Center for Health, Work & Environment, University of Colorado, Aurora, CO. (Control ID #3873820)

BACKGROUND: Effective workplace safety and health (S&H) policies and programs require the engagement of all members of an organization, not just formal leaders. When all have influence, S&H policies and programs become more relevant and consistently implemented. In the hospital setting, shared leadership for S&H can be observed in the daily work of physicians and advanced practice providers (APPs) as they provide clinical care. In this presentation, we will discuss the themes that emerged from a multi- institutional quality improvement effort to understand shared leadership for S&H among hospitalists, including the perspectives of both formal leaders and those without formal leadership roles.

METHODS: We recruited hospitalists and APPs who were members of the Hospital Medicine Reengineering Network (HOMERuN), a collaborative of hospitals, hospitalists, and multidisciplinary care teams founded in 2011. It is a consortium of academic medical centers, with participating sites from the Northeast, Southeast, Midwest, West, and Northwest. We conducted three virtual focus groups with formal hospitalist leaders (n = 12) in Fall 2022 using a standardized focus group guide. We have three additional virtual focus groups planned with hospitalists not in a formal leadership role (n = 12, planned) in January 2023. We will use rapid qualitative methods to analyze the focus groups. The themes and subthemes identified will be used to understand shared leadership in the setting of hospitalist workplace S&H. We will have our final results by the time of the conference.

RESULTS: Preliminary themes from the focus groups with formal leaders include: Violence - The most pressing S&H issue they noted was violence, harassment, and verbal abuse from patients & families.

Advocacy - Everyone should be a leader for S&H, but everyone agreed it starts with formal leadership. They noted that it is hard to be a S&H leader if others around you are not role modeling.

Sharing responsibility - There is a sense that physicians do not need as much support as others, but hospitalist team members step up to share responsibility for each other. A key strategy that hospitalist teams use is communication of boundaries, limits, S&H problems that arise, etc.

Know your partners - You must know who to go to for specific issues that arise and sometimes that is outside of your team, e.g., patient advocacy, office of equity and inclusion, department of public safety. However, they are not always staffed enough to help.

Opportunities for improvement to begin sharing responsibility for S&H amongst hospitalist teams - role modeling, increasing S&H communication, and building safety and health into professional development as well as operations planning.

CONCLUSIONS: Typical leadership-based approaches to leadership development focus on those in a formal leadership role. We will use the findings from this study to inform a shared leadership development approach to advancing the S&H of those in the healthcare industry.

STEREOTYPE PERCEPTION AND BURNOUT IN INTERNAL MEDICINE RESIDENTS Erin L. Dyer¹; Carol Faulk²; Noor Al-Hammadi³; Rakhee Bhayani⁴

¹Internal Medicine, Washington University in St Louis School of Medicine, St Louis, MO; ²Medicine, Washington University in St Louis, St Louis, MO; ³Biostatistics, Washington University in St Louis, Saint Louis, MO; ⁴Medicine, Washington University in St Louis, St Louis, MO. (Control ID #3875211)

BACKGROUND: Burnout is a well-known phenomenon experienced by professionals working in high- stress and demanding fields, including healthcare. It is characterized by physical, mental, and emotional exhaustion that leads to cynicism and dissatisfaction in one’s work. Some research has proposed that women are at higher risk of burnout than men, as the experience of women in medicine may contribute to feelings of emotional exhaustion and reduced sense of personal accomplishment. Salles et al. demonstrated within a group of surgical residents that women were more perceptive of gender stereotypes than men, and women who perceived these stereotypes to a greater degree were more likely to have poorer psychological health. However, this association has not been demonstrated in a population of Internal Medicine residents. Our study will attempt to quantify burnout scores and perception of gender stereotypes within a population of Internal Medicine residents and determine whether there is an association between stereotype perception and burnout.

METHODS: In this prospective cohort study, a survey was distributed annually to the Internal Medicine residents at our academic medical center beginning in 2018. This survey included the Maslach Burnout Inventory (MBI) and questions to assess perceptions of gender stereotypes in the style used by Salles. Results of the MBI included three subscores: Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA). Participants had “burnout” if they scored in the top tertile for EE or DP or the bottom tertile for PA. Stereotype perception was assessed by asking whether faculty and/or society expect men or women to be better physicians, with responses scored 1-7 on a Likert scale. The Cochran-Armitage test was used to identify any trend in participants’ responses to the stereotype perception questions relative to their burnout scores.

RESULTS: We obtained 130 distinct survey responses over the course of three years. Within this group, 113 residents (86.9%) had burnout. The majority of participants chose the neutral response when asked about the faculty’s perception of male vs female physicians (80.0%), while the majority answered in favor of society expecting men to be better physicians than women (57.7%). There was no statistically significant association between responses to the stereotype perception questions and the presence of burnout, including when participants were were stratified by gender.

CONCLUSIONS: We found a high prevalence of burnout among our Internal Medicine residents, which was unexpected in a residency program that makes resident wellness a priority and has already implemented many initiatives to promote wellness and combat burnout. Our results did not show any statistically significant association between perception of gender stereotypes and presence of burnout. Further investigation is needed to determine whether perception of gender stereotypes has any role in the development of burnout.

THE ASSOCIATION OF WORK OVERLOAD WITH BURNOUT AND INTENT TO LEAVE THE JOB ACROSS THE HEALTHCARE WORKFORCE DURING COVID-19

Lisa Rotenstein¹; Roger Brown²; Christine Sinsky³; Mark Linzer⁴

¹Medicine, Brigham and Women's Hospital, Boston, MA; ²University of Wisconsin System, Madison, WI; ³Professional Satisfaction, American Medical Association, Chicago, IL; ⁴Medicine, Hennepin County Medical Center, Minneapolis, MN. (Control ID #3874347)

BACKGROUND: Burnout has risen across healthcare workers (HCWs) during the pandemic, contributing to workforce turnover. While literature has focused on physicians and nurses, current unprecedented levels of staffing shortages highlight a need to better identify predictors of burnout and work intentions in all HCWs. METHODS: This national, cross-sectional survey study conducted at 206 large healthcare organizations from April to December 2020 was administered to physicians, nurses, other clinical staff (e.g., pharmacists, nursing assistants, respiratory therapists, medical assistants), and non-clinical staff (e.g., housekeeping, administrative, and food staff). The survey assessed burnout via the Mini-Z single-item burnout measure and likelihood of leaving the job within two years. Participants also reported on work experiences, including work overload due to COVID.

We built separate maximum likelihood estimation models with standard errors clustered by organization determining likelihood of burnout and intent to leave (ITL) the job for each role type. Models included whether each respondent met criteria for work overload, and adjusted for respondent demographic characteristics, practice setting, state-level COVID burden at the time of survey completion, and other workplace and COVID-related experiences.

RESULTS: The sample of 43,026 respondents (mean response rate 44%) was comprised of 35.2% physicians, 25.7% nurses, 12.5% other clinical staff, and 25.8% non-clinical staff. Two-thirds (66.2%) of respondents identified as female and about half (47.7%) worked in inpatient settings.

The overall burnout rate was 50% (56% in nursing, 54% in other clinical staff, 47% in physicians and 46% in non-clinical staff; p<0.001 for difference). ITL was reported by 29% of HCWs, with nurses most likely to report ITL (41%), followed by non-clinical staff (33%), other clinical staff, (32%) and physicians (24%) (p<0.001 for difference).

The prevalence of perceived work overload ranged from 37% among physicians to 47% in other clinical staff. In adjusted models, work overload was significantly associated with burnout (OR 3.31 to 4.02) and intent to leave (OR 1.26 to 1.63) across role types.

CONCLUSIONS: High rates of burnout and intent to leave across healthcare roles are significantly correlated with workload. Addressing work overload may help with concerning staffing trends in HCWs. This will require a more granular understanding of sources of work overload across role types, and a commitment to matching work demands to capacity for all HCWs.

THE EMOTIONAL IMPACT OF INTER-HOSPITAL TRANSFERS ON HOSPITALIST PROVIDERS

Claire Westcott²; Lauren McBeth²; Eric Grimm²; Amy Yu¹

¹Medicine, University of Colorado, Denver, CO; ²Medicine/Hospital Medicine, University of Colorado, Aurora, CO. (Control ID #3876490)

BACKGROUND: Patients transferred between hospitals, in a process known as inter-hospital transfer (IHT), are at risk for higher rates of mortality, longer lengths of stay, and higher hospitalization costs compared to patients admitted from the emergency department. While patient outcomes have been studied, the impact of IHTs on providers who care for these patients is understudied. To characterize the effect of the IHT process on hospitalist providers, we examined the experiences of hospital medicine physicians and advanced practice providers (APPs) who care for IHT patients.

METHODS: We conducted a qualitative descriptive study using semi-structured interviews from 09/2021-12/2021 with hospital medicine physicians and APPs from an academic acute care hospital that accepts ~5,000 IHT patients annually.

Emotion categories were identified after reviewing and coding interview transcripts. The R package quanteda was used to split up transcripts into individual words, 2-word phrases, and 3-word phrases that were associated with the emotions. Words with different suffixes that share the same base word (e.g. “frustrated”, “frustrating”, “frustration”) were grouped together in order to count similar words as part of a single concept.

We then counted the number of times words and phrases associated with the identified emotions were used across interviews. Analyses were performed using R version 3.6.3.

RESULTS: We interviewed 30 hospitalists with 1-18 years of experience (mean 5.7 years). 17 (57%) of interviewees were physicians and 13 (43%) were APPs. 31 emotion categories were identified through qualitative coding and emotion words were mentioned over 220 times. Of the emotion categories, 23 were negative emotions, 5 were positive, and 3 were neutral or mixed. Positive emotion words including hopeful, appreciate, happy, grateful, incredible feeling were used 17 times. These emotions were most commonly used in the context of describing communication between clinicians, strategies to obtain clinical information, or patients’ feelings towards being transferred for additional care. Neutral/mixed emotion words such as trust, empathy, and surprise were mentioned 12 times. Negative emotion words were used 196 times. The most common emotion word was "frustration", used 102 times. The next most common was "stressed", used 18 times. Additional negative emotions included annoyed, concerned, upset, burned, and angry. Negative emotions were reported in relation to issues with incomplete or inaccurate information, difficulties with communication, differing expectations, lack of agency, cognitive overload, and patient safety issues. CONCLUSIONS: The IHT process brings up strong negative emotions in providers, which is worrying in a time when burnout is so prevalent among health care providers. Further research should focus on ways to ameliorate IHT process factors that lead to negative emotions and highlight elements of the IHT process that engender positive emotions.

THE FUTURE OF GIM RESEARCH IS BRIGHT, BUT WE HAVE WORK TO DO: RESULTS OF A SURVEY OF CURRENT AND FORMER GIM RESEARCH FELLOWS

Nisa Maruthur¹; Kira Ryskina²; Lauren Block³; Kristina M. Cordasco⁴; Deborah Kwolek⁵; Karin Nelson⁶; E. B. Schwarz⁷; Himali Weerahandi⁸; Donna Windish⁹; Michael Paasche-Orlow¹⁰; Mara A. Schonberg¹¹

¹Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; ²Medicine, University of Pennsylvania, Philadelphia, PA; ³medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY; ⁴Medicine, VA Greater Los Angles Healthcare System/ UCLA, Los Angeles, CA; ⁵Medicine, Harvard Medical School, Boston, MA; ⁶Medicine, University of Washington, Seattle, WA; ⁷Division of General Medicine, University of California, Davis, Sacramento, CA; ⁸Medicine/Population Health, NYU Langone Health, New York, NY; ⁹Internal Medicine, Yale University, Cheshire, CT; ¹⁰Medicine, Tufts Medical Center, Boston, MA; ¹¹Medicine, Beth Israel Deaconess Medical Center, Brookline, MA. (Control ID #3875746)

BACKGROUND: The research pipeline is key to the success of academic general internal medicine (GIM), but little is known about factors that influence investigators to select and continue in this career pathway.

METHODS: A team of 10 stakeholders (researchers, fellowship directors) developed and piloted a web- based REDCap questionnaire assessing: 1) GIM research fellowship experiences; 2) strengths/weaknesses of research training; 3) career paths; and 4) SGIM resource use. Respondents were GIM research fellows (in training programs with >50% of focus on research) between 2012 and 2022 identified from SGIM membership and direct outreach to GIM fellowship program directors. Program directors were identified from SGIM membership lists and government and health system/foundation funded training programs. We compared responses by gender (male/female), underrepresented in medicine (URM) status (yes/no), and SGIM membership (yes/no) using chi squared and Wilcoxon rank sum tests. Respondent open-ended comments were analyzed using thematic analysis.

RESULTS: 42% (160/379) of eligible respondents completed the survey. 77% of respondents were ≤40 years of age; 56% were female; 20% belonged to a URM group; 68% were SGIM members; and 76% had completed their research fellowship. Most reported having strong faculty mentors (96%) and sponsors (89%) and having received high-quality training in research methods (94%) during fellowship. Lowest rated domains of training were hiring/building a research team and negotiation. Experiences with training in grant- writing, diversity/cultural awareness, leadership and support of fellows as caregivers were variable. Most respondents (63%) had pursued/were planning to pursue a clinician investigator position after fellowship. Most respondents had participated in SGIM meetings (83%), but use of most other SGIM resources was low 31% reported discrimination during fellowship. While 87% of respondents reported symptoms of burnout, most felt positively about their careers (87%) and the future of academic GIM research (67%). Survey responses did not vary substantially by gender, URM status or SGIM membership. In open-ended comments, respondents expressed concerns about harmful academic culture, competitiveness and research funding. Recommendations included that SGIM have year-long programs to connect research fellows, better advertise their resources, and work to increase external funding opportunities in GIM research.

CONCLUSIONS: Over half of GIM research fellows pursue clinician investigator positions, but 33% do not. Issues identified included inadequacy of training, the research funding landscape, and discrimination during fellowship. SGIM can better support fellows through year-round career development, networking opportunities and advocacy for funding.

WOMEN FACULTY AND FULL-TIME CLINICAL FACULTY MENTORSHIP NEEDS NOT MET WITH TRADITIONAL MENTORSHIP STRUCTURES

Neha Deshpande³; Helene Starks¹; Paul B. Cornia²; Lauge Sokol-Hessner³; Geetanjali Chander³; Somnath Mookherjee³

¹Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA; ²Medicine, VA Puget Sound HCS & University of Washington SOM, Seattle, WA; ³Medicine, University of Washington, Seattle, WA. (Control ID #3865073)

BACKGROUND: Mentorship is vital for academic medicine faculty career advancement, productivity, job satisfaction, and retention, yet specific mentoring needs and preferences are not well understood, particularly for full-time clinical faculty (FTC). There is a gender gap in advancement and promotion in academic medicine and mentorship is also vulnerable to bias. We surveyed our Division of General Internal Medicine (DGIM) faculty to determine gender and promotion pathway differences in 1) having mentors; 2) satisfaction with mentorship; 3) preferences for finding mentors; and 4) barriers to providing and receiving mentorship.

METHODS: DGIM includes 307 inpatient, outpatient and research faculty across multiple sites. We created a 24-item survey to assess the 4 domains above and examined the distribution of responses by gender and promotion track using chi-square tests. Faculty were invited to respond in October 2022.

RESULTS: 192 (63%) faculty completed the survey. 40 were not queried on satisfaction with mentors: 29 had <4 months in DGIM and we presumed their mentors were at prior institutions; 11 were unsure whether they had a mentor.

Frequency: 107/192 (56%) faculty reported having at least 1 mentor; the proportion of faculty with mentors was similar for women (n=108, 54%) and men (n=79, 59%, p=0.667). There were significant differences by track among who had mentors (40/90, 44% FTC vs 46/58, 79% Clinician-Scholar, and 18/23, 78% Physician- Scientist, p<0.001).

Satisfaction with current mentorship: 65% of faculty with mentors were satisfied. Similar proportions of women (67%) and men (64%) reported satisfaction with mentorship (p=0.895). Among faculty with mentors who were dissatisfied, 18% were CS, compared to 11% FTC and 6% PS (p=0.028). 28/52 (54%) faculty without mentors were dissatisfied with their lack of mentorship; most were FTC (n=17, 65%) or CS (n=9, 35%, p=0.002); all 4 PS with no mentor were satisfied.

Preferences: More women preferred assistance (facilitated connection or mentor assignment) with finding a mentor to support promotion (52% vs 44% for men, p=0.044) and career development (80% vs 62%, p=0.009). More FTC, compared to CS or PS, preferred assistance with finding mentors for promotion (80% vs 66% vs 50%, p=0.001) and career development (77% vs 59% vs 42%, p=0.001).

Barriers: Lack of time was the most prevalent barrier for both receiving (56%) and providing (58%) mentorship.

CONCLUSIONS: While many faculty reported satisfaction with current mentorship, we identified opportunities for improvement. Many faculty without mentors were dissatisfied by the lack of mentorship and FTC tended to lack mentorship. Women preferred facilitated connections with potential mentors. Mentorship programs must provide mentorship opportunities that address these differences and invest in protecting time for mentorship activities.

Scientific Abstract - Chronic Disease Management

20 YEAR TRENDS IN PRIMARY PREVENTION STATIN USE: STUCK IN A RUT SINCE 2013

Casey Kim¹; Micah Eades¹; Kenneth J. Mukamal¹; Jeremy B. Sussman²; Timothy Anderson¹

¹Medicine/General Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Internal Medicine, University of Michigan, Ann Arbor, MI. (Control ID #3874079)

BACKGROUND: Statin therapy is a cornerstone of primary prevention of atherosclerotic cardiovascular disease (ASCVD) with historically lower rates of use for patients at increased cardiovascular risk. Little is known about recent trends in statin use for primary prevention of ASCVD and particularly following the 2013 American College of Cardiology (ACC) / American Heart Association (AHA) guideline changes to

pooled risk calculators.

METHODS: We analyzed trends in statin use using the National Health and Nutrition Examination Survey (NHANES) data from 1999-2000 to 2017-2018 in non-pregnant adults without an indication for secondary prevention who completed fasting laboratories. For participants using statins, baseline ASCVD risk was estimated by subtracting the individual statin mean cholesterol lowering effect. Survey-weighted multivariable logistic regression was used to identify predictors of primary prevention statin use including indication (ASCVD risk, diabetes, LDL>190 mg/dL), demographics, and regular source of care from 2015-2018.

RESULTS: Among the 21,691 participants (38.8% age 40-59, 51.8 % female, 67.8 % white) from 1999/2000 to 2017/2018, 31.6% (95% CI, 30.5 - 32.7) met criteria for primary prevention statin use. By indication, 3.6% of participants met criteria of elevated LDL, 10.2% of diabetes diagnosis, 9.9% of ASCVD risk score 7.5-19.9%, and 7.8% of ASCVD >=20%. While primary prevention statin use increased by 22.4% (95% CI, 16.0 – 28.7) from 12.1% (95% CI 8.2 – 16.0) in 1999/2000 to 34.5% (95% CI 29.5 - 39.4) in 2017/2018, growth in statin use plateaued following the 2013 ACC/AHA guidelines (-1.6% change from 2013/2014 to 2017/2018; 95% CI, -8.7 – 5.5). Primary prevention statin use varied greatly by indication and patient characteristics. For example, participants with diabetes were twice as more likely to use statins compared with those with ASCVD > 20% (OR 2.22; 95% CI, 1.33 – 3.70). Factors most strongly associated with not receiving statins were younger age (OR: 0.55 for age 40-59 compared to 60-75 years, 95% CI: 0.02- 0.15) and not having a regular source of care (OR 0.20; 95% CI, 0.07 – 0.63).

CONCLUSIONS: Growth in primary prevention statin use has plateaued since implementation of 2013 ACC/AHA guidelines with two-thirds of patients at increased ASCVD risk not using statins. Strategies to improve primary prevention statin use may include improving access to regular sources of care including primary care, increased attention to middle-age patients, and a population health focus on targeting the highest risk patients, such as those with ASCVD risk over 20%.

ALIGNING ANTI-HYPERTENSIVE PRESCRIBING PRACTICES WITH ACC GUIDELINES TO MITIGATE RACIAL DISPARITIES IN HYPERTENSION CONTROL AMONG BLACK PRIMARY CARE PATIENTS OF RESIDENT PHYSICIANS

Kevin M. Pearlman, Amy E. Wainright, Mim Ari

Internal Medicine, The University of Chicago Medicine, Chicago, IL. (Control ID #3860042)

BACKGROUND: Black patients with hypertension are less likely to have controlled blood pressure, and have increased complications including stroke, heart failure, renal disease, and death compared to non-Black patients. The purpose of this analysis was to assess current hypertension control among Black primary care patients empaneled to resident physicians at the University of Chicago Medical Center (UCMC), with specific analysis of ACC-guideline concordant prescribing practices. Additionally, knowledge and confidence of ACC guidelines was queried to help shape future interventions.

METHODS: Demographic, clinical, and pharmaceutical data was queried from the electronic health records of adult (age 18-84) primary care patients at UCMC with primary hypertension who were empaneled to resident physician PCPs between 3/1/2021 and 9/1/2022 (n =3,485). A voluntary and anonymized survey querying hypertension management practices was sent to all IM residents (n=49, response rate 43%). Questions assessed confidence in managing hypertension and knowledge of ACC guidelines.

RESULTS: Blood pressure was more likely to be uncontrolled (most recent systolic blood pressure reading >140) in Black patients (n=966/3027, 32%) than in non-Black patients (n=105/458, 23%; chi-square p<0.01). Only 9% (n=89/966) of Black patients with a systolic blood pressure (SBP) greater than 140 were prescribed single pill combination (SPC) therapy and 5.6% (n=167/3027) of Black patients were prescribed an ACC guideline-discordant RAS inhibitor as monotherapy.

Despite 86% (n=42/49) of residents feeling very or fairly confident managing a patient with hypertension, only 16% (n=8/49) were very or fairly familiar with the ACC guidelines. About half of respondents chose guideline-discordant options as appropriate monotherapy for a Black patient with stage II hypertension in a clinical vignette (ACE-I=44%, n=15/34; ARB=50%, n=17/34), and 53% (n=26/49) reported race does not affect their choice of anti-hypertensive. Most respondents (63%, n=30/48) indicated they never or rarely prescribe SPC therapy for patients with hypertension with only 45% (n=22/49) feeling very or fairly confident prescribing SPC.

CONCLUSIONS: Uncontrolled hypertension among Black patients is an important national and local healthcare disparity. Our analysis of resident empaneled patients revealed high rates of uncontrolled blood pressure, low rates of SPC therapy and ongoing guideline-discordant monotherapy prescribing. Limited confidence in prescribing SPC therapy and lack of ACC guideline knowledge are potential contributors. Educational interventions are being developed to address these factors and will be followed by additional outcomes evaluation to assess impact.

ALL IN THE FAMILY: BASELINE LIFESTYLE BEHAVIORS AND ADULT/PARENT EFFICACY FOR ACHIEVING LIFESTYLE GOALS AMONG ADULT-CHILD DYADS ENROLLED IN A FAMILY DIABETES PREVENTION PROGRAM PILOT STUDY

Maya S. Venkataramani¹; Nisa Maruthur²

¹Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; ²Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. (Control ID #3875117)

BACKGROUND: Understanding similarities in adult and child lifestyle behaviors and adults’ perceived efficacy to effect behavioral change can inform the development of multi-generational lifestyle interventions. We examined baseline data from adult-child dyads enrolled in a pilot family-oriented Diabetes Prevention Program (Family DPP) to describe lifestyle behaviors and perceived efficacy for behavior change and explore adult-child correlations in these measures.

METHODS: The Family DPP Pilot Study recruited adults eligible for the DPP from an urban metropolitan area and one child they care for (aged 5-12 years). Adult participants were administered baseline surveys within 2 weeks of intervention start (October 2022). The surveys queried adult and child lifestyle behaviors (physical activity, sleep and dietary intake frequencies). Adults' self-efficacy for achieving lifestyle goals (related to physical activity, sleep, sugary drink and vegetable intake) and parenting-efficacy to support analogous child behaviors were measured on a Likert scale (1: “I know I cannot” to 5: “I know I can”). We performed descriptive statistics and examined correlations between adult and child measures (Fischer’s Exact Test).

RESULTS: Among the 12 adult-child dyads enrolled, mean adult age was 46.3 years (range 34 to 70). 83% of adults were female. Mean child age was 9.3 years. 33% of adults reported achieving their physical activity goal (150 minutes/week) in the past week, while only 18% (2 of 11 children >5 years) achieved child activity goals (60 minutes/day). 25% of adults reported achieving daily sleep goals (7 hours/night), compared to 83% of children (9 to 10 hours/night). Adult and child goal achievement was not correlated. While overall, adults and children had limited intake of fruits and vegetables (only 33% ate vegetables at least once daily, and only 50% of adults and 58% of children ate fruits at this frequency), dietary patterns were not significantly correlated. Adults were least confident about achieving sleep goals (42% endorsed a score of 4 or 5); the majority expressed high confidence in achieving physical activity goals (58%), eating vegetables regularly (83%) and limiting sugary drinks (100%). Adults reported the lowest levels of parenting-efficacy in reducing child sugary drink intake and supporting child physical activity (67% endorsed a score of 4 or 5). Correlation was observed between self-efficacy and parental-efficacy for physical activity (p=0.014).

CONCLUSIONS: At baseline, the majority of adults and children enrolled in a lifestyle intervention do not report meeting lifestyle guidelines, but adults endorse high self- and parenting-efficacy to change certain behaviors. Limited sample size prevented more robust examination of correlation of adult and child behaviors and self- and parenting-efficacy for behavioral change. Characterizing these factors in a larger sample is an important next step that can further inform the content and focus of family-oriented lifestyle interventions.

A PILOT STUDY TO DETERMINE EFFICACY OF BLUETOOTH-ENABLED HOME BLOOD PRESSURE MONITORING IN THE MANAGEMENT OF HYPERTENSION

Cody J. Paiva¹; Brinton Clark²

¹Internal Medicine, Providence Portland Medical Center, Portland, OR; ²Medical Education, Providence Portland Medical Center, Portland, OR. (Control ID #3876800)

BACKGROUND: Hypertension is a common diagnosis encountered in primary care settings, affecting more than 45% of the U.S. in 2017-2018. Hypertension is associated with increased risk of death and disability- adjusted life years. Current treatment strategies for managing hypertension have proven challenging, necessitating novel approaches for better blood pressure control. Prior research shows that the use of Bluetooth-enabled home blood pressure cuffs improves hypertension control. Patients engaged in digital home blood pressure monitoring are more often able to meet blood pressure targets. Our study assesses the use of Bluetooth-enabled home blood pressure monitoring on the management of hypertension in an internal medicine residency clinic.

METHODS: 97 adults with uncontrolled hypertension were identified at the Providence Portland Medical Center Internal Medicine Residency Clinic, defined by blood pressure greater than 150/90 in the 3 months prior to enrollment. Patients were provided with a Bluetooth-enabled blood pressure monitor at enrollment, and blood pressure data was transmitted via smartphone apps to the electronic health record. Home blood pressure readings were transmitted every 2 weeks, and PCPs continued to see patients routinely. A clinical pharmacist conducted consultations which were provided to the PCPs for consideration of medication changes. Blood pressure readings were collected for 3-6 months after enrollment to assess differences in blood pressure pre- and post-use of the home blood pressure cuff. In addition, data about number of medications, number of dose increases and decreases, number of pharmacist visits, and medical co- morbidities were reported.

RESULTS: 95 patients (97.9%) successfully transmitted data at enrollment time and 3-6 months after. 46.4% of patients were women. Average age at the time of enrollment in the study was 62.8 years. 29.9% had diabetes, 26.8% had sleep apnea, 53.6% had ASCVD risk equivalents, and 15.5% had CKD3 or greater. Patients enrolled had a reduction of 20.6 mmHg systolic (P < 0.05) and 8.4 mmHg diastolic (P < 0.05). Patients on average received two consultations by the clinical pharmacist. At the start of the study, patients were prescribed on average 1.77 antihypertensive medications compared to 2.01 medications 3-6 months after enrollment.

CONCLUSIONS: This is the first study in a residency-based clinic to demonstrates that Bluetooth-enabled home blood pressure monitoring has clinical benefit in the reduction of both systolic and diastolic blood pressure for patients with uncontrolled hypertension. By utilizing frequent blood pressure monitoring, clinical pharmacist consultations, and medication intensification we show benefit for optimizing hypertension management in the outpatient setting. Limitations of this study include small sample size and limited follow up. Additionally, we do not have data on adherence to medication regimens. Future directions of this study could include expanding the sample size and longer follow-up time.

A RETROSPECTIVE NARRATIVE REVIEW OF LIFESTYLE RISK FACTORS IN COVID-19. Simmy Lahori¹; Daniel Kashani³; Bright Thilagar²; Abhinav Singla²

¹Internal Medicine, Mayo Foundation for Medical Education and Research, Rochester, MN; ²General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; ³Hospital Internal Medicine, Mayo Foundation for Medical Education and Research, Jacksonville, FL. (Control ID #3871929)

BACKGROUND: Since the beginning of the COVID-19 pandemic, there has been evolving consensus on how certain lifestyle risk factors could be associated with an increased risk of infection. For eg., there has been an increase in trends with hospitalizations in class III obese population. We were keen to explore evidence that has been generated on how certain risk factors and comorbidities can affect the probability of contracting COVID-19.

METHODS: We included studies focusing on lifestyle risks for COVID-19 identified by the NCBI (National Center for Biotechnology Information) at the US National Library of Medicine (NLM). We searched cited databases systematic reviews/meta-analyses, randomized control trials, review articles, and retrospective cohort studies (Pic 1).

RESULTS: The findings of alcohol as a risk factor were found to be controversial. A study by Suzuki et. al showed a tendency toward an association between decreased mortality among infected and increased mortality in those uninfected. Among the lack of sleep studies, a meta-analysis, which included 149 studies, conducted by Liu et. al demonstrated that sleep disturbance was significantly associated with illness severity. Among the sleep apnea studies, Pataka, A. et al. demonstrated that OSA is a risk factor for COVID-19, while Gimeno-Miguel, A et al. demonstrated by adjusting the rest of the co-morbidities, COPD only remained significant in men and OSA only in women. When it comes to smoking, even though a study by Paleiron et al. showed that smokers had a lower risk of infection, eventually a lot of data flooded into the state otherwise. The Retrospective cohort study by Kompaniyets L et al. demonstrates that the risk of hospitalization, ICU admission, and death was lowest at normal BMIs of ~24 kg.m2 with a sharp increase with higher BMI. The exercise was a winner overall when it came to decreasing risk. In a large observational retrospective study, consistently inactive patients with COVID-19 infection had higher odds of hospitalization, ICU admission, and death.

CONCLUSIONS: There is plenty of evidence that certain predisposing factors, such as high BMI and sleep apnea, increase the risk of COVID-19 infection. Thus far, there is a lack of evidence that correlates COVID-19 risk and lifestyle, such as alcohol consumption, lack of sleep, and smoking. Exercise, overall decreased risk of COVID-19 and its complications.

ASSESSING MEDICATION DISTRIBUTION AND PATIENT NEEDS FOR UNDERSERVED COMMUNITIES AT URBAN STUDENT-RUN FREE CLINIC

Kathy Lu¹; Alex Wind¹; Nili Modi¹; Sara Kazyak¹; Mina Sitto¹; Jennifer Schmidt¹; Adlai Nelson¹; Sara L. Ma¹; Robert Sherwin²

¹School of Medicine, Wayne State University School of Medicine, Detroit, MI;²Emergency Medicine, Detroit Medical Center, Detroit, MI. (Control ID #3876292)

BACKGROUND: Student-run free clinics have been found to contribute to positive patient health outcomes for a variety of chronic conditions, including diabetes, hypertension, and cardiovascular disease. Uninsured or underinsured patients, many of whom facing houselessness or housing instability, face additional obstacles to obtaining quality healthcare, including access to prescription medications. This study examines an urban student-run free clinic in the Midwest offering medical care to un- or underinsured patients through immunization administration, food prescription, routine vision and hearing screenings, and provision of medications. In order to further understand the needs of the patient population and community, we sought to determine the main types of medications that were prescribed in an effort to better understand the chronic conditions impacting clinic patients.

METHODS: Walk-in student-run clinics were held weekly on Saturday mornings in an urban Midwestern city, with patients consisting primarily of underinsured and uninsured residents experiencing houselessness or housing instability. A list of medications prescribed by the attending physician were recorded weekly by student clinic coordinators in a spreadsheet for the duration of the year. Medication type, dosage, and quantity were recorded and data was compiled into graphical form.

RESULTS: A total of 103 different medications were prescribed at 45 clinics held from December 2021 to November 2022. Medications prescribed for the treatment of hypertension made up 45.7% and medication for diabetes management contributed an additional 15.8% of the total medications distributed. Medications for hypercholesterolemia, gastroesophageal reflux disease (GERD), and respiratory conditions were also distributed (6.3%, 4.1%, and 3.9%, respectively). 6.2% of total distributed medications consisted of antiplatelet drugs while 4.2% composed of vitamin and mineral supplements.

CONCLUSIONS: Many of the patients at walk-in free clinics have chronic, comorbid conditions and rely on these free, interdisciplinary services to regularly obtain medications. Gathering data on the most common medications allows us to curate best fitting lists for our underserved patient population when ordering new prescription medications. This is valuable for this clinic and other free clinics with similar patient populations to ensure community needs are adequately met. Future projects plan to identify major barriers that hinder underinsured patients from refilling prescription medications or the duration of time between medication supplies running out and patients refilling them. These projects would provide further practice-based understanding in areas that free clinics can improve their patient care.

ASSOCIATION BETWEEN FREQUENCY OF HOME BLOOD PRESSURE MEASUREMENT AND SUBSEQUENT BLOOD PRESSURE OUTCOMES AMONG PATIENTS ENROLLED IN A REMOTE PATIENT MONITORING PROGRAM FOR HYPERTENSION

Nadia Liyanage-Don^1,2; Brandon K. Bellows²; Kelsey B. Bryant³; Jessica R. Singer²; Siqin Ye²; Nathalie Moise^1,2; John Cheng¹; Maria-Jose Lopez-Sanchez¹; Adina Fraser⁴; Rakhi Kalra⁴; Nadine Dandan⁵; Ian Kronish^1,2

¹Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, NY; ²Department of Medicine, Columbia University Irving Medical Center, New York, NY; ³Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ⁴IT, NewYork- Presbyterian Healthcare System Inc, New York, NY; ⁵Pharmacy, NewYork-Presbyterian Healthcare System Inc, New York, NY. (Control ID #3874751)

BACKGROUND: Remote patient monitoring (RPM) for hypertension (HTN) involves wireless transmission of home blood pressure (BP) data to the electronic health record, which can be used to guide HTN management. Such RPM programs have been shown to significantly improve BP control, especially when combined with nurse or pharmacist support. However, less is known about how the frequency of home BP measurement impacts subsequent BP outcomes.

METHODS: We implemented a HTN RPM program at an adult primary care network in NYC. Clinicians referred patients at their discretion and could choose between programs that offered remote nurse support alone or remote nurse support plus antihypertensive titration by a pharmacist. In both programs, patients were loaned wireless BP devices free of charge and were instructed to measure home BP 2x/day in the first week and at least 3x/week thereafter. Patients were taught how to properly measure their BP and received reminder calls if they had no home BP readings for >1 week. Descriptive statistics were used to quantify home BP trends and frequency of home BP readings during the first 6 months of enrollment. Linear regression was used to estimate the association between frequency of home BP readings and mean home BP by the end of the program.

RESULTS: From June 2019 to August 2021, 443 patients were referred to the program (mean age 67±13 years, 68% female, 24% Black, 62% Hispanic, 60% non-English). Of these, 329 (74%) were actively enrolled, with 221 (67%) in the nurse-only program and 108 (33%) in the nurse + pharmacist program. At baseline, mean home systolic and diastolic BP were 140±18 mmHg and 81±12 mmHg, respectively, improving to 131±15 mmHg and 78±11 mmHg, respectively, after 6 months. Patients measured their home BP an average of 14±7 times per month and 36±45 times total over the 6-month program duration. Increased frequency of home BP measurement was associated with lower systolic (β -0.05, SE 0.01, 95% CI -0.07-0.02, p<0.01) and diastolic (β -0.02, SE 0.01, 95% CI -0.04, -0.01, p<0.01) BP, even after adjusting for patient age, sex, race, ethnicity, language, baseline BP, and program type. Younger age (β 0.10, SE 0.04, 95%

CI 0.01, 0.19, p=0.03) and female sex (β -2.83, SE 1.21, 95% CI -5.22, -0.45, p=0.02) were also associated with lower systolic BP, though not with diastolic BP.

CONCLUSIONS: Increased frequency of home BP measurement was associated with lower systolic and diastolic BP among primary care patients after 6 months of enrollment in a HTN RPM program. This association persisted even after controlling for sociodemographic factors, type of program support received, and baseline BP. Possible explanations include greater patient awareness of BP trends, increased patient adherence to antihypertensive medications, or decreased clinical inertia in antihypertensive intensification. These findings suggest that strategies to promote sustained patient engagement in home BP monitoring are important to maximize the impact of RPM programs on BP outcomes.

CANNABIS FOR FIBROMYALGIA - WHAT IS YOUR SOURCE?

Abhinav Singla¹; Arya Mohabbat²; Jordan K. Rosedahl³; Lindsey M. Philpot³

¹General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; ²General Internal Medicine, Mayo Clinic, Rochester, MN; ³Community Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #3871746)

BACKGROUND: Fibromyalgia (FM) is a chronic disease with a cardinal manifestation of chronic widespread pain. Patients with FM may experiment with cannabis as an alternative intervention for symptom management. Evidence suggests multiple benefits of using cannabis to help with symptoms, including pain.

METHODS: We conducted a survey (1472 respondents) to gather information regarding cannabis use in FM, including focus on where patients turn for cannabis use information. The survey was constructed using the Symptom Management Theory tool and deployed anonymously via web-based software to patients with a diagnosis of FM.

RESULTS: The overall response rate was around 30%, with the majority being female. We observed significant differences by age between those who reported cannabis use for FM versus those who did not(median age 45 versus 51). Around 50% of the patients used cannabis after receiving a FM diagnosis. Furthermore, 61% of patients never discussed their cannabis use with a healthcare provider (HCP). Picture 1 shows detailed data regarding patients’ primary source of information.

CONCLUSIONS: Cannabis is a popular choice to treat FM symptoms, with 50% of patients utilizing it after diagnosis. Patients mostly seem to get information regarding the benefits of cannabis from FM specialists followed by PCP and rheumatologists. Besides the aforementioned providers, the other sources of information (Figure 1) may have little to no awareness of FM as a disease in general, let alone the targeted benefits of cannabis. Most patients did not discuss with a healthcare provider before using cannabis. Accordingly, the instructions to use cannabis primarily came from vendors/dispensaries. One possible reason is due to the variable legalities associated with cannabis use across states.

CHANGES IN GLYCEMIC CONTROL AND BODY WEIGHT OVER THE COURSE OF THE COVID 19 PANDEMIC IN AN OUTPATIENT SETTING

Keerthana Haridas, Deborah Edelman

Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3850108)

BACKGROUND: The COVID-19 pandemic has altered health outcomes in populations through a host of downstream social, economic, and psychological changes, especially among those with chronic non- communicable diseases (NCDs). Some studies reveal worsened glycemic control and weight gain, while others indicate improved glycemic control and weight loss. Thus, evidence demonstrates conflicting results in this context. We aimed to conduct a study to explore changes in these metrics in an outpatient setting providing for an underserved population.

METHODS: We conducted a single-site observational study at a Federally Qualified Health Center (FQHC) in New York City to compare glycemic control and body weight, measured by Hemoglobin A1c (HbA1c) and body mass index (BMI) respectively, before and after the onset of the COVID-19 pandemic.

RESULTS: After the pandemic, there was a 103% increase in the annual change in average HbA1c from the years prior to the pandemic versus from early 2020 to 2021 (p < 0.005). Mean BMI increased during the pandemic, although this was not statistically significant. The slope for the change in BMI over five years prior to the pandemic is -0.09, while the slope of change in BMI before and after the onset of COVID-19 is 0.31. The difference between the two slopes is 0.48 (p = 0.37).

CONCLUSIONS: Our study reveals that the COVID-19 pandemic may have led to a worsening in the status of metabolic disorders due to decreased physical activity, worsened dietary habits, psychosocial stressors, and reduced access to healthcare, emphasizing the need for enhanced medical, pharmaceutical and emotional support. Concurrently, many individuals practiced healthier lifestyles via dietary and activity modifications, with an improvement in cardio-metabolic parameters. Given the need for limited data of this type in the United States and conflicting data from other parts of the world, it can be concluded that there is a need to explore changes in healthcare outcomes in patients with non-communicable diseases occurring due to downstream effects of the pandemic. There is indeed a pressing requirement to provide continued support to patients with chronic disorders through telemedicine, access to medications, improved access to laboratories or facilities for the collection of samples from home as well as continued emotional support during a pandemic to prevent acute and chronic complications and to decrease the burden on the healthcare system.

CHARACTERISTICS OF LONG COVID PATIENTS PRESENTING TO A DEDICATED POST- COVID-19 CLINIC

Rija Aziz²; William M. Brode²; Mary A. Kelley³; Nadia Siles Alvarado¹; Esther Melamed¹

¹Neurology, The University of Texas at Austin Dell Medical School, Austin, TX; ²Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; ³Neurology , Dell Seton Medical Center at The University of Texas, Austin, TX. (Control ID #3876646)

BACKGROUND: 10-30% of patients with acute SARS-CoV-2 infection may go on to experience post-acute sequelae SARS-CoV-2 infection (PASC), characterized by broad multisystem symptomatology. Currently, there are few publications on the clinical experience of PASC patients in a dedicated multidisciplinary outpatient clinic. In this study, we characterize clinical symptoms and epidemiological risk factors in patients seeking care for PASC at a tertiary care academic center.

METHODS: We assessed 252 patients treated at the Post-COVID-19 clinic, who presented between June 2021 and May 2022 via a cross-sectional study. Patients completed a standardized clinical questionnaire, Montreal Cognitive Assessment (MoCA) and mental health screenings at their initial visit as part of the standard of care. Data analysis was carried out in R and Microsoft Excel. Statistical significance was assessed with Fisher Exact Test and multiple hypothesis testing was completed with False Discovery Testing.

RESULTS: The median patient age was 44.5 years, 65% were female with a median BMI of 27.4. Patients presented at a median of 10.4 months from acute COVD-19 infection. 78% self-identified their race as white and 21% identified their ethnicity as Latino. Employment breakdown revealed 77% to be employed before March 2020, decreasing to 57% at the time of the initial clinic visit. Most patients (82%) had been vaccinated, and 26% developed PASC following a breakthrough infection. During the acute COVID-19 infection, 50% of patients had a moderate disease severity and 10.5% were hospitalized. The top three co- morbid conditions prior to SARS-CoV-2 infection included mental health conditions, hypertension and asthma. Patients reported a median of 18 new symptoms following COVID-19 illness. The most common symptoms were fatigue (89%), forgetfulness or ‘brain fog’ (89%), deficits in concentration and attention (77%), dizziness or lightheadedness (69%), and post-exertional malaise (68%). PROMIS Global 10 v1.2 assessment demonstrated a mean T score of 37.9 and 37.5 for Mental and Physical categories, with 65% of patients endorsing fair to poor mental health and 73% with fair to poor physical health. MoCA assessments demonstrated that 51% had normal scores and 46% had mild cognitive dysfunction. PHQ-9 scoring revealed 42% had moderate to severe depression, and 38% had moderate to severe anxiety on the GAD-7 assessment.

Symptom burden was similar across gender, age, and initial disease severity.

CONCLUSIONS: Patients presenting to a tertiary Post-COVID-19 program demonstrated numerous multisystem symptoms and functional impairment, independent of the initial COVID-19 disease severity. In addition to increasing research on the underlying pathophysiology and targeted treatments for PASC, further longitudinal studies are needed to define how PASC symptoms change over time. Post-COVID-19 programs also need to be scaled to meet the high patient volume toward delivering complex multidisciplinary care for this patient population.

CHARACTERIZING ONCOLOGY AND PRIMARY CARE INVOLVEMENT IN BREAST CANCER SURVIVORSHIP CARE DELIVERY: RESULTS FROM A POPULATION-BASED SURVEY

Archana Radhakrishnan¹; Allison Furgal²; Rachel Tocco¹; Sarah Hawley²; Ann S. Hamilton³; Kevin Ward⁶; Steven Katz⁴; Lauren P. Wallner⁵

¹General Medicine, University of Michigan, Ann Arbor, MI; ²University of Michigan, Ann Arbor, MI; ³Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA; ⁴UNIVERSITY OF MICHIGAN, Ann Arbor, MI; ⁵Internal Medicine, University of Michigan, Ann Arbor, MI; ⁶Emory University, Atlanta, GA. (Control ID #3873774)

BACKGROUND: There are 18 million cancer survivors in the United States (US) and the quality of their survivorship care is suboptimal, especially among vulnerable populations at risk for poor outcomes. While national organizations have called for shared care between primary care providers (PCPs) and oncologists, implementation of these models has been challenging across the diverse care delivery settings in the US. This is due, in part, to our lack of understanding of evolving provider roles during survivorship. We surveyed a large and diverse cohort of breast cancer survivors to characterize provider involvement in the delivery of survivorship care and management of survivorship issues, and explore disparities in provider involvement among vulnerable sub-populations.

METHODS: The iCanCare study is a population-based study of women with early-stage breast cancer diagnosed in 2014-2015 and surveyed 6 years into survivorship (2021-2022) (expected final N=1430, 60% current response rate). Respondents reported on: 1) which provider has been most responsible for providing your survivorship follow-up care (PCP-led, shared-care, oncologist-led); and 2) PCP management of survivorship issues (summary scale of 8-items asking respondents how often they discussed a survivorship issue, such as worry about recurrence and improving physical activity, with their PCP; overall response range from 0-40). We examined patient factors associated with PCP-led delivery and management of survivorship issues using multinomial logistic and linear regression, respectively.

RESULTS: In this preliminary sample, 23% reported PCP-led delivery of their survivorship care, 19% reported shared-care between the oncologist and PCP, and 58% reported oncologist-led delivery. Overall, PCP management of survivorship issues was moderate (mean summary score 19.3, SD 7.0). We did not find statistically significant variation in report of PCP-led delivery of survivorship follow-up care by patient factors. Women who were unemployed (vs. employed) were more likely to report greater PCP management of survivorship issues (mean 22.2 vs. 18.8, p <0.01)) as were patients with 2+ comorbidities (vs. 0 comorbidity) (mean 20.2 vs. 18.0, p<0.01). Results were confirmed in multi-variable analyses.

CONCLUSIONS: We found that in this cohort of breast cancer survivors who are more than five years out from initial treatment, reports of PCP involvement in survivorship was generally low. Notably, some sub- populations of vulnerable patients did report greater PCP management of survivorship issues. Lack of primary care involvement, especially later in survivorship, is a missed opportunity for achieving high-quality survivorship care. As we implement shared-care models as one strategy to improve quality, focusing next steps on engaging PCPs effectively and empowering them to be active participants in survivorship care delivery (e.g., clearly delineating roles and responsibilities, providing educational materials/resources to PCPs) will be critical.

CLINICAL AND GENETIC-BASED REFINEMENT OF THE WARFARIN DOSE

Noor Al-Hammadi^1,2; Kevin B Stephenson¹; Jie Hou³; Anne R. Bass⁴; Charles S Eby¹; Brian F. Gage¹

¹Department of Medicine, Washington University in St Louis School of Medicine, St Louis, MO;²Department of Health and Clinical Outcomes Research, Saint Louis University School of Medicine, Saint Louis, MO; ³Saint Louis University, Saint Louis, MO; ⁴Weill Cornell Medicine, New York, NY. (Control ID #3875225)

BACKGROUND: Warfarin remains a commonly prescribed anticoagulant, use of which is complicated by significant inter-patient variability in the therapeutic dose and a narrow therapeutic index. Algorithms to refine the warfarin dose are needed, especially during days 6-21 of warfarin therapy, when iatrogenic hemorrhages are common. This study is to develop clinical and genotype-guided dosing algorithms for days 6-21 of warfarin therapy.

METHODS: We analyzed data from the Genetic Informatics Trial of Warfarin Therapy to Prevent Deep Venous Thrombosis (GIFT). We randomly split data from the 1471 patients who achieved a therapeutic dose into training (80%) and validation (20%) datasets. We offered clinical, demographic, and laboratory variables into linear regression models. We also offered polymorphisms of the following genes VKORC1, CYP2C9, and CYP4F2 into the genetic models. We used prior research, biologic plausibility, and statistical significance (Akaike information criteria) to select variables. We quantified accuracy using correlation (R²) and mean absolute error (MAE) in the validation dataset.

RESULTS: The clinical model had an R² of 74.0% and MAE of 0.63 mg/day; the genetic model had an R² of 77.4% and MAE of 0.62 mg/day. The strongest predictors of therapeutic dose were the most recent warfarin doses and the current value of the International Normalized Ratio (INR).

CONCLUSIONS: Algorithms using clinical, demographic, and laboratory variables available from the initial 6-21 days of warfarin therapy can predict the therapeutic dose. These dose-refinements may be useful in guiding warfarin dosing.

COMPARATIVE EFFECTIVENESS OF CARE MODELS TO IMPROVE PAIN AND REDUCE OPIOIDS AMONG VA PRIMARY CARE PATIENTS ON LONG-TERM OPIOID THERAPY: A PRAGMATIC RANDOMIZED TRIAL

Erin E. Krebs^1,2; William Becker^3,8; David Nelson^5,2; Allyson Kats⁴; Patrick Hammett^5,2; Beth DeRonne⁵; Sean Nugent⁵; Agnes C. Jensen⁵; Karen H. Seal^7,6

¹Medicine, Minneapolis VA Health Care System, Minneapolis, MN; ²Medicine, University of Minnesota Medical School Twin Cities, Minneapolis, MN;³Internal Medicine, VA Connecticut Healthcare System, West Haven, CT; ⁴Public Health, University of Minnesota Twin Cities, Minneapolis, MN; ⁵CCDOR, Minneapolis VA Health Care System, Minneapolis, MN; ⁶Medicine, University of California San Francisco, SanAnselmo, CA; ⁷Medicine, San Francisco VA Health Care System, San Francisco, CA; ⁸Medicine, Yale University, New Haven, CT. (Control ID#3876626)

BACKGROUND: Patients prescribed long-term opioid therapy (LTOT) are at risk for unrelieved pain, poor quality of life, and serious adverse events. Guidelines recommend multimodal pain care and shared decision- making about opioid dose reduction, but primary care resources are often insufficient. The Veterans’ Pain are Organizational Improvement Comparative Effectiveness (VOICE) trial tested two collaborative care interventions for patients with chronic pain on LTOT. Aim 1 was to compare higher-intensity integrated pain team (IPT) versus lower-intensity pharmacist telecare collaborative management (TCM) for improving pain and reducing opioid dose. We hypothesized IPT would be superior to TCM.

METHODS: VOICE was a 10-site pragmatic randomized trial in VA primary care. Eligible patients had moderate-severe chronic pain and were prescribed opioids ≥20 mg/day. We randomized participants to 1 of 2 active 12-month interventions: 1) IPT, an interdisciplinary team intervention using motivational interviewing and multimodal therapies; or 2) TCM, a clinical pharmacist care management intervention using symptom monitoring and medication optimization. Both interventions provided individualized pain care and opioid tapering support. Masked assessors collected outcomes by telephone at 3, 6, 9, and 12 months. The primary outcome was pain response, defined as ≥30% decrease in Brief Pain Inventory (BPI) score (range 0-10, higher=worse) at 12 months. The main secondary outcome was ≥50% reduction in opioid daily dose. Primary analyses were intent-to-treat and used repeated measures logistic regression for comparisons of response rates.

RESULTS: We enrolled 821 patients and randomized 820. Participants’ mean age was 62.1 years (SD 10.6) and 13.5% were female. At baseline, the mean BPI was 6.7 (SD 1.5) in IPT and 6.6 (SD 1.6) in TCM. The baseline opioid daily dose was 80 mg (SD 73) in IPT and 75 mg (SD 57) in TCM. The primary outcome was assessed for 721 participants (88%) at 12 months. At 12 months, the mean BPI score was 6.1 (SD 1.8) in IPT and 6.0 (SD 1.9) in TCM. The pain response rate was 17% in IPT vs. 15% in TCM (p=0.61) and the model- estimated odds ratio of pain response for IPT vs. TCM was 1.11 (95% CI 0.74, 1.66). At 12 months, the mean opioid daily dose was 54 mg (SD 65) in IPT and 53 mg (SD 52) in TCM. The proportion with 50% dose reduction was 25% in IPT vs. 25% TCM (p=0.85) and the odds of dose reduction for IPT vs. TCM was 1.03 (95% CI 0.75, 1.42). Findings from 4 prespecified subgroup analyses also showed no difference between interventions.

CONCLUSIONS: Pain and opioid dose improvements were similar for two pain care delivery models augmenting primary care management of patients with chronic pain and LTOT. Local resources and preferences should drive decisions about which care model to implement.

COMPARATIVE EFFECTIVENESS TRIAL OF INTERDISCIPLINARY APPROACHES TO PAIN CARE: IMPACT ON CHANGE IN USE OF NON-DRUG THERAPIES IN VA PATIENTS WITH CHRONIC PAIN PRESCRIBED LONG-TERM OPIOID THERAPY

Karen H. Seal^1,2; Patrick Hammett³; William Becker^4,9; Elizabeth S. Goldsmith^3,5; David Nelson³; Allyson Kats³; Agnes C. Jensen⁶; Beth DeRonne⁷; Erin E. Krebs^8,5

¹Medicine, University of California San Francisco, SanAnselmo, CA; ²Integrative Health, San Francisco VA Health Care System, San Francisco, CA; ³Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN; ⁴Internal Medicine, VA Connecticut Healthcare System, West Haven, CT; ⁵Medicine, University of Minnesota Health Sciences, Minneapolis, MN; ⁶Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VA Health Care System, Minneapolis, MN; ⁷CCDOR, Minneapolis VA Health Care System, Minneapolis, MN; ⁸Medicine, Minneapolis VA Health Care System, Minneapolis, MN; ⁹Medicine, Yale School of Medicine, New Haven, CT. (Control ID #3875304)

BACKGROUND: Non-drug therapies (NDTs) are recommended as first-line treatment for chronic pain. Evidence is limited for approaches to increase uptake of NDTs for pain. The Veterans’ Pain Care Organizational Improvement Comparative Effectiveness (VOICE) trial compared two pain care models in veterans with chronic pain prescribed long-term opioid therapy (LTOT). This secondary analysis compared the effect of two pain care approaches on change in VOICE participants’ use of NDTs.

METHODS: From October 2017 to March 2021, 821 patients with chronic pain prescribed LTOT were enrolled in VOICE, a pragmatic trial at 10 VA sites across the U.S. Participants were randomly assigned for

12 months to either the Integrated Pain Team (IPT), an interdisciplinary intervention involving at least 3 clinical visits with medical and allied health providers (e.g., psychologist, physical therapist) and 8 motivational interviewing calls, or to Telecare Collaborative Management (TCM), consisting of at least 6 visits with a clinical pharmacist care manager supported by a consulting physician. Outcome assessors used the Pain Management Inventory to assess frequency of past-year use of NDTs at baseline, 6-, and 12-months. NDTs were categorized as manual therapies (acupuncture, chiropractic, and massage), exercise (yoga, Tai Chi, aerobic, stretching/strength training), and behavioral (relaxation, meditation, psychological). Thresholds for clinically meaningful use of NDTs were defined by expert (investigator and clinician) consensus. Multivariable repeated measures logistic regressions modelled the effect of intervention on change in meaningful use of ≥ 1 NDT at 6- and 12-months compared to baseline.

RESULTS: Of 820 randomized participants, 411 were assigned to IPT and 409 to TCM. Mean age was 62.1 +/- 10.6, 13.5% were female, and 24% identified as non-White race. Most participants in IPT (74%) and TCM (75%) reported meaningful use of ≥ 1 NDT at baseline. There were no significant between-group differences in change in meaningful use of ≥ 1 NDT at 6 and 12 months. In IPT, there were significant increases in meaningful use of ≥ 1 NDT at 6 months (82%, OR=1.58 1.16, 2.17) and 12 months (83%, OR= 1.64, 95% CI: 1.20, 2.23) compared to baseline. In TCM, there was a non-significant increase in meaningful use of ≥ 1 NDT at 6 months (77%, OR=1.09, 95% CI: 0.82, 1.44), and a significant increase at 12 months (85%, OR= 1.84, 95% CI: 1.31, 2.60) compared to baseline. In the overall sample, there were increases in meaningful use of ≥ 1 NDT(s) from baseline to 6- and 12-months; the largest gains were in meditation, relaxation, and strength training.

CONCLUSIONS: Meaningful use of NDTs increased in both IPT and TCM treatment groups over 12 months.

COMPARING GUIDELINES FOR STATIN AND ANTIHYPERTENSIVE TREATMENT AMONG U.S. VETERANS: A MICROSIMULATION STUDY

David Flood³; David Ratz²; Wyndy L. Wiitala²; TImothy Hofer^1,2; Rodney A. Hayward^1,2; Jeremy B. Sussman^1,2

¹Internal Medicine, University of Michigan, Ann Arbor, MI; ²VA Ann Arbor Healthcare System, Ann Arbor, MI; ³Internal Medicine, U. Michigan, Ann Arbor, MI. (Control ID #3874423)

BACKGROUND: While clinical guidelines for the use of anti-hypertensive medications and statins focus on a patient’s risk of developing cardiovascular disease (CVD) and specific risk factor treatment targets, they do not consider individualized estimates of treatments’ benefits and harms, called benefit-based tailored treatment (BTT). Furthermore, they address each risk factor in isolation, missing the chance to identify which treatment should be prioritized for a given patient. In this project, we examined the advantages of a BTT approach compared to current approaches.

METHODS: We conducted a microsimulation to compare the risks and benefits for U.S. veterans of different cholesterol and blood pressure treatment approaches for the primary and secondary prevention of CVD. Our model used all active primary care patients ages 40-79 years in the VA health care system beginning in 2011. We modeled each patient’s CVD health under three common guidelines (American College of Cardiology/American Heart Association, Veterans Affairs, and American College of Physicians/US Preventive Services Task Force) versus a BTT approach in which treatment decisions are guided by an individual’s predicted risks and benefits. The probability of key outcomes was estimated from personalized prediction models, then modified by the treatment recommended by each guideline. We then estimated the impact of each treatment approach compared to the status quo for outcomes including CVD events, deaths, and quality-adjusted life-years (QALYs).

RESULTS: The population included 3,682,371 individuals. Their median age was 65 years (IQR: (56 to 70), 91% were men, and 75% were white. At baseline, 18% had a history of CVD and 34% had a diabetes diagnosis. The BTT approach could prevent more CVD events and deaths and save more QALYs than the other guidelines. It would use less medicines than the ACC/AHA or VA guidelines but more than the ACP/USPSTF guidelines. For example, the BTT approach would prevent 29.2 CVD events per 1000 people over 5 years compared to 23.8 using the ACC/AHA guidelines, while using an average of 182 medications per 1000 people compared to. 214 for ACC/AHA. Findings were consistent across subgroups stratified by CVD history, age, sex, or race.

CONCLUSIONS: Among U.S. veterans, a benefit-based treatment approach, compared to ACC/AHA guidelines, could lead to major improvements in CVD outcomes while significantly decreasing overall medication use.

COVID-19 PANDEMIC DISRUPTIONS AND CHRONIC PAIN AMONG US MILITARY VETERANS ON LONG-TERM OPIOID THERAPY

Elizabeth S. Goldsmith^1,2; Patrick Hammett¹; Brian Martinson¹; Siamak Noorbaloochi^1,2; Barbara Clothier¹; Erin E. Krebs^3,1

¹Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN; ²Medicine, University of Minnesota Twin Cities, Minneapolis, MN; ³Medicine, Minneapolis VA Health Care System, Minneapolis, MN. (Control ID #3876114)

BACKGROUND: The COVID-19 pandemic may influence chronic pain outcomes through pandemic effects on systems and communities as well as through COVID-19 illness. We evaluated associations of COVID-19 illness and pandemic disruptions with pain-related functional interference within a cohort of US military veterans prescribed long-term opioid therapy for chronic pain.

METHODS: The Effects of Prescription Opioid Changes in Veterans (EPOCH) study is a national cohort that enrolled 9082 veterans in 2016. Participants have completed yearly surveys including Brief Pain Inventory Interference scale (BPI-I: 0-10 score, higher = worse; minimum clinically important change 1 point). Year 4 surveys (7/2020 – 2/2021) included NIH-VA-DOD Pain Management Collaboratory COVID-19 questions assessing pandemic disruptions. We compared pandemic indicators by prespecified demographic subgroups using chi-square tests, and estimated binomial logistic regressions with BPI-I change (worsened vs. stable/improved) as the dependent variable and pandemic experience indicators as independent variables, applying design weights and inverse probability weights to adjust for confounding.

RESULTS: Within the final analytic sample (N=3833), 75% (n=2876) of year 4 surveys were returned between July and November 2020, prior to the late 2020 US COVID-19 peak. Mean BPI-I was 6.3 (SD 2.2) at both year 3 and year 4. 5% of respondents reported COVID-19 illness before survey return. 59% reported the pandemic reduced their ability to get healthcare, with higher prevalence among veterans under 65 years old (66%) than 65+ (56%, p<0.001). 53% reported the pandemic worsened their mental and emotional health, with higher prevalence under 65 (60%) vs 65+ (50%, p<0.001) and among urban (56%) vs rural (49%) residents (p<0.001). Self-reported prevalence of all pandemic disruptions was higher among veterans under 65 years old than among veterans 65 and older. Self-reported COVID-19 illness did not significantly associate with BPI-I change between year 3 and year 4 (OR 0.90, 95% CI 0.53-1.54). Self-reported pandemic-related worsening of ability to get healthcare was associated with higher odds of worsening BPI-I vs. remaining stable or improving (OR 1.32, 95% CI 1.04–1.69). Self-reported pandemic-related worsening of mental/emotional health was associated with higher odds of worsening BPI-I (OR 1.72, 95% CI 1.34–2.21). Other pandemic disruptions were also associated with worsening BPI-I (worsened finances OR 1.37, 95% CI 1.07–1.74; worsened ability to meet basic needs OR 1.38, 95% CI 1.08–1.77)

CONCLUSIONS: In the first COVID-19 pandemic year, most veterans with chronic pain reported pandemic-related disruptions to healthcare access or mental/emotional health. Disruptions, but not reported COVID-19 illness, were significantly associated with worse pain outcomes. Health care access and support for mental/emotional health should be maintained during health emergencies.

COVID PANDEMIC EFFECTS ON GLYCEMIC CONTROL AND OTHER OUTCOMES IN PATIENTS WITH TYPE 2 DIABETES AT AN ACADEMIC MEDICAL CENTER

Lawrence Ma, Joseph Diaz, Jennifer DeConde, Melissa A. Wong, Bernice Ruo

Internal Medicine, University of California San Diego, La Jolla, CA. (Control ID #3867955)

BACKGROUND: Few studies within the United States have assessed the effect of the pandemic on the quality of chronic disease management for patients with type 2 diabetes (T2DM). We hypothesized that diabetes management would be adversely impacted, especially in individuals who are older, non-white, or living in zip codes with lower household incomes.

METHODS: This retrospective study compares diabetes outcomes pre-COVID (3/1/2019 – 2/29/2020) to during COVID (3/1/2020 – 2/28/2021) at an urban academic internal medicine practice. Adult patients with T2DM and at least one outcome measure in each time period were included. Patients with end-stage renal disease were excluded. Demographics including age, gender, race, ethnicity, insurance type, and zip codes were collected. Outcome measures included: hemoglobin A1c (Hgb A1c), systolic blood pressure (SBP), diastolic blood pressure (DBP), low-density lipoprotein level (LDL), and body mass index (BMI). T-test and ANOVA were used to determine statistical significance (p-value < 0.05).

RESULTS: 998 total patients were included, 52% were female. Mean age was 65 ± 11 years with 19% of individuals over the age of 75. 57% identified as White, 20% as Asian, 7% as Black, and 16% as other. 12% identified as Hispanic. 50% of the study population lived in zip codes with an estimated annual household income > $80,000. All patients were insured: 35% had commercial insurance, 51% had Medicare, 10% had Medicaid, and 4% had other forms of insurance. See table for diabetes-related outcome measures. There were no significant differences in any of the outcome measures during the two time points including when stratified by income, race, gender, ethnicity, age, or insurance type.

CONCLUSIONS: In this cohort of patients with T2DM, the COVID pandemic did not have a significant clinical or statistical impact on Hgb A1c, BMI, SBP, DBP, or LDL. Reasons for this may include: a cohort with well-controlled diabetes at baseline who had established primary care prior to the pandemic and the rapid implementation of a telehealth program. Limitations include a small sample size at a single academic center that consisted of a relatively healthy and affluent patient population. Further studies are needed to better understand the broader impact that the COVID pandemic has had on chronic disease management, and which populations may be more vulnerable to worsening health outcomes during a pandemic.

CUMULATIVE DOSE OF REPEATED CORTICOSTEROID INJECTIONS AND EMERGENCY DEPARTMENT VISITS/HOSPITALIZATIONS

Terin Sytsma¹; Shannon Thomas²; Laura Greenlund³

¹Internal Medicine, Mayo Clinic, Rochester, MN; ²University of Minnesota Twin Cities, Minneapolis, MN; ³Internal Medicine, Mayo Clinic, Rochester, MN. (Control ID #3869778)

BACKGROUND: Corticosteroid injections (CSI) are a common treatment for numerous causes of pain, particularly in medically complex patients who are poor surgical candidates. Despite decades of use, there is a paucity of literature regarding the systemic effects of cumulative doses of intraarticular/bursa CSIs. Systemically administered corticosteroids are known to cause immunosuppression, adrenal suppression, and significant hyperglycemia, all of which can result in emergency department (ED) visits and potentially hospitalization. We evaluated whether the cumulative dose of injected corticosteroids was associated with an increased number of ED visits/hospitalizations.

METHODS: Utilizing an institutional database, adult patients at our institution receiving joint, bursa and spinal CSI were followed from May 2018 to July 2022. Demographics, cumulative CSI dose, and number of ED visits/hospitalizations were collected. Based on cumulative triamcinolone equivalents received, patients were divided into “High”(≥ 600 mg) , “Medium”(160-599 mg), and “Low”(<160 mg) dose cohorts.

Descriptive statistics summarized the demographics. Logistic regression models ascertained odds of ED visits/hospitalization in relation to cumulative CSI dose.

RESULTS: 8817 patients were included: 247 in the High-dose, 2506 in the Medium-dose, and 6063 in the Low-dose cohort. Mean age was 68 years-old, and 61.9% of patients were female. 43,156 CSI occurred over the study period. The mean total CSI dose was 847 mg of triamcinolone equivalents (range 600-2140 mg) in the High-dose group compared to 276 mg (range 160-599 mg) and 70 mg (range 2.7-159 mg) in the Medium- and Low-dose groups respectively. The total number or ED visits/hospitalizations was 19,121 over the 4-year study period. Logistic regression modeling showed that patients receiving high and medium doses of CSI were more likely to have at least one ED visit/hospitalization during the study period with an odds ratio of 1.28 (CI 1.16-1.41, p<0.001) and 1.56 (CI 1.17-2.08, p=0,002) in the Medium-dose and High-dose groups respectively compared to the Low-dose cohort.

CONCLUSIONS: Patients receiving larger cumulative doses of injected corticosteroids were more likely to have at least one ED visit/hospitalization during the study period. This could represent systemic effects of injected corticosteroids and/or the complex healthcare needs of patients receiving CSI. Further work needs to be done to better isolate the effect of cumulative CSI dose on adverse health outcomes.

DETERMINING RISK FACTORS OF PHYSICAL INACTIVITY AMONG ADULTS WITH CHRONIC CONDITIONS SINCE THE START OF THE COVID-19 PANDEMIC

Nicholas Demetriou¹; Morgan Bonham²; Julia Yoshino Benavente²; Stephanie Batio³; Stacy Bailey²

¹Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ²General Internal Medicine, Northwestern University, Chicago, IL; ³Health Literacy and Learning Program, Northwestern University, Chicago, IL. (Control ID #3876474)

BACKGROUND: Physical inactivity results in greater than 5 million global premature deaths annually. Physical inactivity is closely linked with chronic conditions such as cardiovascular disease (CVD) and type II diabetes and is essential to their management. The Covid-19 pandemic has significantly disrupted physical activity levels, with a particularly stark decrease among individuals with medical conditions. Understanding how this trend has progressed along with the pandemic is vital in equipping clinicians and public health officials with the latest knowledge to address physical inactivity. The goal of this study is first to determine how activity levels have trended since the start of the Covid-19 Pandemic. Second, we aim to identify adults with the highest risk of persistent inactivity.

METHODS: A cohort of 673 adults with 1+ chronic conditions from across Chicago enrolled in our cohort study in March 2020. Interviews were conducted with this cohort every four months for 28 months. The Behavioral Risk Factor Surveillance System Questionnaire, Section 10, assessed participants' physical activity levels to determine if the participants met the CDC’s adult physical activity guidelines targets: an aerobic target of 150 minutes of moderate-intensity physical activity per week and a strength target of two days of muscle-strengthening activity per week. Trajectory mixture models were used to identify clusters of participants following the same trajectories of physical activity. Multivariate logistic regression models were then applied to identify subgroups likely to be classified in different physical activity trajectories, adjusting for potential confounders.

RESULTS: Participants were on average 62 years old, with 60% females, 29% living under poverty, and 67% with 3+ chronic health conditions. Physical activity trajectory analysis for the two years following the onset of the Covid-19 pandemic identified two distinct groups; individuals who persistently met physical activity targets and individuals that did not. Within our study population, (45%) consistently met the aerobic target, (29%) consistently met the strength training target, and (21%) consistently met both. Subgroups less likely to meet physical aerobic, strength and overall physical activity targets included those identifying as Latinx (Aerobic: aOR: 0.45, 95% CI: 0.26,0.79; Strength: aOR: 0.46, 95% CI: 0.25,0.85; Overall: aOR: 0.35, Overall: aOR: 0.37, 95% CI:0.20,0.68).

CONCLUSIONS: In conclusion, our study has identified race as a key predictor of whether a person with chronic health conditions meets recommended physical activity targets. Other confounders, such as geography, specific disease states, and family and work commitments, likely confound the correlation between race and physical activity. Our next steps are to analyze other factors that may account for the correlations thus far identified.

DO RACIAL AND ETHNIC DISPARITIES IN SGLT2 OR GLP1 PRESCRIPTIONS DIFFER BY PAYER: A NATIONALLY REPRESENTATIVE STUDY

Lurit Bepo^2,1; Oanh K. Nguyen²; Anil Makam²

¹National Clinician Scholars Program at UCSF, San Francisco, CA; ²Internal Medicine, University of California San Francisco School of Medicine, San Francisco, CA. (Control ID #3877316)

BACKGROUND: Sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP1) receptor agonists lower atherosclerotic cardiovascular disease (ASCVD) risk, morbidity, and mortality. Among persons with type 2 diabetes mellitus (T2DM), there is differential access to these medications by race and ethnicity. However, the extent to which insurance type and its interaction with race and ethnicity is associated with decreased SGLT2 and GLP1 use is unknown. This cross-sectional study examines the association between insurance type, race and ethnicity, and SGLT2 and GLP1 prescription rates in adults with T2DM.

METHODS: Design: Our study used nationally representative survey data of the U.S. civilian noninstitutionalized population from the 2018 and 2019 Medical Expenditure Panel Survey (MEPS). We used descriptive statistics to assess prevalence of SGLT2 and GLP1 prescriptions, sociodemographic factors, and clinical characteristics. We used sequential multivariate logistic regression to analyze the interaction between insurance type and race and ethnicity: 1) unadjusted, 2) adjusted for cardiovascular risk factors, and 3) adjusted for socioeconomic (SES) and health care access factors.

Participants: Adults ≥18 years old with T2DM.

Exposures: Primary insurance type defined as >6 months of private insurance, Medicare, or Medicaid. Race and ethnicity defined as Non-Hispanic White or Non-White and Hispanic.

Outcome: Rate of any SGLT2 or GLP1 prescription.

RESULTS: There were 4997 adults with T2DM in the 2018-2019 MEPS surveys who were 50% female with mean age 64 years. 34% had private insurance, 57% had Medicare, and 10% had Medicaid. Overall, 13% had any SGLT2 or GLP1 prescription (6% SGLT2, 9% GLP1). Individuals with private insurance had the highest prescription rates (17%), followed by Medicare (11%), and then Medicaid (10%).

In our unadjusted logistic regression, Non-Hispanic White individuals with private insurance and Medicare had statistically significant higher rates of any SGLT2 or GLP1 prescription than Hispanic and non-White persons (21% vs 10%, p=0.000 and 12% vs 9%, p=0.034, respectively). This disparity persisted in private insurance after adjusting for clinical (15% vs 7%, p=0.000) and SES/access factors (14% vs 7%, p=0.000) but was no longer statistically significant for Medicare. There were not statistically significant racial and ethnic disparities in Medicaid.

CONCLUSIONS: Overall SGLT2 and GLP1 prescription rates are low for adults with T2DM and differ by insurance type and race and ethnicity. Although privately insured individuals had the highest prescription rates, they also had the largest racial and ethnic disparities. Disparities in Medicare were attenuated by adjustment, suggesting that these findings may be due to differences in cost-sharing, prior authorization, and other formulary restrictions. Interventions targeting formulary policies may be a helpful first step to reduce inequities among privately insured individuals with T2DM.

ECONOMIC FACTORS ARE A MAJOR DRIVER OF MEDICATION NON-ADHERENCE FOR NON-COMMUNICABLE DISEASES IN RURAL KENYA

Pooja Gala¹; Jemima Kamano²; Manuel Vazquez-Sanchez³; Richard Mugo²; Vitalis Orango²; Sonak Pastakia⁵; Carol Horowitz⁴; Joseph Hogan⁶; Rajesh Vedanthan¹

¹Department of Medicine and Population Health, New York University Grossman School of Medicine, New York, NY; ²Medicine, Moi University, Eldoret, Uasin Gishu County, Kenya; ³Population Health, New York University Grossman School of Medicine, New York, NY; ⁴General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ⁵Purdue University, West Lafayette, IN; ⁶Biostatistics, Brown University, Providence, RI. (Control ID #3874431)

BACKGROUND: Poor medication adherence in low-and middle-income countries (LMICs) is a major cause of suboptimal hypertension (HTN) and diabetes (DM) control. We aimed to identify key factors that contribute to suboptimal medication adherence in western Kenya.

METHODS: We conducted a cross-sectional analysis of baseline data of participants enrolled in the BIGPIC study in western Kenya. All participants were age ≥ 35 with either DM or HTN who had been prescribed medications in the past three months. Baseline data included socio-demographic characteristics, economic status, and medication adherence. Predictors of medication adherence were separated into the five WHO dimensions of medication adherence: conditions-related factors, patient-related factors, therapy-related factors, economic-related factors (monthly income, cost of transportation, monthly cost of medications), and health system-related factors. A multivariable analysis, controlling for age and sex, was conducted to identify drivers of suboptimal medication adherence. Estimated predicted values of medication adherence at different combinations of transportation and medication costs were calculated, generated from the multivariable regression model.

RESULTS: The analysis included 1,496 participants (73.7% women) with a mean age of 60 years (range 35-97). Suboptimal medication adherence was reported by 71.2% of participants. Economic factors were associated with medication adherence. In a multivariable analysis that investigated specific costs, transportation costs were found to be associated with worse medication adherence (transportation costs Kenyan Shillings (KSH) 1-99 beta-coefficient 0.7 (95% CI 0.4, 1.1); transportation costs KSH 100+ beta- coefficient 0.5 (95% CI 0.1, 0.9)). In contrast, we found no association between medication costs and medication adherence. Figure 1 demonstrates that transportation costs were associated with higher (worse) estimated predicted adherence scores, while medication costs were not associated with adherence scores.

CONCLUSIONS: Suboptimal medication adherence is highly prevalent in Kenya, and primary associated factors include costs, particularly indirect costs of transportation. Addressing all economic factors associated with medication adherence will be important to improve outcomes for non-communicable diseases.

EFFECT OF OFFERING BUPRENORPHINE TO IMPROVE PAIN AND REDUCE OPIOIDS AMONG PATIENTS ON HIGH-DOSE LONG-TERM OPIOID THERAPY: A PRAGMATIC RANDOMIZED TRIAL

William Becker^1,2; Karen H. Seal³; Beth DeRonne⁷; Joseph Frank⁹; Agnes C. Jensen⁶; Allyson Kats⁵; David Nelson⁷; Patrick Hammett⁸; Erin E. Krebs⁴

¹VA Pain Research Informatics Multi-morbidities and Education Center, West Haven, CT; ²Yale School of Medicine, New Haven, CT; ³Medicine, University of California San Francisco, SanAnselmo, CA; ⁴Medicine, Minneapolis VA Health Care System, Minneapolis, MN; ⁵University of Minnesota School of Public Health, Minneapolis, MN; ⁶Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VA Health Care System, Minneapolis, MN; ⁷CCDOR, Minneapolis VA Health Care System, Minneapolis, MN; ⁸Research, Minneapolis VA Health Care System, Minneapolis, MN;⁹University of Colorado, Denver, CO. (Control ID #3875757)

BACKGROUND: Opioid tapering is challenging for patients and providers. Observational studies show promise for switching to the partial opioid agonist buprenorphine as an alternative to tapering. Buprenorphine (BUP) has similar analgesic properties yet is safer than other opioids. The Veterans’ Pain Care Organizational Improvement Comparative Effectiveness (VOICE) trial tested interventions to improve pain and reduce opioid use among VA primary care patients with chronic pain on long-term opioid therapy (LTOT). We examined whether offering the option of BUP, compared with no BUP option, would lead to improved pain and greater opioid dose reduction.

METHODS: VOICE was a 12-month, 10-site, randomized trial that enrolled VA primary care patients with moderate to severe pain despite LTOT. Participants were randomized to 1 of 2 pain care models; both models involved individualized opioid tapering recommendations. Participants prescribed high-dose opioids (≥70 mg/day) were additionally randomized to receive/not receive the option to discuss BUP and, if deemed appropriate, to switch to BUP. Masked assessors collected outcomes at 3, 6, 9, and 12 months. The primary outcome was change from baseline to 12 months in the Brief Pain Inventory (BPI: score range 0-10, higher=worse). The main secondary outcome was opioid dose in milligram morphine equivalents (MME). For MME calculations, BUP was considered to be 0. Primary analyses were intent-to-treat and used repeated measures logistic regression for comparisons of primary outcomes.

RESULTS: We randomized 207 to BUP option (n=104) or no BUP option (n=103). Mean age was 60.9 years (SD 10.2), 10.6% were female, and 13.9% were Black. At baseline, the mean BPI was 6.8 (SD 1.5) for the BUP arm and 6.8 (SD 1.6) for the no BUP arm. The baseline opioid daily dose was 157 mg (SD 75) for BUP and 165 mg (SD 88) for no BUP. Of 104 BUP option participants, 28 consented to switch to BUP. Across the 10 study sites, the proportion of patients assigned to the BUP arm who switched to BUP was 0-64%. At 12 months, the mean BPI score was 6.1 (SD 1.9) in the BUP arm and 6.3 (SD 1.7) in the no BUP arm; mean BPI change did not differ between groups (.62 for BUP vs .49 for no BUP, p=0.67). At 12 months, the mean opioid daily dose was 92 mg (SD 98) in the BUP arm and 105 mg (SD 89) in the no BUP arm; mean opioid dose reduction did not differ between treatment groups (65 mg for BUP vs. 61 mg for no BUP, p=0.55). CONCLUSIONS: Adding the option to switch from full-agonist opioids to BUP did not improve pain severity nor opioid dose reduction compared with individualized tapering alone. Minimal uptake of BUP at some sites limited ability to detect an effect. Qualitative analyses will explore patients’ experiences with the BUP option. To maximize patient-centeredness, prescribers may consider offering switch to BUP as an alternative to standard opioid tapering.

ENROLLMENT IN A CARE MANAGEMENT INTERVENTION AND CONTROL OF BLOOD CHOLESTEROL LEVELS FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESS

Karly A. Murphy¹; Elizabeth Sarker^3,2; Elizabeth A. Stuart³; Courtney Cook⁴; Stacy Goldsholl⁴; Gail L. Daumit⁴

¹Medicine, University of California San Francisco, San Francisco, CA; ²Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; ³Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; ⁴Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. (Control ID #3866776)

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death for people with serious mental illness (SMI), contributing to 10-20 year premature mortality. Despite this risk, people with SMI often do not receive guideline-concordant care processes. We examined whether a care management intervention improved control of blood cholesterol for adults with SMI and identified factors associated with improved care quality.

METHODS: We used data from an 18-month comprehensive CVD risk reduction clinical trial for adults with SMI that was shown to reduce overall CVD risk. Trial participants had at least one CVD risk factor.

Intervention participants met with a health coach bi-weekly and a nurse for lifestyle counseling, medication adherence counseling, and care management, tailored to their CVD risk profile. This analysis examined participants recommended for cholesterol management: dyslipidemia, aged 40-75 years with diabetes, and/or with a 10-year ASCVD risk of >=7.5%. Our primary outcome was change in LDL cholesterol (LDL-C). We used t-tests and chi-square tests to describe differences in patient characteristics, intervention components, and changes in mean LDL-C levels; we also stratified by whether participants received an increase in cholesterol medication as a marker of active clinical care.

RESULTS: Of the 216 participants, 81% (N=174) of participants had dyslipidemia, 43% (N=92) had diabetes, 51% (N=110) had an elevated ASCVD risk score, and 62% (N=134) were not prescribed any cholesterol medications. During the study, 26% (N=27) of intervention participants and 16% (N=18) of control participants received cholesterol medication changes (p=0.1). Intervention participants were more likely to receive medication changes if they were older, female, Black, had a higher number of CVD risk factors, elevated ASCVD risk score, or diabetes at baseline compared with presence of depression or elevated ASCVD risk score in the control arm. Across the study, mean LDL-C levels declined more for the intervention group (-11.7 mg/dl, SD=29.9) than for the control (-3.0 mg/dl, SD=32.4) (p=0.046). In stratified analysis, LDL-C levels declined more for intervention participants who received medication changes (-24.0 mg/dl, SD=38.8) compared with those who did not (-7.2 mg/dl, SD=24.8) (p=0.01). In the control group, LDL-C levels did not differ when stratified by medication changes (-4.4 mg/dl [SD=41.7] vs -2.7 mg/dl [SD=30.9]) (p=0.8). Intervention participants with medication changes had more visits with their PCP when accompanied by the study nurse (3.3 visits [SD=2.9] vs. 1.2 visits [SD=1.4]) (p<0.001).

CONCLUSIONS: Mean LDL-C levels declined in participants who received a comprehensive CVD risk reduction intervention but not for participants who did not. Given the long-term risks of elevated cholesterol, interventions that sustain reductions in LDL-C are of great interest. Future population health interventions are needed to address cholesterol management for people with SMI.

EPIDEMIOLOGY, TRENDS AND UTILIZATION DISPARITIES OF CATHETER ABLATION AND ITS ASSOCIATION WITH CORONARY VASOSPASM AMONGST PATIENTS WITH NON- VALVULAR ATRIAL FIBRILLATION- A NATIONWIDE STUDY

Siva Naga S. Yarrarapu¹; Parth Shah²; Aditya Desai⁷; Andrea Mestre³; Adedolapo A. Ottun⁶; Shiv Shah⁴; Beshoy Iskander⁵; Abdelhakim Ouled Said⁹; Deepika Vunnam⁸; Vikramaditya Samala Venkata¹⁰; Renu Bhandari¹¹; Sahithi Kantamneni¹²; Anmol Bharti¹³; Ya-Ching Hsieh¹⁴; Urvish K. Patel¹⁵

¹Internal Medicine, Monmouth Medical Center, Long Branch, NJ; ²Internal Medicine, Reading Hospital, West Reading, PA; ³Universidad del Rosario, Bogota, Cundinamarca, Colombia; ⁴Government Medical College Surat, Surat, Gujarat, India; ⁵Case Western Reserve University, Cleveland, OH; ⁶Agogo Presbyterian Hospital, Agogo, Ashanti, Ghana; ⁷Internal Medicine, University of California Riverside, Riverside, CA; ⁸Dr Pinnamaneni Siddhartha Institute of Medical Sciences & Research Foundation, Vijayawada, Andhra Pradesh, India; ⁹IBN-SINA UNIVERSITY HOSPITAL, Rabat, Morocco; ¹⁰Cheshire Medical Center and Dartmouth- Hitchcock Keene, Keene, NH; ¹¹Manipal College of Medical Sciences, Pokhara, Nepal; ¹²Alluri Sitarama Raju Academy of Medical Sciences, Eluru, Andhra Pradesh, India; ¹³University College of Medical Sciences, Delhi, Delhi, India; ¹⁴Public Health, Icahn School of Medicine at Mount Sinai, New York, NY;¹⁵Public Health and Neurology, Icahn School of Medicine at Mount Sinai, Jersey City, NJ. (Control ID #3871811)

BACKGROUND: Non-valvular atrial fibrillation(NVAF), the most common supraventricular tachyarrhythmia, poses severe economic burden with high mortality rates. Catheter ablation(CA) is an important curative treatment for NVAF. Nationwide data on utilization and outcomes of CA is limited. Additionally, coronary vasospasm is a rare, life-threatening peri-operative complication of CA with limited literature in Caucasians.

METHODS: A retrospective cross-sectional cohort study was designed from NIS 2007-2017. Hospitalizations with NVAF treated by CA were identified using ICD 9 & 10 codes. CA induced vasospasm was identified. Univariate analysis was performed using chi square and unpaired t test to evaluate socio- demographic and geographic disparities. Cochran Armitage trend test was used to evaluate utilization trend. Multivariate survey logistic regression to identify predictors of coronary vasospasm. We calculated adjusted OR, 95%CI keeping p<0.001 as significant.

RESULTS: Out of 35,906,946 primary & secondary diagnosis of NVAF, 343641(0.96%) patients underwent CA. Utilization trend of CA declined from 1% in 2007 to 0.73% in 2017(p<0.0001). Patients aged 50-75yrs(aOR 1.6,95%CI:1.52-1.66), Native American race(1.39,1.24-1.55), CHF(1.06,1.05-1.08), higher annual income(1.15,1.12-1.18), private insurance(1.3,1.28-1.33) had higher odds of utilization. The Mid-West region (0.71, 0.69-0.73) fared lower than the South, the West and the North-East.(all p values < 0.0001). Prevalence of coronary vasospasm was higher among CA vs without CA(0.03% vs 0.02%; p<0.0001), however, non-significant association seen between CA & vasospasm(aOR1.29,0.83-2.03;p<0.2599). Predictors of vasospasm were male(2.04, 1.80-2.31), non-elective procedure(0.84, 0.70-0.99), substance abuse(3.36, 2.68-4.21), and hypertension(1.25, 1.09–1.45)(all p<0.0001).

CONCLUSIONS: The overall trend for catheter ablation utilization was found to be decreasing from 2007 to 2017. However, the outcomes of catheter ablation such as odds of death, discharge to non-home, severe disability, morbidity, and risk of death were found to have statistically improved outcomes compared to no ablation group. The Mid-West region had lower odds of utilization while the people of Native American race had higher odds compared to remainder of US population. Identification of factors associated with lower utilization of CA and its disparities will help to mitigate the burden associated with NVAF.

EVALUATING THE FINANCIAL SPENDING OF THE 2022 FISCAL YEAR AT AN URBAN STUDENT-RUN FREE CLINIC

Mina Sitto¹; Jennifer Schmidt¹; Adlai Nelson¹; Sara L. Ma¹; Kathy Lu¹; Alex Wind¹; Nili Modi¹; Sara Kazyak¹; Robert Sherwin²

¹School of Medicine, Wayne State University School of Medicine, Detroit, MI; ²Emergency Medicine, Detroit Medical Center, Detroit, MI. (Control ID #3876289)

BACKGROUND: Medical student-run free clinics (SRFC) provide the resources to support healthy outcomes for patients experiencing financial hardship. This study examines a SRFC in an urban Midwestern community that provides longitudinal healthcare to the underserved and uninsured populations. The clinic treats chronic conditions like diabetes, hypertension, and other comorbidities through regular visits, pharmaceutical interventions, and medical tests and screenings. This requires the clinic to take a prudent approach with the distribution of their funds in order to best serve the community and their needs. Few studies focus on the financial spending and budgeting aspects of operating a SRFC. The goal of this study is to analyze the yearly spending and the distribution of funds to efficiently operate as a SRFC in the community.

METHODS: Walk-in student-run clinics were held every Saturday morning in an urban Midwestern city. A list of supplies was recorded weekly within a spreadsheet by two student clinic coordinators. The costs and quantities were also recorded and divided into ten categories: Over-the-Counter Medications, Medical Tests, Electronic Medical Record System, Clinic Security, Prescription Medications, Food/Drinks, Office Supplies, Medical Supplies, Hygienic Items, Immunization Supplies, and Non-Profit Status and Website Subscriptions. The costs for each category was summed and the data was compared using percentages.

RESULTS: A total of $34,186.50 was accrued in the December 2021 to November 2022 fiscal year. Preliminary results show that 48.6% of the clinic’s funds were spent on prescription medications, followed by 10.5% on medical tests and screenings, 8.8% on immunization supplies, 8.4% on maintaining the electronic medical record, and 8.1% on securing the clinic.

CONCLUSIONS: This study found that the majority of the clinic’s funds were allocated to prescription medications, and medical tests and screenings such as lipid panels, hemoglobin A1C, blood glucose, and rapid COVID-19 tests. A likely explanation for this distribution is based on patient compliance and consistent monitoring through follow-up appointments for the management of chronic disease. These results can shape future budgeting and estimate spending costs for our clinic, as well as for other free health clinics. Future projects could focus on evaluating the fiscal spending for the past five years, using the trends to forecast future costs. Determining the estimated costs can assist the clinic in making informed decisions on their spending and grant submissions.

EVALUATION OF THE ROLE OF MILD COGNITIVE IMPAIRMENT AND FRAILTY IN 30-DAY READMISSIONS DURING ADMISSION FOR AN ACUTE EXACERBATION OF COPD

Juhi C. Gupta¹; Nicole Kappel²; Leah J. Witt³; Alex Spacht⁷; Megan Huisingh-Scheetz²; Steven R. White⁴; Vineet M. Arora⁵; Valerie G. Press⁶

¹Pritzker School of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; ²General Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL;³Geriatrics, University of California, San Francisco, CA; ⁴Medicine, University of Chicago, Chicago, IL; ⁵Medicine, University of Chicago Medical Center, Chicago, IL; ⁶Medicine, University of Chicago, Chicago, IL; ⁷Brigham and Women's Hospital Department of Medicine, Boston, MA. (Control ID #3876226)

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is the third leading cause of readmissions among patients aged 65 years or older in the US. Sixty-eight percent of patients with COPD have at least one comorbidity, and 30% admitted for acute exacerbations of COPD (AECOPD) have more than four comorbidities. Frailty, a syndrome of limited reserve to withstand/recover from stress (e.g., hospitalizations), affects many older patients with AECOPD. Our prior work showed that weak grip strength, a frailty marker, was associated with a 30-day COPD readmission risk. There is published evidence of an association between mild cognitive impairment (MCI) and frailty. Additionally, there is a greater prevalence of MCI in patients with COPD (versus normative data). MCI has been associated with poor outcomes post- AECOPD and difficulty with self-management (e.g., poor inhaler technique). To address this, we examined associations between impaired cognitive function in admission and all-cause 30-day readmissions among frail and pre/non-frail patients with COPD.

METHODS: Between July 2016 – December 2022 we prospectively identified adult inpatients admitted to an urban, academic hospital with AECOPD who were ≥ 18 years. Participants completed surveys and underwent physical assessments at one timepoint during their admission to assess demographics, frailty status (frail/pre-frail/non-frail) using Frieds Frailty Criteria (score= 0 non-frail, 1-2 pre-frail, and 3-5 frail), and MCI using the Montreal Cognitive Assessment (MoCA) (MoCA score <26, version 7.1 or 8.1). Descriptive statistics, chi-squared tests, and t-tests were used to analyze the data using STATA 15.1.

RESULTS: Enrolled participants (n=78) had a mean age of 63.7±9.4 years; 93% self-identified as black and 53% as female. Most of our population had MCI (84%). There were no significant differences in mean MoCA scores between participants who were frail versus pre/non-frail (19.4 ± 4.7 vs. 20.9 ± 4.7, p=0.2) or MCI (64% vs 77%, p=0.2). All-cause 30-day readmissions were not significantly different between frail and non-frail/pre-frail groups (15% vs. 13%, p=0.8). Similarly, there were no significant differences in 30-day readmissions comparing MCI vs. no MCI, though effect size for 30-day readmissions was nearly 2 times greater for the MCI group (MCI 15% vs. no MCI 8%, p=0.5).

CONCLUSIONS: Our data suggest that MCI is prevalent among patients admitted with AECOPD. Further, patients who demonstrated MCI during their inpatient evaluation had twice the rate of 30-day readmissions. MCI thus may be a potential risk factor for readmission among this population. Our future work will continue to evaluate the role of MCI and frailty in post-discharge functional trajectories regarding readmissions amongst older adults with COPD to determine their roles in risk-stratification and the potential for tailored interventions to reduce early readmissions.

EXAMINING THE INTERPLAY BETWEEN RACE/ETHNICITY, PATIENT-PHYSICIAN COMMUNICATION AND CANCER-RELATED POST-TRAUMATIC STRESS IN BREAST CANCER SURVIVORS WITH COMORBID DIABETES

Karisma Pantaleon¹; Christina Wang³; Lauren Guerra¹; Mita S. Goel²; Yael T. Harris⁴; Jenny J. Lin¹

¹Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Northwestern University Feinberg School of Medicine, Chicago, IL; ³Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY; ⁴Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY. (Control ID #3874378)

BACKGROUND: Breast cancer is the most common cause of cancer in women in the United States. Although curable, breast cancer survivors (BCS) are at risk of developing significant psychological distress associated with their cancer. BCS are also more likely to experience comorbid diabetes mellitus (DM), which may worsen distress. Prior studies suggest that minoritized BCS commonly experience cancer-related post- traumatic stress (PTS), a condition that is associated with reduced quality of life. Effective patient-physician communication is associated with improved psychological well-being, higher quality of life, and may prolong survival. We aim to evaluate the relationship between race/ethnicity, patient-physician communication, and cancer-related distress in BCS with comorbid DM.

METHODS: BCS with DM were surveyed using the Impact of Events Scale-Revised (IES-R) to assess for cancer-related PTS and the Patient Reactions Assessment (PRA) to assess perceptions of patient-provider communications with their cancer (PRA-C) and DM providers (PRA-D). BCS with IES-R score >24 were characterized as having probable cancer-related PTS. Race/ethnicity, PRA scores, and IES-R scores were compared using Pearson’s correlation for continuous variables and the Kruskal-Wallis test for those with and without PTS.

RESULTS: A total of 162 female BCS with DM [mean (SD) age: 66.6 (7.1) years] who self-identified as White (40.1%), Black (31.5%), or Hispanic/Other (28.4%) were included. Non-White groups reported worse communication with their cancer providers [median PRA-C (IQR): White: 51 (14) vs. Black: 46 (9) vs. Hispanic/Other 45 (5), p=0.003] but not with their DM providers [median PRA-D (IQR): White: 48 (12) vs. Black: 46 (9) vs. Hispanic/Other: 46 (5), p=0.22]. PRA-C and IES-R scores were significantly correlated, such that improved communications with cancer providers (r=-0.23, p=0.004), but not DM providers (r=-0.13, p=0.08), were associated with lower cancer-related PTS. BCS with cancer-related PTS had lower PRA-C scores [median (IQR): 45(3) vs. 48(12), p=0.04] but no difference in PRA-D scores [median (IQR): 46(10) vs. 47(10), p=0.22] compared to those without cancer-related PTS. In subgroup analyses by race and ethnicity, the correlation between cancer-related PTS and PRA-C scores was strongest in Hispanic/Other BCS (r=-0.39, p=0.009) and weakest in Black (r=-0.12, p=0.42) and White BCS (r=-0.09, p=0.49). No significant correlation between cancer-related PTS and PRA-D scores were observed by race or ethnicity.

CONCLUSIONS: Minoritized BCS with comorbid DM report less satisfaction in communication with their cancer providers which may, in turn, result in higher levels of cancer-related PTS. Future investigations will evaluate whether differences in patient-provider communications mediate the association between race/ethnicity and cancer-related PTS.

EXPERIENCES TRANSITIONING FROM FULL-AGONIST OPIOIDS TO BUPRENORPHINE FOR PAIN: A QUALITATIVE STUDY

Sara Edmond³; Jennifer L. Snow²; Danielle Wesolowicz¹; Amanda Jankelovits³; Sophia Currie⁴; Manik Chhabra⁵; William Becker^2,3

¹VA Connecticut Healthcare System, US Department of Veterans Affairs, Washington, DC; ²PRIME, VA Connecticut Healthcare System, West Haven, CT; ³Yale School of Medicine, New Haven, CT; ⁴Yale University, New Haven, CT; ⁵VA Medical Center Corporal Michael J Crescenz, Philadelphia, PA. (Control ID #3874305)

BACKGROUND: Guidelines recommend tapering or discontinuation of long-term opioid therapy (LTOT) for chronic pain when harms of continued opioid therapy outweigh benefits, yet tapering is often challenging and may be associated with adverse events. An emerging alternative to tapering or discontinuing LTOT is switching to the partial agonist buprenorphine. The goal of this study was to understand the experiences of patients with chronic pain who transitioned from LTOT to buprenorphine.

METHODS: We conducted semi-structured qualitative interviews with 19 patients from two VA medical centers; eligible patients had previously been on LTOT and switched to buprenorphine (any formulation) for at least 30 days during the past three years. The interview guide included questions about perceptions of and experiences with buprenorphine. We performed team-based inductive thematic analysis including two independent coders and full research team meetings to form consensus on coding concepts and findings.

RESULTS: Participants primarily had chronic back pain and included 15 men and 4 women ranging in age from 38 to 81. Analyses identified five major themes; here, we focus on three. First, while there were diverse experiences, participants generally reported satisfaction with buprenorphine as a pain treatment that improved overall function. Most viewed buprenorphine as either equally effective to LTOT, or less effective for pain but superior overall given improved quality of life in part due to decreased side effects leading to clear headedness and feeling more even keeled. Next, a patient’s preconceptions about buprenorphine were often associated with subsequent reported experiences. One participant noted, “As long as you go into it with the right mindset… it works.” Finally, patient-provider communication, including a nonjudgmental approach and transparency about risks and benefits of buprenorphine, was identified as essential; one participant said: “That’s something I’ve always appreciated, there was no judgment.”

CONCLUSIONS: Veterans switching from LTOT to buprenorphine had mostly positive yet mixed experiences. While perceived analgesia varied, Veterans identified benefits beyond pain reduction as important to them. This highlights the need for research in this context that assesses a wide array of patient- reported outcomes beyond analgesia. Given the importance of preconceptions about buprenorphine and patient-provider communication, motivational interviewing targeting willingness to try buprenorphine along with patient education may contribute to improved patient outcomes

FASTING TO REDUCE CHEMOTHERAPY SIDE EFFECTS: AN UPDATED SYSTEMATIC REVIEW

Isabela Azevedo Ferreira de Souza¹; Cintia Gomes²; Caroliny Hellen Azevedo da Silva³; Isabele Ayumi Miyawaki⁴; Isabela Reis Marques⁵; Vittoria Caporal Salles Moreira⁶; José Eduardo Riceto Loyola Júnior⁷; Eduardo M. Padrao⁸; Anand Bhagat⁸

¹Faculdade de Medicina de Petrópolis, Petrópolis, Rio de Janeiro, Brazil; ²Maimonides Medical Center, Brooklyn, NY; ³Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil; ⁴Universidade Federal do Parana, Curitiba, PR, Brazil; ⁵International University of Catalonia, Barcelona, Spain; ⁶University Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil; ⁷Hospital Alemão Oswaldo Cruz, São Paulo, Brazil; ⁸Internal Medicine, University of Connecticut School of Medicine, Farmington, CT. (Control ID #3871757)

BACKGROUND: Chemotherapy (CTx) for the treatment of cancer may cause significant toxicity to patients and impair quality of life (QoL). Research in mice demonstrated that fasting minimizes CTx side effects and increases tumor sensitivity. Some clinical studies revealed that fasting might improve QoL in patients receiving CTx, although this remains controversial.

METHODS: We aimed to perform an updated systematic review of randomized controlled trials (RCTs) and non-randomized studies of intervention (NRSI) exploring the effects of fasting versus normocaloric diet in patients with cancer undergoing CTx. Pubmed, Embase, and Cochrane library were searched for studies published up to June 2022. The risk of bias was assessed by RoB-2 for RCTs and ROBINS-I for NRSI. The primary outcomes of interest were toxicity and QoL. The study was registered at PROSPERO CRD42022337752.

RESULTS: We found 4465 citations, of which 5 studies (4 RCTs) met inclusion criteria, with a total of 290 patients, 146 (50.3%) of whom received CTx with fasting. The population included gynecological malignancies with an average age of 49 to 57 years. Many types of fasting were used including fasting- mimicking diets, modified short-term fasting, short-term, and water only fasting. Time of fasting varied between 1 to 3 days before and after CTx. All studies found fasting to be safe and well-tolerated without significant side effects. Only two studies found that fasting improved patients’ tolerability to CTx with reduced symptoms such as stomatitis, headaches, weakness, and fatigue. One study found that fasting had beneficial effects only on hematologic toxicity and on DNA damage of healthy cells, such as lymphocytes and myeloid cells, with no benefits in non-hematological toxicity; however, another study verified that radiological and pathological tumor responses to CTx could potentially be enhanced by fasting. Four studies evaluated QoL with conflicting results. Two studies found statistically significant improvement in QoL. Two further studies yielded negligible improvement in QoL; however, one verified fewer CTx dose reductions and delays due to intolerable side effects.

CONCLUSIONS: In this systematic review of 5 studies and 290 patients, fasting at the time of CTx did not improve overall tolerability to CTx, however can reduce some significant side effects. It can potentially decrease hematological side effects and enhance the response of the tumor to CTx.

GUIDELINE-INDICATED PRESCRIBING OF SGLT2 INHIBITORS AND GLP1 RECEPTOR AGONISTS FOR TYPE 2 DIABETES AMONG PRIMARY CARE AND SPECIALTY CARE PROVIDERS

Michael E. Bowen^1,2; Kelsea Marble¹; Christine Mai¹; Jonathan Pak³; Mujeeb Basit¹; Ildiko Lingvay¹

¹The University of Texas Southwestern Medical Center, Dallas, TX; ²Parkland Health, Dallas, TX; ³Clinical Development & Medical Affairs , Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield , CT. (Control ID #3868156)

BACKGROUND: Although Sodium-Glucose Cotransporter-2 inhibitors (SGLT2i) and Glucagon-like Peptide-1 receptor agonists (GLP1RA) improve glycemic control, cardiovascular outcomes, and mortality, significant gaps in guideline-indicated prescribing remain. SGLT2i and GLP1RA medications can be prescribed by various specialties; however, it is unknown if seeing multiple specialties increases prescribing.

METHODS: Using EHR data from a large, academic medical center, we conducted a cross-sectional analysis of patients with type 2 diabetes and cardiorenal disease eligible for American Diabetes Association 2022 guideline-indicated treatment with SGLT2i and GLP1RA to determine their currently prescribed rates. Eligible patients were ≥18 years and had at least one completed outpatient encounter in either primary care, endocrine, cardiology, or nephrology from January 1, 2019 to October 30, 2022. All patients had type 2 diabetes and one or more of the following: atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease. We describe current prescribing rates overall and by specialties (primary care, endocrine, cardiology, nephrology) who commonly manage these conditions.

RESULTS: A total of 10,819 patients (mean age of 67 years, 47% female, 41% with ASCVD, 25% with CHF, 47.9% with CKD stage 3-5) were eligible for guideline-indicated treatment with a SGLT2i or GLP1RA. Overall, 17.9% of eligible patients had an active prescription for at least one of these agents. The percent of patients (N=10,819) seen by the respective specialty and currently prescribed guideline-directed therapy were as follows: 55% and 20% in primary care, 48% and 20% in cardiology, 44% and 25% in endocrinology, and 18% and 18% nephrology. The increase in prescribing among patients seen vs. not seen within each specialty were as follows: endocrine 12.2%, primary care 5%, cardiology 4.7%, and renal 0.5%. Among patients seen only in a single specialty, prescribing rates were highest for endocrinology (N=1573; 17%), followed by primary care (N=2200; 11.3%), cardiology (N=1699; 10%), and renal (N=415; 3%).Among patients seen by two specialties, prescribing rates were highest for endocrine+cardiology (N=629; 27%), followed by primary care+endocrine (N=809; 26%), endocrine+nephrology (N=185; 26%), and primary care+cardiology (1169; 21%). The 816 patients seen by primary care+endocrine+nephrology had the highest prescribing rate (33%) and was similar to the 30% prescribing rate among the 325 patients seen by all 4 specialties

CONCLUSIONS: Overall rates of guideline-indicated treatment with SGLT2 inhibitors and GLP1 receptor agonists in a large academic medical center were low among both primary care and specialty providers. However, prescribing rates were higher among patients seen by multiple specialties who may prescribe the medications for guideline-indicated conditions independent of diabetes. System level interventions targeting multiple specialties and clinic types are needed to close treatment gaps.

HEALTHY BEHAVIORS IN CANCER SURVIVORS

Carter Baughman, Kathryn Norman, Kenneth J. Mukamal

Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #3871967)

BACKGROUND: Primary care providers play an important role in continuity of care for people who have completed cancer treatment. The American Cancer Society (ACS) provides discrete lifestyle recommendations for these survivors, including avoiding obesity, engaging in regular physical activity, following a healthy diet, and avoiding alcohol. Adherence to these guidelines is unknown, as are factors that may affect adherence. Greater understanding of guideline adherence would better equip primary care physicians to support healthy behaviors among the increasing numbers of patients who have survived cancer

METHODS: We analyzed the 2017, 2019, and 2021 iterations of the Behavioral Risk Factor Surveillance System (BRFSS), a nationally-representative telephone survey conducted by the Centers for Disease Control and Prevention. A total of 17 states and 2 territories included modules on cancer survivorship. Adherence to the guidelines was evaluated in the four domains defined by the ACS: body-mass index <30 kg/m², exercise in the past 30 days, daily consumption of ≥2.5 servings of vegetables and ≥1.5 servings of fruit, and alcohol abstention. We summed the total number of healthy behaviors and used linear regression with survey weights to evaluate sociodemographic correlates of greater adherence.

RESULTS: A total of 10,020 adults reported having completed cancer treatment, representing 2.7 million.

Americans during the three surveyed years. Of these, 9,121 reported their adherence to all four metrics. The mean age of cancer survivors was 64±0.26 years and 56% were women. Adherence among cancer survivors was 72% (CI 0.71-0.74) for physical activity, 68% (CI 0.66-0.69) for healthy weight, 50.3% (CI 0.49-0.52) for alcohol abstention, and 12% (CI 0.11-0.13) for healthy diet. In total, 3.5% of cancer survivors adhered to all four guidelines, and the mean number of guidelines met was 2.0 (CI 2.0-2.1). Women reported 0.16 more healthy behaviors than men (p<0.001) and each decade of age was associated with 0.06 more healthy behaviors (p=0.003). Black adults reported 0.26 more healthy behaviors than white individuals (p=0.004). Greater educational attainment was associated with a roughly dose-response increase in behaviors (p=0.079). Region was also associated with adherence, with individuals in the West reporting 0.19 more healthy behaviors than those in the Midwest (p<0.001).

CONCLUSIONS: Healthy lifestyle practices are essential for cancer survivors. Our work suggests only 3.5% of cancer survivors fully adhere to current ACS recommendations. Independent factors associated with greater adherence include female gender, older age, Black race, greater education, and residence in Western states. Improved understanding of uptake of healthy behaviors will help primary care providers more effectively guide recommendations for their patients who have finished cancer treatment.

HELPING PATIENTS WITH CHRONIC CONDITIONS OVERCOME THE CHALLENGES OF HIGH-DEDUCTIBLE HEALTH PLANS

Alexandra Peirce²; Ying-Jen Lin²; Angela Fagerlin^3,4; Michele Heisler^2,1; Jeffrey T. Kullgren^1,2

¹VA Ann Arbor Healthcare System, Ann Arbor, MI; ²University of Michigan, Ann Arbor, MI; ³University of Utah Health, Salt Lake City, UT; ⁴VA Salt Lake City Health Care System, Salt Lake City, UT. (Control ID #3877048)

BACKGROUND: Patients with chronic conditions who are enrolled in a high-deductible health plan (HDHP) experience high levels of cost-related access barriers and out-of-pocket (OOP) spending. These patients could potentially experience fewer cost-related access barriers and pay less for healthcare by using cost-conscious strategies such as having cost conversations with clinicians, saving for future costs, and using online price information. Our objectives were to develop a novel behavioral intervention to help HDHP enrollees with chronic conditions use these and other cost-conscious strategies and evaluate the acceptability, feasibility, and preliminary efficacy of the developed intervention.

METHODS: We used findings from a prior study of intervention preferences of HDHP enrollees with chronic conditions to develop a website with educational modules on discussing costs with clinicians, saving for future costs, comparing prices and quality, and steps to take before and after appointments. We developed email messages that directed individuals to each module and refined the website and emails through iterative user-centered testing. We then conducted a 5-week, single-arm proof-of-concept pilot study of the refined intervention among 36 HDHP enrollees with chronic conditions. Participants completed baseline and post- intervention surveys that measured our main outcomes of health insurance literacy (20-80 scale) and confidence in using cost-conscious strategies (0-10 scale). After the intervention we used purposive sampling to interview 10 participants with different levels of baseline health insurance literacy and intervention engagement.

RESULTS: 31 participants completed baseline and post-intervention surveys. Health insurance literacy increased from a baseline mean of 56.5 to a post-intervention mean of 67.1 (p<0.001). Surveys also showed an increase in confidence in talking to a healthcare provider about cost from a baseline mean of 6.1 to a post- intervention mean of 7.6 (p=.0094), an increase in confidence in saving for healthcare from a baseline mean of 5.8 to a post-intervention mean of 6.6 (p=.068), an increase in confidence in comparing prices from a baseline mean of 5.4 to a post-intervention mean of 6.9 (p=.005), and an increase in confidence in comparing quality from a baseline mean of 6.1 to a post-intervention mean of 7.6 (p=.0034). Post-intervention interviews showed that participants found the website easy to use and helpful for supporting use of cost- conscious strategies.

CONCLUSIONS: A novel behavioral intervention to support use of cost-conscious strategies was acceptable to HDHP enrollees with chronic conditions, feasible to deliver, and associated with an increase in health insurance literacy and confidence in using cost-conscious strategies. As more patients with chronic conditions enroll in HDHPs, this intervention should be tested in a randomized trial to evaluate its effects on cost-related access barriers, OOP costs, and other patient-centered outcomes.

HETEROGENEOUS ASSOCIATIONS OF E-CIGARETTE USAGE WITH HEALTH-SEEKING BEHAVIOR IN THE US: THE EXAMPLE OF INFLUENZA VACCINATION

Hannah Kerman¹; Kenneth J. Mukamal^2,3

¹Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Medicine, BIDMC, Brookline, MA; ³Harvard Medical School, Boston, MA. (Control ID #3872224)

BACKGROUND: Since entering the US market in 2007, E-cigarettes have grown steadily in popularity. However, concern remains that e-cigarette usage is heterogeneous in origin and outcome, with use both beneficially for smoking cessation and potentially deleteriously as a new habit or as a supplement to traditional tobacco products. We hypothesized that the association of e-cigarette usage with markers of engagement with the healthcare system, such as influenza vaccination, would differ by specific characteristics of users.

METHODS: The Behavioral Risk Factor Surveillance System (BRFSS) is a nationally-representative annual telephone survey conducted by the CDC. The 2021 survey queried e-cigarette usage and self-reported influenza vaccination in the preceding year. We determined the adjusted relationship of e-cigarette usage to influenza vaccination and tested for the consistency of this relationship across strata of age and current cigarette smoking. We used STATA 17.0 and generalized linear models to derive weighted relative risks that account for the BRFSS sampling design.

RESULTS: Among 406,664 participants with information on e-cigarette usage, 6.5% (95% confidence interval [CI], 6.3-6.7%) reported current use. The prevalence of influenza vaccination was 45.1% (44.7-45.4%). In analyses adjusted for age, sex, and race, e-cigarette usage was associated with an overall relative risk (RR) of 0.79 (95% CI: 0.76-0.83) for getting a flu vaccine. Age and current cigarette smoking both modified the association of e-cigarette usage with influenza vaccination (p<0.001 when mutually adjusted). RRs of influenza vaccination associated with e-cigarette usage were lower and similar among age groups of 18-24, 25-34, 35-44, and 45-54 (0.78, 0.67, 0.77, 0.78 respectively). In contrast, the magnitude of association of e-cigarette usage with vaccination rates was lower among respondents aged 55-64 (RR 0.90) and ≥65 (RR 0.91). Similarly, the RR of influenza vaccination associated with e-cigarette usage was 1.12 (1.07 - 1.17) among those concurrently smoking cigarettes, but 0.82 (0.77 - 0.90) among former cigarette smokers and 0.83 (0.77 - .88) among never cigarette smokers.

CONCLUSIONS: E-cigarette use is associated with a lower prevalence of self-reported receipt of influenza vaccination. However, we observed significant heterogeneity in this relationship related to both age and current smoking status. This relationship was attenuated among middle-aged and older adults and positive among current smokers, suggesting that e-cigarette usage may represent a marker of positive health behaviors among these groups. In contrast, e-cigarette usage was associated with lower prevalence of influenza vaccination among younger adults and former and never smokers, populations in which e-cigarette usage is not recommended. Guidelines for e-cigarettes should reflect the heterogeneity of their use with respect to health-seeking behaviors.

HYPOGLYCEMIA ASSESSMENT AND PREVENTION IN PRIMARY CARE VISITS

Scott J. Pilla¹; Kayla A. Meza^15,14; Judith A. Long^3,2; Howard Gordon^4,5; Jeffrey T. Bates^6,7; Donna L. Washington^8,9; Barbara G. Bokhour¹⁰; Anaïs Tuepker¹¹; Somnath Saha¹²; Mary Catherine Beach¹³; Nisa Maruthur¹⁴

¹General Internal Medicine, Johns Hopkins University, Baltimore, MD; ²Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA; ³Corporal Michael J. Crescenz VA Center for Health Equity Research and Promotion, Philadelphia, PA; ⁴Jesse Brown VA Chicago Healthcare System, Chicago, IL; ⁵University of Illinois Chicago, Chicago, IL; ⁶Michael E DeBakey VA Medical Center, Houston, TX; ⁷Baylor College of Medicine, Houston, TX; ⁸VA Greater Los Angeles Healthcare System, Los Angeles, CA; ⁹University of California Los Angeles, Los Angeles, CA; ¹⁰VA Bedford Healthcare System, Bedford, MA; ¹¹VA Portland Health Care, Portland, OR; ¹²Medicine, Johns Hopkins Medicine, Baltimore, MD; ¹³Medicine, Johns Hopkins University, Baltimore, MD; ¹⁴Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; ¹⁵University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #3870638)

BACKGROUND: Hypoglycemia is a major cause of morbidity and reduced quality of life in patients with diabetes, yet limited prior studies suggest it is rarely discussed in primary care visits. We conducted the first multicenter study examining how primary care providers (PCPs) assess for hypoglycemia in at-risk patients, provide anticipatory guidance, and modify medications for hypoglycemia prevention.

METHODS: This mixed methods study examined visits between patients (N=237) with diabetes using hypoglycemia-causing medications and their PCPs (N=50) at 4 geographically diverse Veterans Affairs medical centers. Visits were audio-recorded between 2017-2020, transcribed verbatim, and independently coded by 2 investigators to identify hypoglycemia dialogue that was analyzed using a directed content analysis approach. Medications and clinical data were extracted from the VA Corporate Data Warehouse. Predictors of deintensifying (decreasing/stopping) hypoglycemia-causing medications were assessed using logistic regression, adjusted for insulin use and accounting for clustering by PCP.

RESULTS: Patients’ mean age was 67 years, 89% were male, the mean A1c was 8.3%, and insulin and sulfonylureas were used by 66% and 42%, respectively. Hypoglycemia history was discussed in 77 of 237 visits (32%), assessed by the PCP in 47 visits (20%) and reported by the patient unprompted in 30 (13%). PCPs referred to hypoglycemia as “low blood sugar” while patients predominantly described symptoms or specific glucose values. Several patients expressed not understanding what the PCP meant by “low blood sugar” or reported concerns about normal glucose values being too low. Lower A1c level was associated with more frequent PCP assessment of hypoglycemia (p=0.03), but not with events. PCPs provided anticipatory guidance for hypoglycemia prevention in 50 visits (21%) consisting of holding diabetes medications while fasting and carrying glucose tabs; avoiding driving and glucagon emergency kits were not discussed. Hypoglycemia-causing medications were deintensified more often (p<0.01) where the patient reported hypoglycemia (14 of 51 visits, 27%) than where the patient reported no hypoglycemia or it was not assessed (4 of 182 visits, 2%). Deintensification was not associated with A1c, and only 6 of 15 patients (40%) who reported hypoglycemia with A1c <7.0% had medications deintensified.

CONCLUSIONS: PCPs assess for hypoglycemia in less than one third of primary care visits for at-risk patients, and use language that is not understood by some patients. Few PCPs provide hypoglycemia anticipatory guidance, which misses key concepts. Counter to diabetes guidelines, deintensifying hypoglycemia-causing medications often does not occur after hypoglycemia in patients with lower A1c levels. Routine assessment of hypoglycemia and provision of diabetes self-management education is needed to improve the safety of diabetes care.

IMPACT OF COVID-19 PANDEMIC ON STUDENT-RUN FREE CLINIC SERVICES FOR UNDERSERVED URBAN PATIENT POPULATION

Adlai Nelson¹; Sara L. Ma¹; Sara Kazyak¹; Nili Modi¹; Kathy Lu¹; Alex Wind¹; Mina Sitto¹; Jennifer Schmidt¹; Robert Sherwin²

¹School of Medicine, Wayne State University School of Medicine, Detroit, MI; ²Emergency Medicine, Detroit Medical Center, Detroit, MI. (Control ID #3874742)

BACKGROUND: The COVID-19 pandemic has significantly impacted healthcare delivery, especially in high density urban communities. This community clinic provides free medical care to patients in an urban Midwestern community. The clinic has offered longitudinal healthcare to many patients with chronic disease, such as diabetes and hypertension. Services include basic medical care services as well as limited prescriptions, vaccines, and over-the-counter medications. Adjunct services offered at the clinic by local partners include vision and hearing exams and women’s health screening. The objective of this study is to understand how the patient demographics and medical services offered at the clinic have been impacted by the COVID-19 pandemic.

METHODS: Walk-in student-run clinics were held weekly on Saturday mornings in an urban Midwestern city, with patients consisting primarily of underinsured and uninsured residents experiencing houselessness or housing instability. Number of returning and new patients, physicals, flu shots, blood glucose readings, HbA1c, lipid panels, and referrals were collected weekly by student coordinators and recorded in a spreadsheet by year (2019-2020 vs 2021-2022). Data was divided by year and quarter and compared using paired student two-tailed t-tests.

RESULTS: A total of 274 and 293 patients were seen between 2019-2020 and 2021-2022, respectively. Preliminary results demonstrate the number of patients significantly varied from December to February between these two time periods (p<0.05). Number of physicals and the number of blood glucose tests in 2021-2022 significantly differ from those of 2019-2020 (p<0.05). Number of Covid-19 vaccines significantly differed between these two time periods (p<0.01), while the number of flu shots did not.

CONCLUSIONS: Many of the patients at walk-in clinics rely on free, interdisciplinary services to obtain healthcare services, medications, and vaccines. Patients during the 2021-2022 year became more vigilant about their health, reflected by the increase in total physicals and increase in total patients (Dec-Feb). The clinic became better at pre-screening patients’ overall health, demonstrated by total blood glucose recorded, to diagnose patients earlier, provide necessary medications sooner and minimize the number of visits a patient needed to attend. Future projects could focus on factors that prevent patients’ from receiving and completing the COVID-19 vaccination series and attending clinics during peak flu/COVID seasons.

Exploring this would provide clinics insight in how to address patient’s needs and bolster patient compliance.

IMPACT OF INTRA-ARTICULAR CORTICOSTEROID INJECTION ON GLYCEMIC CONTROL: A POPULATION-BASED COHORT STUDY

Terin Sytsma¹; Laura Greenlund²; Karen Fischer³; Rozalina G. McCoy^1,4

¹Internal Medicine, Mayo Clinic, Rochester, MN; ²Internal Medicine, Mayo Clinic, Rochester, MN; ³Clinical Statistics, Mayo Foundation for Medical Education and Research, Rochester, MN; ⁴Mayo Foundation for Medical Education and Research, Rochester, MN. (Control ID #3875465)

BACKGROUND: Intra-articular corticosteroid (IACS) injections are a common pain management intervention, especially in complex, multimorbid patients. With nearly half of the United States adult population having diabetes or prediabetes, blood glucose control is a concern in a substantial proportion of patients receiving IACS. Previous case-series have described the short-term hyperglycemic effects of IACS. However, the impact of IACS on longer-term glycemic control is unknown. Furthermore, rates of dangerous hyperglycemic events following IACS are not well described. We investigated the hyperglycemic effects of IACS injections by evaluating the change in hemoglobin A1c (HbA1c) levels and examining rates of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic syndrome (HHS) following large joint IACS.

METHODS: This retrospective cohort study examined change in HbA1c and rates of DKA/HHS among adults receiving large joint IACS in the US Upper Midwest from 2012-2018. For each individual, observed HbA1c change was compared with the predicted HbA1c change, which was calculated using linear regression. Change in actual HbA1c of ≥0.5% above predicted was deemed a “greater-than-expected rise”. Multiple logistic regression identified risk factors for greater-than-expected rise in HbA1c following IACS. Rate of DKA/HHS in the 30 days following IACS was also quantified.

RESULTS: 1169 patients were included (mean age 66.1 years-old [SD 12.06]; 52.8% female). Overall, the difference between actual and predicted HbA1c following IACS was 0.0% (SD 0.82). 184 patients (15.7%) had a greater-than-expected rise in HbA1c. This group had a higher proportion of patients with diabetes than the non-rise group (97.3% vs 91.8%, p = 0.009). Upon regression analysis, baseline HbA1c was the only factor associated with greater-than-expected rise in HbA1c following IACS with OR 4.80 (95% CI 2.83-8.14) for baseline HbA1c >8.0% compared to <7.0%. Patient age, sex, race, diabetes medications and number of comorbidities were not associated with a greater-than-expected rise in HbA1c. Only one patient had DKA attributable to IACS.

CONCLUSIONS: This is the first study evaluating effects of IACS on blood glucose control by following HbA1c after IACS in a population-based sample. The majority of patients did not have a substantial rise in HbA1c, suggesting that IACS does not substantially worsen diabetic control in most people. However, nearly 16% of patients did experienced a greater-than-expected rise in HbA1c following IACS. Baseline HbA1c was the most important predictor of greater-than-expected rise in HbA1c following IACS, suggesting that clinicians should counsel patients with sub-optimally controlled diabetes about risks of further hyperglycemia following IACS. Episodes of DKA/HHS following IACS were rare (<0.1%), thus concern for dangerous hyperglycemia should not delay IACS administration. Future, prospective studies are need to confirm these results and further delineate risk factors for elevated HbA1c following IACS.

IMPROVEMENT IN PRIMARY CARE PHYSICIAN (PCP) KNOWLEDGE ABOUT NONALCOHOLIC FATTY LIVER DISEASE (NAFLD) AFTER IMPLEMENTING A FIB-4 BASED REFERRAL STRATEGY

Janet N. Chu¹; Rena K. Fox²; Danielle Brandman⁵; Delia Falliers²; Kendall Islam⁴; Max L. Goldman³

¹Internal Medicine, University of California San Francisco, San Francisco, CA; ²Division of General Internal Medicine, University of California San Francisco, San Francisco, CA; ³Department of Medicine, University of California San Francisco, San Francisco, CA; ⁴School of Medicine, University of California San Francisco, San Francisco, CA; ⁵Center for Liver Disease, Weill Cornell Medicine, New York, NY. (Control ID #3863244)

BACKGROUND: PCPs care for many patients with NAFLD but lack confidence and consistency in its detection and management. FIB-4 is a non-invasive tool incorporating age, AST, ALT, and platelets that can be used for risk stratification of NAFLD severity, but few PCPs are aware of FIB-4 or its utility. We evaluated a FIB-4-based algorithm to help PCPs identify NAFLD patients appropriate for specialty referral and assessed PCPs’ experiences before and after this intervention.

METHODS: We conducted a three-part study at a large diverse health system: 1) a pre-intervention PCP needs assessment survey; 2) an intervention prompting PCPs’ attention to likely NAFLD patients with high FIB-4s; and 3) a post-intervention survey to determine the impact of the FIB-4 algorithm on PCPs’ practices and NAFLD knowledge one year later. During the intervention, PCPs received an electronic medical record (EMR) message for each patient with diabetes mellitus and either a low- or a high-risk FIB-4, including a recommendation to refer high-risk patients to hepatology. The message included educational content on NAFLD management by PCPs. We created two EMR tools for PCPs: an automated FIB-4 calculator with score interpretation guidance and a pre-populated NAFLD order set. Two-sample z-tests for proportions were used to compare differences between pre- and post-intervention survey responses.

RESULTS: Respondents included 88/115 PCPs to the pre- and 69/119 to the post-intervention surveys. Among post-survey respondents, 44 (64%) and 37 (54%) PCPs received a message for a low- or high-risk patient, respectively. Post-intervention, multiple knowledge areas improved including knowledge of the long- term complications of NAFLD (79% vs. 90%, p=0.01), fibrosis as a predictor of cirrhosis (76% vs. 86%, p=0.02), and the FIB-4 score components (25% vs 46%, p=0.003). PCPs increased use of FIB-4 for patients with elevated liver enzymes (16% vs. 59%, p<0.001). Yet, in diagnosing NAFLD, uncertainty remained high (42% vs. 44%, p=0.80) and post-intervention, only 13% were “very confident” and 52% “somewhat confident.” Pre-intervention, 67% reported a need for an EMR NAFLD order set with imaging, laboratory

and referral orders and 63% for an EMR FIB-4 calculator; post-survey, most were unaware of the new NAFLD order set (67%) or FIB-4 calculator (59%) yet stated they would use them if they knew it was available.

CONCLUSIONS: After implementing a FIB-4 risk stratification strategy, we found significant improvement in PCPs’ NAFLD knowledge and practices. PCPs still reported lack of confidence in diagnosing NAFLD but had increased awareness of FIB-4 and incorporated FIB-4 into their practice. Developing and promoting convenient FIB-4 tools and EMR order sets can help improve PCP confidence in diagnosing and managing NAFLD.

INCIDENCE OF NEW-ONSET DIABETES AFTER INFECTION WITH COVID-19 IN THE COVID-OUT RANDOMIZED TRIAL

Jacinda M. Nicklas¹; Thomas A. Murray²; Hrishikesh Belani³; Jared Huling⁴; David M. Liebovitz⁶; Ken Cohen⁷; Carolyn Bramante⁵

¹General Internal Medicine, University of Colorado School of Medicine, Aurora, CO; ²Biostatistics, University of Minnesota Twin Cities, Minneapolis, MN; ³Primary Care, UCLA Medical Center Olive View, Los Angeles, CA; ⁴Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN; ⁵Medicine, University of Minnesota Twin Cities, Minneapolis, MN; ⁶Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ⁷Optum Center for Research and Innovation, Minnetonka, MN. (Control ID #3875918)

BACKGROUND: There are mixed data on whether COVID-19 infection leads to increased incidence of type 2 diabetes. Recent studies have demonstrated an incidence of ~1.5% within 6 months of Covid-19 infection, as compared to a rate of 1.2% seen historically with other acute upper respiratory infections. The majority of data have so far been derived from retrospective datasets. We sought to examine the incidence of new onset type 2 diabetes in a prospective cohort enrolled in the multi-site phase 3 randomized quadruple- blinded placebo-controlled COVID-OUT clinical trial.

METHODS: Adults with overweight or obesity defined by race/ethnicity specific cutpoints and aged 30-85 were enrolled in the trial within three days of a positive SARS-CoV-2 test and fewer than seven days of symptoms. We randomized participants to one or two of three oral medications (metformin, ivermectin, fluvoxamine) or placebo using a two by three parallel treatment factorial design to efficiently share placebo controls. The intervention included immediate-release metformin with an increase in dose over the course of 6 days to 1500 mg daily for 14 days, ivermectin 430mcg/kg/day for 3 days, and fluvoxamine, 50mg on day one then 50mg twice daily through 14 days. Following their participation in the initial phase of the trial, we sent surveys via automated email or other per patient preference every 30 days through 300 days (10 months), beginning 60 days after randomization. Surveys included questions about any new medical conditions participants were diagnosed with, including diabetes mellitus. Trial registration: NCT04510194.

RESULTS: Among 1093 subjects in our sample, there were 25 new diagnoses of diabetes within 300 days of Covid-19 diagnosis, with similar incidence in each treatment condition: Metformin 2.4% vs. 2.2% control, Ivermectin: 2.9% vs. 1.9% control, Fluvoxamine 2.4% vs. 1.4% control. Participants with new onset diabetes had a higher median BMI than those who did not develop diabetes 34.3 (IQR 31.0 - 39.5) vs. 29.7 (IQR 26.8-33.9).

CONCLUSIONS: The incidence of new diabetes diagnoses was similar among outpatients treated with metformin, ivermectin, and fluvoxamine during their acute COVID-19 infection in this randomized controlled study, and higher than previously reported in retrospective cohorts studied over shorter time periods, perhaps related to the inclusion criteria restricted to participants with overweight/obesity. We will conduct multivariable models to identify predictors of diabetes incidence in this cohort.

INFLAMMATORY ARTHRITIS AFTER COVID-19 INFECTION: A CASE SERIES

Siddhant Yadav¹; Elizabeth A. Gilman¹; Nerissa Collins²; Michael Mueller²; Ryan Hurt²; Ravindra Ganesh¹

¹general internal medicine, Mayo Clinic Minnesota, Rochester, MN; ²General Internal Medicine, Mayo Foundation for Medical Education and Research, Rochester, MN. (Control ID #3873040)

BACKGROUND: Some patients who have recovered from acute infection with coronavirus 19 (COVID-19) develop persistent symptoms that have been termed post COVID syndrome (PCOS). PCOS may affect the musculoskeletal system, with arthralgias and myalgias being common. Preliminary evidence supports PCOS as an immune mediated condition predisposing and increasing risk for autoimmune diseases such as rheumatoid arthritis (RA) and reactive arthritis. In this case series, we describe patients who developed inflammatory arthritis (both reactive arthritis and RA) after COVID-19.

METHODS: We present 5 patients who developed joint pain several weeks after recovery from acute COVID-19 infection. These patients were seen in our Post COVID Clinic (PCOCC) and came from all regions of the United States.

RESULTS: All 5 patients were female with age of diagnosis of COVID-19 between 19-61 years (mean 37.8 years). All presented with joint pain as the primary complaint to the PCOCC. All patients were diagnosed with COVID between November 2020 and August 2021. The mean time difference between COVID diagnosis and onset of arthritic symptoms was 2.8 months (range 1-6 months). Abnormal joint imaging was present in all patients. Treatments varied and included NSAIDs, acetaminophen, corticosteroids, immunomodulators (golimumab), methotrexate, leflunomide, and hydroxychloroquine (Table 1).

CONCLUSIONS: COVID-19 is a potential cause of Inflammatory arthritis, with both RA and reactive arthritis demonstrated in our PCOS population. Approach to these patients with arthralgia and joint swelling requires a multidisciplinary approach which may eventually include Rheumatology.

INTEGRATING DEPRESSION AND HYPERTENSION CARE THROUGH COMMUNITY HEALTH WORKERS IN NAVRONGO, GHANA: THE COMBINE PILOT STUDY

David J. Heller¹; Engelbert A. Nonterah²; Benedict Weobong⁵; Irene Kuwolamo²; Khadija Jones¹; Allison Squires³; Carol Horowitz⁴; Raymond Aborigo²

¹Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY; ²Navrongo Health Research Centre, Navrongo, Ghana; ³College of Nursing, New York University, New York, NY; ⁴General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ⁵University of Ghana, Legon, Greater Accra, Ghana. (Control ID #3876144)

BACKGROUND: Non-communicable chronic diseases now cause 71% of deaths worldwide, and the proportion is rising. However, the primary care infrastructure in many low- and middle-income countries focuses chiefly on treatment of acute infectious conditions, which have historically caused the majority of preventable morbidity and mortality. In Ghana, the nationwide Community-Based Health Planning and Services (CHPS) initiative has decreased infectious and perinatal mortality by sending nurses and health volunteers to rural homes and villages to provide vaccinations, health education, and other primary care where doctors are scarce. However CHPS does not yet provide non-communicable disease care.

METHODS: We trained eight nurses and eight health volunteers at four CHPS coverage zones to provide door to door screening for hypertension and depression, the leading global causes of death and disability respectively. Persons screening positive (a blood pressure between 140 and 179 mm Hg or 80-99 mm Hg systolic or diastolic for hypertension, or a physician’s health questionnaire [PHQ-9 ]s core of 10-19 for depression) received an eight-week intervention combining seven home counseling visits from a health volunteer with four clinic visits from a CHPS nurse offering medication. Persons with higher disease scores were referred to specialty care. Counseling comprised motivational interviewing techniques for medication adherence for hypertension, and behavioral activation techniques for depression, as well as coaching on changes in diet, exercise, and alcohol and tobacco use for all patients.

RESULTS: Results: As of November 2022, we screened 574 persons, and enrolled 37 persons with hypertension and 23 with depression. Seven persons declined the intervention. Of the 60 enrolled, one was referred to specialty care for suicidality; three were lost to follow-up; one was referred due to treatment failure, one developed liver disease unrelated to the intervention and expired, and the last migrated out of the study area. Among the remaining 56, 44 have completed the intervention to date, of which 100% achieved the endpoint of a blood pressure under 140 mm Hg systolic or a PHQ-9 score under 10. Final analysis will occur in February 2023.

CONCLUSIONS: Our findings in this pilot study suggest that CHPS nurses and volunteers can effectively screen for, diagnose, and treat these two noncommunicable diseases in the setting of routine care. Subsequent qualitative evaluation will identify strategies to improve program efficiency and efficacy, and a powered randomized controlled trial will follow to formally evaluate clinical effectiveness.

INTENSIFICATION AND DEINTENSIFICATION RECOMMENDATIONS IN CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF CHRONIC CONDITIONS IN ADULTS

Audrey D. Zhang, Susan N. Hastings

Medicine, Duke University School of Medicine, Durham, NC. (Control ID #3875978)

BACKGROUND: There is growing interest in low-value care, defined as care in which risk of harm outweighs potential benefit. However, popular approaches such as Choosing Wisely have largely focused on highlighting specific practices constituting low-value care, rather than normalizing the identification and discontinuation of low-value practices within a continuum of care. We aimed to describe the extent to which current clinical practice guidelines (CPGs) include recommendations for both intensification and deintensification as part of guidelines for the routine care of adults, focusing on pharmacologic management of chronic conditions.

METHODS: We identified CPGs for 9 prevalent chronic conditions previously recognized to be managed in primary care (Boyd 2005) using GuidelineCentral. We included the most recent and comprehensive CPG for each chronic condition issued by national and international organizations. Within each CPG, we abstracted each recommendation pertaining to pharmacologic management of the chronic condition, identified by discrete headings or table rows with an assigned strength of recommendation and/or level of evidence. We characterized each recommendation by clinical indication, drug/drug class, and whether it was focused on initiation, withholding, intensification, or deintensification of medications. We further characterized intensification/deintensification recommendations based on whether they identified criteria (e.g. target thresholds), strategies (e.g. dose change plan), or monitoring plans (e.g. follow-up schedule) for titration. We summarized recommendations aggregated by drug or drug class-indication pairs, and compared their characteristics using chi-square tests with a p-value threshold of 0.05.

RESULTS: We identified 10 relevant CPGs for chronic conditions (two separate CPGs were identified for osteoporosis in women and men) with recommendations aggregated into 185 drug-indication pairs. Of these, 142 (76.8%) described medication initiation and use and 43 (23.2%) described medication withholding for lack of benefit or harm. Among 142 recommendations for medication use, 29 (20.4%) included any guidance on anticipated duration of use. Recommendations were more likely to include intensification than deintensification criteria (43 [30.3%] vs 16 [11.3%], p<0.001), strategies (36 [25.4%] vs 7 [4.9%], p<0.001), or monitoring plans (23 [16.2%] vs 7 [4.9%], p=0.002). Among 59 indications containing recommendations addressing low-value care, most (n=43, 72.9%) addressed withholding initiation of a medication rather than deintensification or discontinuation of an existing medication (n=16, 27.1%).

CONCLUSIONS: Existing CPGs frequently offer recommendations for initiation and intensification of medications for chronic diseases without specifying recommendations for anticipated duration of use or associated deintensification. This presents an opportunity for further elaboration to enhance high-value, patient-centered care.

INVESTIGATING THE CURRENT AND FUTURE ROLE OF PRIMARY CARE PROVIDERS IN MANAGEMENT OF POST-ACUTE SEQUELAE OF COVID-19

Katherine C. Wu⁴; Aimee E. Willett¹; Michelle L. Pershing³; Kim M. Jordan²

¹Graduate Medical Education, Internal Medicine, OhioHealth, Columbus, OH; ²Internal Medicine, OhioHealth, Columbus, OH; ³Research Institute, OhioHealth, Columbus, OH; ⁴Department of Psychiatry, University of Virginia, Charlottesville, VA. (Control ID #3876164)

BACKGROUND: Post-acute sequelae of COVID-19 (PASC) is an evolving constellationof symptoms, most notably including fatigue, malaise, cognitive dysfunction, dyspnea, and musculoskeletal pain. PASC persists for at least 12 weeks following acute COVID-19 infection. As of December 2022, 256 clinics have been established to provide multidiscipinary care for an estimated 7.7 - 23 million people suffering from PASC. To fulfill evolving needs for PASC care, primary care providers (PCPs) may have to expand their knowledge of PASC. The project aims to understand how PCPs work in collaboration with PASC clinics to ensure continuity of care, to engage in accrual of knowledge about PASC, and to increase access to PASC care.

METHODS: This project is a cross-sectional descriptive study using qualitative survey methods. A list of post-COVID-19 clinics in the United States was compiled using Survivor Corps and Becker's Hospital Review online resources. An 18-item investigator developed survey was designed on RedCap and electronically shared with clinics. Questions in Likert and multiple-choice format inquired about referral pathways to post-COVID-19 clinics and how clinics ensured dissemination of treatment information to PCPs. Survey results were collected over a 6-week period. This project recieved non-human subject research determination by the OhioHealth Riverside Methodist Hospital IRB.

RESULTS: Of the 113 PASC clinics in the United States with publically available contact information, 39 clinics (34.5%) returned completed surveys. The responding clinics were primarily community and academic hospitals with some outpatient therapy sites. PCP involvement in the reporting clinics varied: 48.7% reported PCPs were not involved at all, 41.0% indicated that PCPs are clinic physician-leads, and 2.9% indicated that PCPs can serve as consultants or in other roles in the clinic. Although 83.8% of clinics stated they agree with the aim to transfer care back to the PCP as soon as possible, 30.8% of clinics stated that that there is no formalized process to transfer care back to a PCP. Regarding instruction to PCPs on PASC care, 25.6% of clinics said that they offered workshops and educational seminars on PASC to PCPs.

CONCLUSIONS: As the COVID-19 pandemic and knowledge of PASC continues to evolve, it is anticipated that PCPs will play an increasingly important role in long term PASC care. Though a majority of survey repondents report the goal is to transfer care back to the PCP, not all PASC clinics have made active efforts to involve PCPs within patient care or have a standardized process to transfer care back to a PCP. A minority of clinics offer educational outreach to PCPs. This report highlights the need for increased post- COVID-19 clinic integration with and education of PCPs as we work to continue to provide long term care to a growing population of PASC patients.

IS ONE PILL BETTER THAN FOUR? A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS COMPARING THE POLYPILL TO STANDARD OF CARE FOR SECONDARY CARDIOVASCULAR PREVENTION

Rimsha Ali, Taaha Mirza, Jessica Cunningham

Internal Medicine, UPMC Central PA, Harrisburg, PA. (Control ID #3870964)

BACKGROUND: Atherosclerotic cardiovascular disease (ASCVD) is known to be the leading cause of mortality and disability worldwide, yet secondary prevention rates remain low primarily due to suboptimal medication compliance. The idea of a fixed-dose combination of an anti-hypertensive, a cholesterol-lowering agent and an antiplatelet treatment into one pill (also known as the polypill) has been proposed as a strategy to potentially decrease this risk by reducing medication non-adherence. The aim of this systematic review and meta-analysis is to assess the safety and efficacy of the fixed dose combination regimen compared to the standard of care.

METHODS: A search was performed on PubMed, Cochrane, and Web of Science using the MeSH terms for "(Polypill) AND (Secondary cardiovascular prevention)” from the conception of data to 10/19/2022. A total of 514 articles were screened by two independent reviewers out of which 20 full length articles were evaluated for eligibility.

RESULTS: We identified six randomized controlled trials with a total population of 13,139 with 6567 in the treatment group and 6562 in the standard of care group. Fifty four percent were males, and the mean age of the patients was 66.8 years. The median follow-up period was one year. The main outcome of interest was the effect of the fixed dose combination on medication non-adherence. The random effects model meta-analysis for non-adherence showed a Mantel-Haenszel (MH) odds ratio of 0.40 (confidence interval (CI) 0.25-0.64; p value <0.0001) favoring the polypill. High heterogeneity was noted in this with an I² of 93% as the methods to assess compliance differed among the trials. Secondary outcomes assessed included a change in systolic blood pressure, decrease in low density lipoprotein, and mortality. The random effects model meta-analysis on the standard difference of means of systolic blood pressure among the two groups showed a minor decrease of 0.083 mmHg with a standard error of +/- 0.019 (p value < 0.0001), favoring the polypill. Low heterogeneity was noted with an I² of 0.000. Similarly, the random effects model meta-analysis showed a statistically significant decrease in the standard difference of means of mean for LDL of -0.088 mg/dL with a standard error of +/-0.024 (p value < 0.0001) with an I² of 0.000. Two trials discussed cardiovascular mortality, with random effects meta-analysis favoring the polypill group an MH odds ratio of 0.60 (CI 0.46-0.77, p value < 0.001).

CONCLUSIONS: Polypill use plays an important role in decreasing medication non-adherence. There is a minor statistical benefit of the polypill in decreasing systolic blood pressure, LDL, and cardiovascular mortality but a clinical benefit may not be appreciated. More randomized controlled trials specifically focused on secondary cardiovascular prevention with longer follow-up periods are needed to assess these outcomes.

LONG COVID AND SYMPTOM SEVERITY

Raymond Van Cleve¹; Amanda Purnell²; Robert Petrin³; Alan Roshwalb³; Kelly Bell³; Megan Shaheen³. ¹Office of Health Innovation and Learning, Veterans Health Administration, Washington, DC; ²Veterans Health Administration, Washington, DC; ³Ipsos, New York, NY. (Control ID #3876475)

BACKGROUND: Social determinants of health are an emerging field of research and that has given the Veterans’ Health Administration a new understanding of how to best care for and promote the health of their patients. Acute COVID-19 infection, morbidity, and mortality is highly associated with many social determinants of health, including but not limited to race, ethnicity, gender, income, social support structures, and access to health care. The social determinants of health associated with acute COVID-19 is aligned with other disease patterns, people who experience more stress, belong to disadvantaged demographic groups, and have lower levels of wealth are more likely to become infected with COVID-19 and are more likely to experience severe illness and mortality from COVID-19. This is true for the general US population as well as the US Veteran population (Ferguson et al, 2021)

METHODS: This study used KnowledgePanel®, a probability-based online panel, to survey 3340 Veterans. This survey asked questions regarding demographic factors, social determinants of health, their health care use, health history, and their experience with COVID-19. Specifically, this survey asked which symptoms related to COVID-19 each person experienced and the severity of those symptoms.

RESULTS: Given our preliminary analysis of US Veterans with Long COVID, none of the social determinants of health associated with Acute COVID-19 are statistically significantly associated with contracting Long COVID. Not only is the risk of developing Long COVID not associated with traditional social determinants of health, the severity of Long COVID is also not associated with any traditional social determinant of health. Race, marital status, education, income, and employment status are not in any way predictive of Long COVID or severity of Long COVID.

CONCLUSIONS: This is surprising, but it is congruent with prior research on Long COVID, that it seems to be very difficult to predict and is very different on a population level from other diseases. This presentation shares these findings and possible new observations that can be explored to better understand the course and predictors of Long COVID.

MANY PATIENTS TAKE MEDICATIONS FOR CHRONIC DISEASES WITHOUT KNOWING THEIR DIAGNOSIS

Alexander Chaitoff¹; Nancy Haff⁴; Julie Lauffenburger²; Niteesh K. Choudhry³

¹Medicine, Brigham and Women's Hospital, Boston, MA; ²Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; ³Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School, Boston, MA; ⁴Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA. (Control ID #3875484)

BACKGROUND: Patients' understanding of a given medical condition is often a prerequisite for participating in shared-decision making (SDM) conversations and other aspects of care. Arguably the most fundamental piece of information a patient can have is whether they carry the diagnosis for a given disease. The aim of this study was to assess the prevalence of discrepancies between patient self-reported chronic conditions and their prescribed medications.

METHODS: The sample consisted of adults who took part in the National Health and Nutrition Examination Survey (NHANES) from January 2017 to March 2020. NHANES is a cross-sectional survey that uses a complex, multistage, clustered probability method to sample non-institutionalized civilians to provide nationally representative estimates. Respondents self-reported (yes/no) whether they had been told they had hypertension, hyperlipidemia, or diabetes, respectively. Respondents also self-reported (yes/no) whether they were currently taking any medications for each of these diseases, respectively. Actual medication use was confirmed by pill bottle examination. Frequencies and counts were used to compare discordance between self-reported disease status, self-reported medication status, and actual medication use status. Chi-square and t-tests were used to assess for characteristics associated with discordance between stated disease status and actual medication use status. All percentages reported in the results are weighted while all counts are unweighted unless otherwise specified.

RESULTS: Of the 9217 respondents, 8.2% (95%CI 7.6%-8.8%, n=888), corresponding to a weighted count of 19,696,464 individuals (95%CI 17,509,460-21,883,469), reported never receiving a diagnosis of diabetes, hypertension, or hyperlipidemia but were found to be taking at least one medication to treat these diseases. Of respondents who stated they had one of these chronic diseases, 5.4% (95%CI 4.3%-6.5%, n=285) stated they were currently taking medications for the respective condition but did not have a corresponding medication on pill-bottle examination, while 2.8% (95%CI 2.2%-3.4%, n=110) stated they were not currently taking medications for the respective condition but did have a corresponding medication on pill-bottle examination. Age, sex, race/ethnicity, education, and total number of prescriptions were not associated with discordance between respondents’ self-reported and actual medication statuses (p>0.05). However, those who had discordance between their self-reported and actual medication status did have lower average family-income- to-poverty-ratios (2.8 versus 3.2, p=0.03).

CONCLUSIONS: Many people are taking medications for chronic diseases that they report not knowing they have been diagnosed with. These discordances are not clearly related to sociodemographic factors. The prevalence of this issue and the barrier it presents for SDM conversations necessitates implementation science strategies to better educate patients.

OUTCOMES OF PATIENTS WITH MITRAL REGURGITATION AND CONCOMITANT AORTIC AND TRICUSPID VALVE DISEASE AFTER TRANSCATHETER EDGE-TO-EDGE MITRAL VALVE REPAIR

Kristina D. Menchaca¹; Nemanja Draguljevic²; Catherine A. Ostos¹; Virginia Velez Quinones¹; Guo Cheng³; Marcos Nores¹; Robert Chait¹

¹Internal Medicine, University of Miami School of Medicine, Miami, FL; ²Univerzitet u Beogradu, Beograd, Beograd, Serbia; ³University of California System, Oakland, CA. (Control ID #3875415)

BACKGROUND: Patients with severe mitral valve regurgitation (MVR) and coincidental aortic or tricuspid valve disease represent a management challenge. Traditionally, if an interdisciplinary heart team decides to perform open-heart surgery to replace the mitral valve, aortic stenosis or regurgitation is usually corrected simultaneously. However, patients at high surgical or prohibitive risks are usually referred to a less invasive alternative, such as transcatheter edge-to-edge mitral valve repair (TEER) for severe mitral valve regurgitation. We decided to observe the outcomes of the patients who underwent TEER for severe mitral valve regurgitation associated with aortic or tricuspid valve disease.

METHODS: In this retrospective cohort study, 170 patients participated that underwent TEER. Patients only with severe MVR 73/170 (42.9%) were compared to patients who had associated either moderate to severe aortic stenosis or regurgitation or tricuspid insufficiency 97/170 (57.1%). The patients had similar basic characteristics in terms of gender, prior diseases such as stroke, peripheral arterial disease, diabetes, heart failure, chronic lung disease, KCCQ12 score, MR severity, and ejection fraction. We assessed the impact of coincidental aortic or tricuspid valve disease on post-TEER outcomes such as MR reduction, total-in-hospital stay, and mortality.

RESULTS: Post-TEER, no difference was found in reducing the severity of MR (p=0.91.), total-in-hospital stay (p=0.77), and survival between patients with only MVR and patients with MVR associated with either aortic stenosis or regurgitation or tricuspid insufficiency. Both groups exhibited a reduction in the severity of MR, average total in-hospital stay of 6.33~ 6.73 (mean 6.53), and survival of 100% compared to another group with good outcomes.

CONCLUSIONS: There was no difference in feasibility and short-term outcomes of TEER in patients only with MVR compared to patients with MVR and associated aortic or tricuspid valve disease. In the era of minimally invasive procedures such as TEER, when performed in patients with concomitant and very often complicated valve pathology, we need large-scale trials to follow up on these patients' short- and long-term outcomes.

PATIENT EXPERIENCES NAVIGATING CARE COORDINATION FOR LONG COVID: LESSONS FOR HEALTHCARE SYSTEMS AND PROVIDERS

Sarah MacEwan¹; Saurabh Rahurkar²; Willi Tarver³; Cortney Forward⁴; Jennifer Eramo⁴; Alice Gaughan⁴; Laura J. Rush⁴; Erin McConnell⁵; Andrew Schamess⁶; Ann S. McAlearney⁷

¹General Internal Medicine, The Ohio State University, Columbus, OH; ²Biomedical Informatics, The Ohio State University, Columbus, OH; ³Cancer Prevention and Control, The Ohio State University, Columbus, OH; ⁴CATALYST, The Ohio State University, Columbus, OH; ⁵General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ⁶Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ⁷Family and Community Medicine, The Ohio State University, Columbus, OH. (Control ID #3874495)

BACKGROUND: Long COVID is emerging as a new chronic condition for individuals who continue to experience negative health effects after the resolution of an acute COVID-19 infection. Little is known about best practices to evaluate, diagnose, and treat long COVID which presents challenges to patients as they seek care to address their symptoms. This study served to better understand the perspectives of patients as they navigate care coordination for long COVID.

METHODS: One-on-one interviews were conducted with adult patients seeking care at a post-COVID recovery clinic. Patients for which long COVID symptoms were continuing to have an impact on their lives at 3 months or more after an acute COVID infection were eligible to participate. Interviews were conducted using a semi-structured interview guide that covered topics including long COVID symptoms and treatments, support from healthcare providers, and what participants would want providers to know about being a patient with long COVID. Thematic analysis of interview transcripts was used to characterize perspectives relative to the following components of care coordination: access to care, evaluation/diagnosis, care planning, and follow-up.

RESULTS: Interviews were conducted with 21 patients ranging in age from 19-68 years. The majority (76%) were female. Nearly one half of patients (48%) were first infected with COVID in 2020; approximately a quarter were first infected in 2021 (28%) or 2022 (24%). Patients described differing experiences accessing care for long COVID. Some noted that providers listened to their concerns and validated their symptoms which facilitated access to subsequent care. Others reported experiences in which providers did not believe their symptoms which they felt hindered their access to care. Many patients described experiences of evaluation and diagnosis related to long COVID as complicated processes involving coordination among primary and specialty providers. Patients reported confusion about communicating with numerous providers and not knowing which overlapping symptoms to discuss with each specialist. Some patients reported frustration when diagnoses did not affirm a connection with long COVID. Overwhelmingly, patients acknowledged that their providers were still learning how to treat long COVID, and they expressed an appreciation for providers who were willing to try new approaches to treatment. Finally, patients described concerns related to their follow-up including questions about if/when their long COVID symptoms would improve and if long COVID would affect their life expectancy or other aspects of aging, such as cognitive decline.

CONCLUSIONS: Our findings demonstrate the challenges of patients with long COVID as they navigate healthcare for this new chronic condition. Shedding light on these patient perspectives serves to inform improvements in the provision of compassionate and effective care, and especially in care coordination, for this population.

PATIENT-REPORTED BARRIERS TO EXERCISE AND ACCEPTABILITY OF A REMOTELY DELIVERED HOME CARDIAC EXERCISE REHABILITATION FOR HEART FAILURE

Yulia Khodneva, Andrea Cherrington, Elizabeth A. Jackson

Medicine, The University of Alabama at Birmingham School of Medicine, Birmingham, AL. (Control ID #3875826)

BACKGROUND: Adults living in the Deep South are disproportionally affected by heart failure (HF) mortality — with HF annual deaths reported as 203 per 100,000 persons compared to 168 per 100,000 persons in the Northeast of the US. This significant regional difference is related to higher poverty rates, poor adherence to important lifestyle modifications, such as physical activity, and higher levels of comorbidities, including hypertension, obesity and diabetes, in adults with HF in the South. Cardiac rehabilitation (CR) is an existing intervention for patients with HF that focuses on exercise training, dietary modifications and stress management; it is an effective but grossly underutilized intervention. Only 10% of eligible patients with HF are referred to CR anually. This study investigated the roots of this under-utilization by engaging HF patients into a patient-oriented participatory research.

METHODS: We aimed to identify patient-reported barriers to physical activity and to investigate the HF patients’ level of acceptability of home-based CR program, delivered remotely. We conducted a qualitative study of patients with HF via in-depth semi-structured interviews, guided by the framework of the “Theory of Planned Behavior”.

RESULTS: 22 patients with HF, stage C, aged 27-85, were recruited from two outpatient HF clinics in Birmingham, AL; of them 58% were women, 42% men, 73.7% African American, 21.1% White, 6.2 % Hispanic; 58% had HF with preserved ejection fraction. Patients with advanced HF, on home inotropic infusion and/or on Left Ventricular Assist Device (LVAD) were excluded. Interview were coded using two independent coders and Nvivo software. Major and minor themes were identified. Patient-reported barriers to physical activity included severity of heart failure symptoms, chronic pain, obesity, depressive symptoms, stress, feeling of grief after receiving HF diagnosis, fear of heart attack, low motivation, lack of knowledge about the type of exercise, appropriate for HF, lack of guidance from physicians and lack of access to specialized programs and qualified trainers. Participants requested more supervision during the exercise and were skeptical about programs, deliver via video-based platforms.

CONCLUSIONS: In the diverse sample of adults with HF the level of physical activity was low, patients reported numerous barriers to exercise and were skeptical about remotely delivered CR. This results will inform CR intervention development for HF; and a hybrid (combination of in-center and home-based) may be a more acceptable mode of delivery.

PERITONEAL DIALYSIS MANAGEMENT AUGMENTED WITH POINT OF CARE LUNG ULTRASONOGRAPHY:

A PILOT IMPLEMENTATION PROJECT

Robert J. Williams, Carolina Ortiz-Lopez, Isaac Teitelbaum, Michelle Fleshner

Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #3877132)

BACKGROUND: Point of care lung ultrasound (lung POCUS) has been increasingly utilized as a tool to augment traditional physical exams. More specifically, it has been utilized to perform volume assessments in patients with end stage renal disease (ESRD) on hemodialysis (HD) by identifying sonographic signs of pulmonary congestion. It is unknown, however, if lung POCUS can guide treatment in the peritoneal dialysis (PD) patient population. We aimed to perform a pilot implementation study to assess the feasibility and utility of integrating lung POCUS into a single outpatient nephrology clinic (UCH) to help manage a cohort of PD patients.

METHODS: A cohort of eighteen PD patients were followed over four consecutive monthly nephrology appointments. Three monthly appointments included a standardized 12-zone lung POCUS exam performed by credentialed Internal Medicine (IM) hospital medicine providers. The presence or absence of lung congestion identified by lung POCUS (presence of bilateral B-lines and/or pleural effusion(s)) was communicated to the patients’ treating nephrologist following their nephrologist’s standard examination. The patients treating nephrologist could decide whether to incorporate the lung POCUS into final day-of-visit management decisions. Patient weight, blood pressure, physical exam versus POCUS exam findings, and management changes were recorded over the study period. Informal qualitative interviews were performed with two treating nephrologists to assess their perception of feasibility and utility of lung POCUS in their PD clinic.

RESULTS: Forty-five of an anticipated fifty-four (83.3%) lung POCUS exams were successfully completed. Of all offered POCUS exams, only one was declined by a participant (2.1%) during their visit and eight exams (14.8%) were not completed primarily due to patient scheduling issues. Five participants (11.1%) had volume overload identified by physical exam (pretibial edema, elevated jugular venous pulse, or crackles on lung auscultation) whereas pulmonary congestion was noted on 11 (24.4%) participants’ lung POCUS. Lung POCUS findings were discordant with a traditional physical exam 26.6% (N = 12) of the time. Fourteen patient encounters were associated with a clinical management change, of which 72% (N= 8) occurred when lung POCUS and traditional volume exams were discordant . Informal qualitative interviews with treating nephrologists revealed feasibility of lung POCUS but uncertainty as to the utility of this addition, particularly in relatively stable outpatients without respiratory complaints.

CONCLUSIONS: It is feasible to integrate lung POCUS into the care of outpatient peritoneal dialysis patients. Lung POCUS may provide additional information regarding volume status of PD patients, however, its influence on treatment decisions, particularly among stable outpatients, is not clear. Further research is needed to better understand the utility of lung POCUS in managing PD patients.

POST-ACUTE SEQUELAE OF SARS COV-2 INFECTION (PASC) IN VETERANS SEEN AT A LARGE, INNER-CITY VA MEDICAL CENTER

Howard Gordon^1,2; Israel Rubinstein^1,2

¹Jesse Brown VA Chicago Healthcare System, Chicago, IL; ²University of Illinois Chicago College of Medicine, Chicago, IL. (Control ID #3875865)

BACKGROUND: After contracting acute SARS-CoV-2 illness, some patients experience a plethora of physical and mental health manifestations that last four or more weeks, the Post-Acute Sequelae of SARS

CoV-2 infection (PASC). We sought to determine the burden of PASC among Veterans with prior PCR- positive COVID-19 infection seen at a large, inner-city VAMC.

METHODS: We mailed surveys to Veterans at a large inner-city VAMC, who had a positive RT-PCR test for SARS-CoV-2 and had survived at least 30-days after diagnosis (N = 1,849). Respondents indicated symptoms they experienced during their acute COVID-19 illness and if they were still experiencing symptoms. Demographic and clinical characteristics were obtained through medical record linkage. Frequency of initial COVID-19 symptoms and long-lasting symptoms were reported. Chi-square tests were used to compare differences between COVID-19 initial and on-going symptoms by race and age. Written responses to an open-ended question about experiences with COVID-19 were analyzed with qualitative content analysis.

RESULTS: A total of 211 surveys were completed and returned between February and July 2022. Survey respondents had mean age 65.7 years (SD 12) and were 93.8% male (N = 197), 54% Black (N = 114), 13.2% Latinx (N = 27), 71.6% had a high school education or higher (N = 151), 69.1% (N = 143) lived with at least one other person, and 53.5% (N = 93) did not report trouble affording basic needs such as food and utilities. Survey respondents experienced a mean of four (SD 4.1) PASC symptoms. The most frequent on-going symptoms reported were fatigue (41.9%), trouble sleeping or staying asleep (40.5%), mental fog (36.7%), shortness of breath (32.2%), and body aches (28.4%). There were no statistically significant differences between initial symptoms, on-going symptoms, and race. When asked about on-going symptoms, those 65 years and older were more likely to report trouble sleeping (p = 0.029) and mental fog (p = 0.01). These older Veterans were twice or more likely to seek care for their PASC symptoms compared to younger patients (p = 0.02). Older Veterans experienced more symptoms when initially diagnosed with COVID-19 in comparison to younger Veterans (p = 0.002). We collected 95 (45%) responses to an open-ended question about experiences with COVID-19 and 30 Veterans provided accounts of severe illness that included descriptions of perceived near death experiences and prolonged hospital stays. Also, 12 Veteran respondents described difficulty with PASC, including ongoing respiratory, GI, neurological and cognitive symptoms.

CONCLUSIONS: Though these findings are limited by the low response rate, they indicate a substantial burden of PASC in this inner-city Veteran population. On average, survey respondents continued to experience 4 symptoms long after acute COVID-19 illness. We posit that assessment of PASC burden by age, race, sex, and other clinical characteristics could inform the need for dedicated PASC clinics in Veterans Health Administration.

PREDICTORS OF DEVELOPING LONG COVID FROM PROSPECTIVELY COLLECTED DATA FROM A PHASE 3 CLINICAL TRIALS.

Hrishikesh Belani²; Seema Belani³; Jacinda M. Nicklas⁴; Sarah Fenno⁵; Spencer Erickson⁶; Carolyn Bramante¹

¹Medicine, University of Minnesota Twin Cities, Minneapolis, MN; ²Medicine, Los Angeles County Department of Health Services, Los Angeles, CA; ³College of Allopathic Medicine, Nova Southeastern University College of Allopathic Medicine, Davie, FL; ⁴General Internal Medicine, University of Colorado School of Medicine, Aurora, CO; ⁵University of Minnesota Medical School, University of Minnesota Medical School Twin Cities, Minneapolis, MN; ⁶General Internal Medicine, University of Minnesota Medical School Twin Cities, Minneapolis, MN. (Control ID #3877381)

BACKGROUND: The COVID-OUT trial was a phase 3, randomized, quadruple blinded clinical trial of early outpatient treatment of Covid-19 using generic medications (Trial registration: NCT04510194). One unique aspect of the trial is that it continued 10-month follow-up, the longest follow-up from any phase 3 outpatient Covid-19 treatment trial at the time of this submission.

METHODS: For 10 months after randomization, participants were sent monthly serveys asking questions including: had they been diagnosed with Long Covid; had they received any new diseases; started medications; had they been re-infected with Covid-19, and if so how was this diagnosed (home test or a lab), and was their subsequent infection more or less severe than their initial infection; had they received booster vaccinations. Patient-reported diganoses i.e. Long Covid; new onset diabetes, were confirmed in the health record. This is an observational analysis of risk factors for developing Long Covid, controlling for study drugs.

RESULTS: Overall 1,125 participants consented for longterm follow-up and completed at least one survey about Long Covid. Two percent identified as Native American; 3.7% as Asian; 7.4% as Black/African American; 82.8% as white; and 12.7% as Hispanic/Latino. The median BMI was 29.8 kg/m² (IQR 27 to 34); 51% had a BMI >30kg/m². Overall, 8.4% reported a medical provider diagnosed them with Long Covid. As seen in the table, among those who reported being reinfected with Covid-19, 13% developed Long Covid. Of those with Long Covid, 74.5% were female, versus 54% of those with no Long Covid; 11.7% were Black, versus 7.0% without Long Covid; 44% were vaccinated before enrollment versus 56% without Long Covid. Of those with Long Covid, 83.7% did not seek care at the ED; 10.9% had ED visits; and 5.4% were hospitalized during their initial Covid infection. Of those with Long Covid, 28 (29.8%) had been re-infected with Covid-19; and 54% had obesity, compared to 48% of those without a Long Covid diagnosis.

CONCLUSIONS: In this cohort of adults who participated in a randomized clinical trial, overall 8.4% developed long Covid. Women, those with obesity, those who had been reinfected with SARS-CoV-2, and those who identify as Black appear more likely to report a medical provider diagnosis of Long Covid.

PREDISPOSING, ENABLING, AND RETAINING FACTORS FOR PRIMARY CARE STAFF AS COACHES IN AN ELECTRONIC HEALTH RECORD (EHR)-BASED WEIGHT MANAGEMENT STUDY: DATA FROM THE MAINTAIN PRIME STUDY (PROMOTING REAL-WORLD IMPLEMENTATION)

Maribel Cedillo²; Jesell Zepeda³; Emily Zheutlin⁴; Polina Kukhareva⁵; Bernadette Kiraly⁸; michael c. flynn⁶; Jorie Butler⁵; Rachel Hess¹⁰; Kensaku Kawamoto⁷; Paul Estabrooks⁹; Molly Conroy¹

¹General Internal Medicine, University of Utah, Salt Lake , UT; ²General Internal Medicine, University of Utah, Salt Lake, UT; ³Department of General Internal Medicine, University of Utah Health, Salt Lake City, UT; ⁴Internal Medicine, University of Utah Health, Salt Lake City, UT; ⁵Department of Biomedical Informatics, University of Utah, Salt Lake City, UT; ⁶Community Clinics, University of Utah, West Valley CIty, UT; ⁷Biomedical Informatics, University of Utah, Sandy, UT; ⁸Family and Preventive Medicine, University of Utah Health, Salt Lake City, UT; ⁹Health and Kinesiology, University of Utah Health, Salt Lake City, UT; ¹⁰Population Sciences, University of Utah, Salt Lake City, UT. (Control ID #3876432)

BACKGROUND: MAINTAIN PRIME (MP) is an adaptation of an effective weight management program designed for implementation by primary care staff. Key to the success of MP is the use of coaching to facilitate sustained weight loss. We sought to determine the utility of using a theory-based planning tool focused on predisposing, enabling, and retaining (PER) factors to guide coach training strategies.

METHODS: Medical assistants, nurses, and other staff were recruited as coaches from participating University of Utah primary care clinics. The PER tool guided our training plan. Predisposing: At an environmental level, motivation was achieved by clinic participation and leadership engagement. Leadership support for MP was crucial for staff motivation in understanding MP value. Staff required clinic leaders’ approval to participate in training, to which all staff was invited. Next, we aimed to attract staff with intrinsic motivation for lifestyle coaching. We designed a stepwise self-selection process, including registration, confirmation of interest, online self-paced training, and electronic health record (EHR) hands-on training. Enabling: Training provided skills, gave access to evidence-based resources (including EHR smart phrases), and removed barriers such as lack of confidence, writing skills, and time allocation. Reinforcing: Reminders and support from registered dietitians were planned to promote retention.

RESULTS: Predisposing: 65 of 187 staff from various clinical roles (35%) at 11 participating clinics expressed interest in training. 50 potential coaches viewed an informational video; 46 (92%) confirmed

interest. Intrinsic Motivation. 31 of 46 (67%) who confirmed interest completed training; 28 completed training and started coaching, 3 completed training but did not coach, and 12 potential coaches started but did not complete training. Enabling coaches. Coaches who completed post-training evaluations (97%) felt they had learned enough to coach patients (5.9, 7=you feel ready) and were likely to recommend the training to others (8.0, 10=extremely likely). All (100%) reported achieving learning objectives. Most (93%) felt the course had practical value; 97% reported the course and instructor met their needs and 93% agreed with instruction method, rating both online and EHR hands-on training components highly (5.2 and 6.1, respectively; 7=max). Reinforcing. Turnover of clinical staff is common. 13 (43%) coaches have left the clinic site, and completed an exit survey reporting coaching seemed implementable, possible, doable, and easy (4.2, 4.2, 4.2, 3.7, respectively; 5=completely agree). The highest rated coaching role components were helping and connecting with patients. The tool that most facilitated coaching was EHR smart phrases. Opportunities for improvement related to EHR functions included task due dates, patient reminders, and EHR documentation.

CONCLUSIONS: The PER strategies allowed us to implement a well-received training program found effective by primary care coaches.

PREVALENCE AND DISPARITIES IN AWARENESS AND KNOWLEDGE OF MEDICATION OVERUSE HEADACHE AMONG PATIENTS WITH MIGRAINE

Stacy Bailey¹; Wei Huang¹; Andrea Zuleta¹; Yvonne Curran³; rodolfo zuleta¹; Melissa Herman⁴; Steven M. Kymes²; Allison Pack¹

¹General Internal Medicine, Northwestern University, Evanston, IL; ²Lundbeck LLC, Deerfield, IL; ³Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL; ⁴H Lundbeck A/S, Valby, Hovedstaden, Denmark. (Control ID #3875824)

BACKGROUND: Medication overuse headache (MOH) occurs when patients with a pre-existing headache disorder overuse medication in an attempt to relieve headache pain or symptoms. MOH results in additional headaches and, for many patients, is a root cause of the transition from episodic to chronic migraine. Patient education is necessary to inform patients of the risks associated with MOH and to ensure that prescription and over-the-counter (OTC) pain relievers are being used safely and effectively. Yet few studies have comprehensively examined patient knowledge of MOH, its risk factors, and signs of progression.

METHODS: English-speaking adults with a history of migraine and a clinic visit within the past month were identified via an electronic health record (EHR) query from an academic health center in Chicago, IL.

Potential participants were contacted by research coordinators, who introduced the study, engaged interested patients in the informed consent process, and enrolled participants. Participants completed one survey that measured MOH awareness and knowledge, patient-provider communication, and sociodemographic characteristics.

RESULTS: A total of 200 adults participated. Participants were predominately female (82.9%) and middle- aged, 57.4% were White, 31.8% made <$50,000 annually, and 18.2% had limited health literacy. On average, participants had been diagnosed with migraine for over a decade; 64% had severe migraine-related disability. More than a third (35.9%) reported taking an OTC pain reliever on ≥15 days in the past month, putting them at risk of MOH. A total of 38.6% of participants reported that they had never heard the term ‘medication overuse headache.’ In bivariate analyses, participants who were Black or Hispanic, those with limited health literacy, and patients with less severe disability were less likely to have heard of the term. Almost 1 in 5 participants (19.0%) did not know that ‘medications taken to treat headache can also cause headaches.’ Participants who were older, less educated, and with limited health literacy were significantly less likely to be aware of this concept. Participants who reported better patient-provider communication were more likely to have greater MOH knowledge and to know how often they could take OTC medicine to avoid MOH.

CONCLUSIONS: Findings indicate that awareness and knowledge of MOH is suboptimal, with clear disparities by patient sociodemographic factors. Results also indicate about one-third of migraine patients are at risk of MOH due to high frequency OTC use. Additional patient education and improved patient-provider communication about MOH may help prevent the condition.

PREVALENCE OF PRESCRIPTION MEDICATION USE THAT CAN CAUSE OR EXACERBATE HEART FAILURE AMONG ADULTS WITH HEART FAILURE

Alexander Chaitoff¹; Joshua D. Niforatos²; Alexander Zheutlin³

¹Medicine, Brigham and Women's Hospital, Boston, MA; ²Johns Hopkins Medicine, Baltimore, MD; ³University of Utah Health, Salt Lake City, UT. (Control ID #3876279)

BACKGROUND: Professional societies are increasingly recognizing the role of iatrogenesis in disease outcomes. The 2022 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Failure Society of American (HFSA) heart failure (HF) guidelines identify medications that can cause or exacerbate HF and should be avoided when possible. In this study, we determined the prevalence of using these medications among adults with self-reported HF.

METHODS: The sample included US adults (> 20 years) with self-reported HF participating in the National Health and Nutrition Examination Survey (NHANES) between 2011 and March 2020. NHANES samples non-institutionalized civilians to provide nationally representative estimates. Respondents' use of medications the AHA/ACC/HFSA identified as potentially causing/exacerbating HF was assessed by pill-bottle review. We describe the prevalence of taking these medications overall, by sex (male/female), by race/ethnicity (non- Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian, Other/Multi-race), and stratified by level of evidence for medication harm as reported by the guidelines (A vs. B/C). We used multivariable logistic regression to generate odds ratios (aOR) of being prescribed one of these medications by gender and race/ethnicity adjusting for age, education status, and income-to-poverty ratio, insurance status, self-reported comorbidities (arthritis/diabetes/hypertension/nocturia), total number of medications, and survey cycle. Proportions are presented as weighted estimates while counts are unweighted unless otherwise stated.

RESULTS: Among adults with HF (n=687), 26.1% (95% CI 21.3%-30.9%, n=173) were prescribed a medication that can cause/exacerbate HF, which represents approximately 1.42 million adults. 4.1% of respondents were on a medication with A level evidence of potential to cause/exacerbate HF, while 24.4% were on a medication with B/C level evidence of potential to cause/exacerbate HF. 32.1% (95% CI 25.4-38.8%, n=113) and 20.4% (95% CI 13.8%-27.0%, n=60) of males and females, respectively, were prescribed a medication that can cause/exacerbate HF. Male participants were more likely to be prescribed a medication that can cause/exacerbate HF (aOR 2.24, 95% CI 1.40-3.60). In multivariable analysis there were no statistically significant differences in medication use that can cause/exacerbate heart failure by race (p>0.05 for all). History of hypertension (aOR 2.27 95%CI 1.09-4.70), nocturia (aOR 1.23, 95%CI 1.07-1.41), and number of medications (aOR 1.23, 95%CI 1.15-1.31) were the only model covariates that reached statistical significance.

CONCLUSIONS: 26.4% of adults with self-reported HF were prescribed medications that the AHA/ACC/HFSA recommends avoiding. Balancing the competing demands of HF- and non-HF medications is imperative to maximizing the quantity and quality of life for adults with HF, and increased attention to polypharmacy likely has a role to play in reducing HF morbidity.

PROCEDURAL/SURGICAL RHYTHM CONTROL FOR PATIENTS WITH ATRIAL FIBRILLATION: A META-ANALYSIS

Bryce Montane¹; Shiyang Zhang¹; Jonathan D. Wolfe¹; Daniel H. Cooper¹; Michelle Doering¹; Brian F. Gage². ¹Washington University in St Louis, St Louis, MO; ²Medicine, Washington University in St Louis School of Medicine, St Louis, MO. (Control ID #3875471)

BACKGROUND: Atrial fibrillation quadruples the risk of ischemic strokes. Whether rhythm control via catheter ablation or surgical rhythm reduces this risk is unknown. Our objective was to understand long term ischemic stroke risk for different treatments of atrial fibrillation.

METHODS: We combined prior trials to quantify the reduction on ischemic stroke from rhythm control via catheter ablation or surgery (e.g. the Maze procedure). We included trials that met the following inclusion criteria: >1 month of follow up, adult patients with atrial fibrillation, English language, and randomization to either catheter ablation or surgical rhythm control vs. conservative therapy. The primary outcome was the relative risk of ischemic stroke after a 30-day blanking period (when no strokes were included). We combined trials using the Cochran-Mantel-Haenszel method to quantify the relative risk (RR) of stroke. We used the Haldane correction for trials that observed 0 strokes in either arm.

RESULTS: The 22 trials of catheter ablation randomized a total of 5,659 patients and had a RR (95% CI) of 0.64 (0.43-0.95). The 20 trials of surgical rhythm control randomized a total of 2,083 patients and had a relative risk (95% CI) of 0.64 (0.41-0.998). Together, the 42 trials had a RR (95% CI) for ischemic stroke of 0.64 (0.48-0.87).

CONCLUSIONS: After the 30-day blanking period, catheter ablation or surgical rhythm control reduced the risk of ischemic stroke in trial participants with atrial fibrillation. We hypothesize that over a longer period, maintenance of sinus rhythm associated with procedural/surgical rhythm therapy reduces the risk of ischemic stroke for patients suffering from atrial fibrillation.

READINESS TO TAPER: PSYCHOSOCIAL FACTORS ASSOCIATED WITH MOTIVATION TO TAPER OPIOIDS AMONG INDIVIDUALS WITH CHRONIC PAIN

Danielle Wesolowicz^1,2; Sara Edmond^1,2; Brent A. Moore^3,1; Manik Chhabra⁵; Liana Fraenkel^4,2; William Becker^1,2

¹Research, VA Pain Research Informatics Multi-morbidities and Education Center, West Haven, CT; ²Yale School of Medicine, New Haven, CT; ³Psychiatry, Yale School of Medicine, New Haven, CT; ⁴Berkshire Medical Center, Pittsfield, MA; ⁵VA Center for Health Equity Research and Promotion, Philadelphia, PA. (Control ID #3872943)

BACKGROUND: Guidelines encourage primary care providers to taper or discontinue long-term opioid therapy for chronic pain when harms outweigh benefits; however, tapering may come with challenges including withdrawal symptoms, distress, and fears of increased pain. Patient-centered approaches to tapering are necessary to manage such risks and enhance likelihood of success. Given the difficulties associated with tapering, a patient’s motivation to taper may be an important variable to target when considering approaches to support patients interested in tapering. The purpose of this analysis was to explore psychosocial predictors of motivation among veterans with chronic pain voluntarily undergoing an opioid taper.

METHODS: We performed this cross-sectional study among thirty veterans with chronic pain in VA care (80% men, mean age= 65, 33% White, 60% Black, 7% other) enrolled in a pilot randomized controlled trial evaluating the feasibility and acceptability of a web-based, interactive program to support opioid tapering. Prior to randomization, participants completed baseline questionnaires, including assessment of motivation to change opioid regimens (Change Questionnaire; CQ). Based on CQ scores, we divided participants into categories reflecting low, moderate, and high motivation to taper. We conducted ordinal logistic regression to examine associations between independent variables (demographics, experience of opioid-related side effects, functioning, pain, anxiety, and depression) and the dependent variable (motivation to taper category).

RESULTS: Results from ordinal logistic regression indicated patients were more likely to have high motivation to taper if they reported higher pain intensity (OR=10.93, 95% CI=1.66-72.10), greater anxiety (OR=1.30, 95% CI=1.30-20.18), lower pain interference (OR=.31, 95% CI=.11-.88), were younger (OR=.57; 95% CI=.37-.87), and reported higher physical functioning (OR=.16, 95% CI=.03-.07). Gender, race, opioid side effects, and depression were not associated with motivation level.

CONCLUSIONS: Among patients voluntarily tapering opioids, having higher pain, greater anxiety, and having lower pain interference were independently associated with increased odds of being more motivated to taper. Difficulty engaging in physical activity and activities of daily living may serve as a barrier to tapering among patients considering tapering opioids, and could be an important target for efforts to enhance motivation. Future studies should further explore the association between motivation and tapering to inform potential interventions to enhance tapering outcomes.

RELATIONSHIP BETWEEN HEMATOLOGIC INFLAMMATORY MARKERS AND GLYCATED HEMOGLOBIN IN PATIENTS WITH TYPE 2 DM ATTENDING A TERTIARY TEACHING HOSPITAL IN NIGERIA

Lemchukwu Amaeshi¹; Olufunto Kalejaiye²; Oluwarotimi Olopade²; Michael Kehinde²

¹Internal Medicine, Montefiore Health System, Bronx, NY; ²Lagos University Teaching Hospital, Surulere, Lagos, Nigeria. (Control ID #3876309)

BACKGROUND: The pathophysiologic hallmark of Type 2 DM is insulin resistance, and sub-clinical inflammation is involved in its pathogenesis. Inflammatory markers such as neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and mean platelet volume (MPV) are elevated in Type 2 DM. Studies have shown that glycated hemoglobin (HbA1c), a standard measure of glycemic control, correlates with these markers. In low-resource countries, where the burden of Type 2DM is increasing, and many cannot afford HbA1c as a measure of glycemic control, a less expensive alternative is necessary. Complete blood count (CBC), which has the indices from which these hematologic inflammatory markers are derived, are easily available and affordable even for the poor rural population. This study aimed to assess the role of NLR, PLR, and MPV as surrogates of HbA1c in predicting glycemic control in patients with Type 2 DM.

METHODS: This cross-sectional study comprised 109 adults with Type 2 DM and 109 age-and sex-matched controls. Convenience sampling was used to recruit the participants. Adult patients (>18 years) with diabetes were recruited from the diabetic clinic of a large teaching hospital in Lagos, Nigeria. The controls were healthy adults without diabetes. The NLR, PLR, and MPV were derived from the CBC of the participants. Those with Type 2 DM were subdivided in terms of their glycemic control, where optimal glycemic control comprised those with Hb A1c <7% and suboptimal glycemic control had Hb A1c > 7%. Data were analyzed using the Statistical Package for Social Sciences software. Categorical and continuous variables were compared using the chi-square test and student t-test, respectively. The strength of the association between Hb A1c and the inflammatory markers were assessed using Spearman’s rank correlation coefficient and scatter plot charts. A P-value of <0.05 was considered statistically significant.

RESULTS: The mean age of the participants was 57 + 11 years. Ninety-five percent of the patients with diabetes were on glucose-lowering medications. Patients with Type 2 DM had significantly higher NLR compared with controls [(6.2 + 1.8) vs. (4.9 + 1.2) x 10⁹ cells/L, P<0.001]. PLR and MPV were not statistically higher among Type 2DM patients compared with controls. In patients with Type 2DM, there was no statistically significant difference in NLR, PLR, and MPV between those with good glycemic control and those with suboptimal glycemic control. In addition, there was no correlation between these markers and Hb A1c.

CONCLUSIONS: Neutrophil-lymphocyte-ratio is elevated in Type 2 DM, but there is no relationship between NLR, PLR, MPV, and HbA1c. The medications that patients with diabetes take, may have anti- inflammatory properties that reduce the levels of these inflammatory markers. Therefore, these markers may not be helpful in predicting glycemic control in the management of patients with diabetes. A larger study may show an association between Hb A1c and these markers.

RISK FACTORS FOR INPATIENT MORTALITY IN PATIENTS WITH END STAGE KIDNEY DISEASE ON MAINTENANCE DIALYSIS, DURING AN ADMISSION FOR COVID-19 USING A NATIONALLY REPRESENTATIVE SAMPLE

Sae X. Morita, Akshay Agrawal, Bessy S. Flores Chang, Carlos E. Arias Morales

Medicine, City University of New York, New York, NY. (Control ID #3876961)

BACKGROUND: Several studies reported that the COVID-19 pandemic has disproportionately affected socioeconomically vulnerable populations. No study evaluated risk factors for inpatient mortality in patients with end stage kidney disease (ESKD) on maintenance dialysis admitted with the diagnosis of Covid-19, using a US nationwide sample.

METHODS: We extracted data from the National Inpatient Sample year 2020, the largest nationally representative inpatient-care database in the US. We created a cohort of all adults with ESKD on maintenance dialysis hospitalized for Covid-19 by ICD-10 codes. The outcome was inpatient mortality. We excluded transplant patients. We compared baseline characteristics and used multiple logistic regression to determine risk factors for inpatient mortality in this cohort.

RESULTS: A total of 789,855 admissions with a diagnosis of Covid-19 were detected in patients with ESKD on maintenance dialysis. The mean age was 62.1±0.2 years and Females accounted for 46%. Inpatient mortality was 5.9%. The table showed the results of the multivariable logistic model. Older patients, Males, with higher Charlson Comorbidity Index scores were associated with a higher risk of inpatient mortality. White patients had a higher risk compared to Black patients and among ethnicities/races, Native Americans had the highest risk, although not statistically significant. Those with commercial payments had a higher risk than those with Medicare and Medicaid payments. Admission to a larger, urban, teaching, publicly owned hospital and those in the Northeast had higher odds of inpatient mortality.

CONCLUSIONS: Our study showed Males, commercial payment type, hospital settings such as regions and teaching status were risk factors for inpatient mortality in patients with ESKD on maintenance dialysis.

Further studies are needed to evaluate whether differences in clinical practice underly some of these risks.

RISKY USE BEHAVIORS IN PATIENTS CERTIFIED FOR MEDICAL CANNABIS FOR CHRONIC PAIN

Yuval Zolotov¹; Deepika Slawek¹; Chenshu Zhang¹; Jonathan Ross¹; Chinazo Cunningham¹; Joanna L. Starrels¹; Julia Arnsten¹; Nancy Sohler²

¹Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY; ²City University of New York, New York, NY. (Control ID #3875103)

BACKGROUND: Although use of medical cannabis is increasing, data on risky use behaviors among patients certified for medical cannabis is limited. We explored several risky use behaviors in a cohort of patients who were newly certified for medical cannabis for pain in New York State.

METHODS: We analyzed data from the Medical Marijuana and Opioids study, which enrolled patients with chronic or severe pain who reported opioid use and were newly certified for medical cannabis. We included data from 170 participants who completed nine months of follow-up. At baseline and every three months, we assessed: (1) DSM-IV Cannabis Abuse and Cannabis Dependence, measured by The Mini-International Neuropsychiatric Interview; (2) medical cannabis diversion, measured by a modified version of the Massachusetts General Hospital Medication Questionnaire; (3) medical cannabis misuse potential, determined using two items from the Current Opioid Misuse Measure. Unregulated cannabis use was measured by self-report in web surveys every two weeks. Participants were categorized with a risky use behavior if it was reported at any time during follow-up. Days of medical cannabis use, measured in the web surveys, was the average number of days of medical cannabis use during a two-week period. We calculated frequencies and used logistic regressions to determine the effect of the frequency of medical cannabis use on each behavior, adjusting for demographic characteristics.

RESULTS: The median age was 54 years and 92 participants (54.1%) identified as female, 69 (40.6%) as non-Hispanic White, 50 (29.4%) as non-Hispanic Black, and 40 (23.5%) as Hispanic. Participants reported medical cannabis use on an average of 7.3 days every two weeks. Fourteen participants (8.2%) met the criteria for cannabis abuse or dependence, 6 (3.5%) reported medical cannabis diversion, 95 (59.0%) reported potential for medical cannabis misuse, and 68 (40.0%) reported unregulated cannabis use. Adjusted for age, insurance status, and pain severity, frequency of medical cannabis use was associated with lower odds of unregulated cannabis use (OR 0.91, 95% CI 0.85, 0.98). No other associations reached statistical significance.

CONCLUSIONS: In this longitudinal study of patients newly certified for medical cannabis with chronic pain, we observed low frequencies of cannabis abuse or dependence and medical cannabis diversion over nine months. More participants reported potential for medical cannabis misuse and unregulated cannabis use, and those with more frequent medical cannabis use were less likely to report unregulated cannabis use. These results indicate that the availability of medical cannabis alone may not prevent risky use behaviors. A limitation of our study is that the study measures were developed for studies of people who use unregulated cannabis or prescription opioids and may not be valid for medical cannabis studies.

SELF-REPORTED FRAILTY AND HEALTHCARE UTILIZATION IN COMMUNITY-DWELLING MIDDLE-AGED AND OLDER ADULTS IN THE UNITED STATES

Aaron Yao¹; Shengyu Zhou²; Joyce Cheng³; Dae Hyun Kim⁴

¹VillageMD, Chicago, IL; ²Center for Management and Policy Research, Shandong University, Jinan, Shandong, China; ³School of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; ⁴Harvard Medical School, Boston, MA. (Control ID #3872013)

BACKGROUND: The aging of the population has increased the prevalence of frailty substantially, especially among the costliest patients; however, the current healthcare response to frailty is mainly reactive and acute care-based. And previous studies on frailty have mainly been conducted using nonrepresentative samples in people aged 65 years and above. With a nationally representative sample, we describe the prevalence of frailty in the United States and evaluate the associations between frailty, demographic characteristics, and healthcare utilization in community-dwelling middle-aged and older adults. And these results are discussed to inform policymaking and quality improvements in primary care settings.

METHODS: This study included 2019 National Health Interview Survey demographic and healthcare utilization data for about 20000 participants. Frailty was measured using the revised FRAIL scale (Fatigue, Resistance, Ambulation, Illnesses, and Low BMI) and five survey questions in the National Health Interview Survey questionnaire. Individuals were classified into different health status categories: robust, pre-frail, or frail. About healthcare utilization, emergency room usage was determined by asking participants, "During the past 12 months, how many times have you gone to a hospital emergency room about your health?" Similarly, overnight hospitalization, delay of care due to cost, and omission of medical care due to cost were also measured using self-reported data. Rao-Scott chi-squared tests and logistic regression analyses were used to analyze relationships between age, frailty, family income, educational attainment, and healthcare utilization.

RESULTS: The weighted prevalence of frailty was 39% in those aged 85 or older, 25% in those aged 75-84 years, 15% in those aged 65-74 years, and 9% in those aged 45-64 years. Frailty prevalence was two times higher in older adults and eleven times higher in middle-aged adults earning less than the federal poverty line (FPL) compared to those earning ≥400% FPL. Frailty was associated with increased emergency room visits and hospitalizations, and delay and omission of medical care due to cost. Lower family income and educational attainment exacerbated the associations between frailty and delay and omission of medical care. These trends appeared stronger in middle aged adults compared to older adults.

CONCLUSIONS: Frailty is prevalent in both middle-aged and older adults; however, delays and omissions of medical care were more prevalent in middle-aged adults. Primary care providers can play an important role in identifying frailty early and addressing both over-use and under-use of health care services.

SPINAL CORD INJURY AND PRESCRIBED OPIOIDS FOR PAIN: A SCOPING REVIEW

Jo Ann Shoup¹; JoEllen Welter^2,3; Ingrid A. Binswanger^1,4; Florian Hess²; Alexander Dullenkopf³; Jennifer Coker⁵; Jeffrey Berliner^5,6

¹Institute for Health Research, Kaiser Permanente Colorado Institute for Health Research, Aurora, CO; ²Department of Orthopedic Surgery and Traumatology, Spital Thurgau AG, Frauenfeld, Thurgau, Switzerland; ³Institute for Anesthesia and Intensive Care Medicine, Spital Thurgau AG, Frauenfeld, Thurgau, Switzerland; ⁴Division of General Internal Medicine, University of Colorado, Denver, CO; ⁵Craig Hospital Research Department, Craig Hospital, Englewood, CO; ⁶CNS Medical Group PC, Englewood, CO. (Control ID #3874669)

BACKGROUND: Spinal cord injury (SCI) is a life-altering neurological condition affecting physical and psychosocial functioning. Individuals with traumatic and nontraumatic SCI experience very high rates of pain. An estimated 60% to 80% of people with SCI report high rates of chronic pain, with one-third experiencing intense pain. Effective treatment options for SCI pain management beyond pharmaceuticals are limited, resulting in elevated exposure to prescribed opioids. A scoping review was conducted to identify and synthesize literature on traumatic and nontraumatic SCI and prescription opioid use for pain. We focused on the following research questions: (i) what type of evidence on this topic is available in the peer-reviewed published literature, (ii) what research gaps exist, and (iii) what recommendations and priorities for future research and clinical practice have been or should be proposed.

METHODS: We searched six electronic bibliographic databases (PubMed (MEDLINE), Ovid (MEDLINE), EMBASE, Cochrane Library, CINAHL, PsychNET) for articles published from 2014 through 2021. Terms for “spinal cord injury” and “prescription opioid use” were used. Included articles were in English and peer reviewed. Data were extracted using an electronic database by two independent reviewers. Opioid use risk factors for chronic SCI were identified. An analysis was performed to identify gaps in knowledge on SCI and prescription opioids.

RESULTS: Of the 347 publications screened for eligibility, 16 articles included in the scoping review. A majority were conducted in the United States (n=9). Most articles lacked information on income (87.5%), ethnicity (87.5%), and race (75%). In studies reporting prescription opioid use, the range was from 35% to 60%. Descriptively, polypharmacy of benzodiazepine, sedative or hypnotic prescriptions co-occurred with opioid prescriptions in up to 38% of participants. Risk factors for prescription opioid use in those with chronic SCI included middle age, lower income, osteoarthritis diagnosis, prior opioid use, and lower-level spinal injury. The three primary gaps in the literature were: lack of reporting of diversity such as race, ethnicity, and age in study populations and settings; absence of polypharmacy as a variable in statistical modeling in prescription opioid risk; lack of knowledge of opioid-related overdose and death in the SCI population; and limited high quality research designs and methods.

CONCLUSIONS: In a population with high rates of pain and high exposure to prescription opioids and other pharmaceutical treatments, knowledge is needed to understand needs and potential effectiveness of treating SCI-related pain. Future research should address gaps in the literature such as reporting demographics of the research population, inclusion of polypharmacy in prescription opioid risk modeling, reporting opioid-related overdose and death in those with SCI and implementing clinical trials on pain management and harm reduction.

SYMPTOMS DESCRIPTION AND SEVERITY OF LONG COVID

Kelly Bell¹; Raymond Van Cleve²; Robert Petrin¹; Alan Roshwalb¹; Megan Shaheen¹; Amanda Purnell²

Learning, Veterans Health Administration, Washington, DC. (Control ID #3876548)

BACKGROUND: Post Acute Sequelae of COVID-19, also known as Long Haul COVID-19 or simply Long COVID, has proven to be a significant threat to public health. One of the current challenges with Long COVID is that we do not know exactly how to classify the disease beyond COVID-19 related symptoms that lasted more than four weeks after the initial infection. This paper presents results from a specialty sample survey of US Veterans, which provides insight into COVID-19 symptom incidence rates for twenty-two acute COVID and long COVID symptoms, as well as levels of overall symptom severity for the Veteran population. This is a descriptive study to examine the nature of Veterans’ experience with Acute COVID and Long COVID.

METHODS: This study used KnowledgePanel®, a probability-based online panel, to survey 3340 Veterans. This survey asked questions regarding demographic factors, social determinants of health, their health care use, health history, and their experience with COVID-19. Specifically, this survey asked which symptoms related to COVID-19 each person experienced and the severity of those symptoms.

RESULTS: Of the 3340 Veterans who had COVID-19, 658 Veterans had tested positive for COVID-19 and 303 experienced symptoms for longer than four weeks. 245 Veterans had slight or moderate symptoms in the long period, while 68 veterans had severe or debilitating symptoms in the long period. The most common symptoms experienced in the long period were fatigue, difficulty staying asleep, body aches, general pain, and coughing. People who had debilitating or severe symptoms in long period did not necessarily have debilitating or severe symptoms in acute period.

CONCLUSIONS: The symptoms experienced ranged from psychological, to respiratory, to broader physiological. Long COVID symptoms span a wide range of medical areas, and some symptoms could become move from mild to severe. People who test positive for COVID have a low but significant chance of developing severe symptoms many weeks after initially testing positive.

THE 12-MONTH COST-EFFECTIVENESS OF TELEPHONE-DELIVERED "BLENDED" COLLABORATIVE CARE FOR TREATING HEART FAILURE AND COMORBID DEPRESSION Bruce L. Rollman¹; John F. Dickerson²; Scott D. Rothenberger¹; Amy Anderson¹; Kwonho Jeong³; Kaleab Z. Abebe¹; Maureen O'Keeffe-Rosetti²; Lucy Fulton²; Bea H. Belnap¹; Frances L. Lynch²

¹Medicine, University of Pittsburgh, Pittsburgh, PA; ²Kaiser Permanente Center for Health Research Northwest Region, Portland, OR; ³Biostatistics, University of Pittsburgh, Pittsburgh, PA. (Control ID #3868941)

BACKGROUND: Depression is co-morbid in 20-25% of patients with heart failure (HF), associated with poorer clinical outcomes, and often goes unrecognized and untreated. We previously reported telephone- delivered collaborative care (CC) for treating HF and depression together improves 12-month health-related quality of life and mood symptoms more than primary care physicians’ (PCPs’) usual care (UC). We now report the cost-effectiveness of our intervention so as to guide health systems on whether to adopt our “blended” CC strategy.

METHODS: From 3/14-10/17 we enrolled 629 hospitalized patients with systolic HF (ejection fraction ≤45%) who screened positive for depression on the 2-item Patient Health Questionnaire (PHQ-2); had at least a moderate level of mood symptoms two weeks after hospitalization (PHQ-9 ≥10); and randomized them to either 12-months of nurse-provided “blended” CC, CC for HF-alone, or to their PCPs’ UC. Later, we obtained 12-months continuous enrollment insurance claims data from Medicare and the two largest health insurers in our region on 503 (80%). We then applied 2016 Medicare prices to merge claims datasets,

approximated our interventions’ costs to estimate incremental costs from the payor’s perspective, used generalized linear models with gamma distribution and log link to correct for skewness in costs, and conducted a sensitivity analysis removing the 1% most costly patients. We also converted baseline, 3-, 6-, and adjusted life year (QALY) gained at 12 months.

RESULTS: At baseline, the 503 patients with continuous 12-month claims data were similar by sociodemographic and clinical characteristics (58% male, 65.3 mean age, 77.5% White, PHQ-9 14.0 (SD: 3.6)) to the 126 excluded from our analyses due to incomplete claims data. At 12-months following randomization, “blended” CC, CC for HF-alone, and UC all had similar mean total claims costs of $285,499, $306,727, and $322,359 respectively, after adjusting for gender, hospital recruitment type (university, community, underserved), and total claims for the 12 month period before randomization, or removing the top 1% (five) most costly patients in a sensitivity analysis (12-month costs >$2.7M). Notably, rehospitalizations costs accounted for most expenditures ($337,203 “blended” ($310,403 excluding top 1%), $392,084 ($351,552), HF-only, and $412,209 ($374,031) UC, respectively). Blended CC yielded incremental cost effectiveness ratios (ICER) per QALY of -$798,276 (95% CI: -$31.8M to +$4.9M) versus UC, and -$1.9M (-55.5M to +5.0M) versus HF-alone. A bootstrapped cost-effectiveness plane also demonstrated a 61% probability of blended CC "dominating" UC, and an 80% probability of blended CC “dominating” HF- alone (more QALYs at lower cost).

CONCLUSIONS: Telephone-delivered blended CC for treating HF and depression is a quality-improving and cost-effective treatment that meets generally accepted criteria for high-value care.

THE ASSOCIATIONS OF VITAMIN D AND PRO-INFLAMMATORY CYTOKINES IN WEST TEXAS PATIENTS WITH RHEUMATOID ARTHRITIS: A PILOT STUDY

Kristina M. Cross¹; Kushal Gandhi¹; Asley Sanchez¹; John Garza²; Srikanth Mukkera¹; Swapna Kolli¹; Hema Kondakindi¹; Barath Rangaswamy¹

¹School of Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; ²Mathematics, The University of Texas Permian Basin, Midland, TX. (Control ID #3872077)

BACKGROUND: Rheumatoid arthritis (RA) is a systemic autoimmune multifactorial complex disease primarily presenting as pain and inflammation in joints affecting about 1.5 million Americans. Disease progression and pathogenesis in RA is directly related to pro-inflammatory cytokine levels, and the systemic increase in pro-inflammatory cytokines is believed to be correlated to immunomodulators. Vitamin D (VD) is a known immunomodulator in innate and adaptive immunity. This study seeks to provide the novel quantification of VD measurements and pro-inflammatory cytokine levels in West Texas patients with RA.

METHODS: Adult participants with BMI <30 and taking less than 1000 IU/day of VD were separated into a control group (n = 40) and a RA group (n = 40). Participants had blood samples collected, completed a Rapid 3 assessment, and submitted a demographics survey. RA patients were excluded if taking prednisone or methotrexate. Serum samples were analyzed for 25-hydroxy VD level using multiplex electrochemiluminescence assay and 10 cytokines were assessed: Interferon gamma (IFN-γ), Interleukin (IL)-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, and tumor necrosis factor alpha (TNF-α). Patients were stratified into sufficient (≥ 30 ng/mL), insufficient (20 ng/mL ≤ VD < 30 ng/mL), or deficient (< 20 ng/mL) VD levels.

RESULTS: The association of RA and the distribution of cytokines was observed to be very large (η² = 0.31) and highly significant with modified permutational MANOVA resulting in p < 0.001. Additionally, nine of the ten cytokines had statistically significant higher levels in the RA group with large effect sizes observed for TNF-α, IL-10, and IL-6, moderate effect sizes observed for INF-γ, IL-12, and IL-8, and small effect sizes observed for IL-4, IL-1β, and IL-2. After stratifying patients as sufficient, insufficient, or deficient VD level, the association of VD level on cytokine distributions was observed to be small (η² = 0.07) and statistically insignificant (p = 0.882). However, using Spearman correlation, small but statistically significant positive associations with VD level in IL-10 (ρ_s = +0.338, p = 0.002), IL-1β (ρ_s = +0.287, p = 0.010), and TNF-α (ρ_s = +0.222, p = 0.048) were observed.

CONCLUSIONS: As expected, the RA group had higher proinflammatory cytokines most likely due to the primary mechanism of RA disease progression being increased systemic inflammation. Although much research has shown that VD is immunomodulatory in inflammatory diseases, our results showed that VD levels across groups has a comparatively small effect on cytokine levels in RA patients with only IL-10, IL-1β, and TNF-α having small positive associations with VD level. Based on these results, the routine practice of VD use in RA may not be an effective method of immunomodulation.

THE EFFECTS OF AIR QUALITY ON ASTHMA HOSPITALIZATION RATES IN CALIFORNIA COUNTIES

Sebastian Cano-Besquet, Mei Liang, Karina Smolyar, Jeff Chen, Colton Rosendahl, Anmol Shrestha, Ashley Choi, Nicholas Eremita, Vinh Nguyen, Hani Atamna, Shabana Masood, Joseph Dhahbi

School of Medicine, California University of Science and Medicine, Colton, CA. (Control ID #3853728)

BACKGROUND: Asthma is a chronic lung disease that affects nearly 25 million people in the United States. Common symptoms include coughing, chest tightness, wheezing, and shortness of breath due to oxidative injury to the airways. Outdoor air pollution can exacerbate asthma conditions. The U.S. Environmental Protection Agency (EPA)’s air quality index (AQI) accounts for five major air pollutants including ground-level ozone.

Through our study, we explore whether air quality index and ground-level ozone can each predict asthma hospitalization rates in counties within California. We will consider the interconnections among these variables as well as the broader health impact.

METHODS: Data sources:

1. Open access data from the U.S. EPA and associated air quality data for California counties from 2014-2018: https://aqs.epa.gov/aqsweb/airdata/download_files.html#Meta

2. Open access data from California Health and Human Services (CHHS), Asthma Hospitalization Rates for California (CA) counties from 2014-2018: https://data.chhs.ca.gov/dataset/asthma-hospitalization-rates-by- county

Statistical procedures in brief: Asthma Hospitalization Rates across the years 2014-2018 were averaged for each CA county, and for CA statewide. Median AQI and Days Ozone for 2014-2018 were separately averaged for each CA county, except for counties with missing data. Simple linear regression was performed on (1) Asthma Hospitalization Rates versus Median AQIs and (2) Asthma Hospitalization Rates versus Days Ozone. p-values were calculated using a t-distribution and a two-sided alternative hypothesis.

RESULTS: Using simple linear regression, the study revealed a moderate correlation (r = 0.399, adjusted R-squared = 0.16, p-value = 0.002) between median AQI and asthma-related hospitalization rates in CA counties with nonzero asthma hospitalizations. Our linear models predict that with every 18.18 unit increase in median AQI, there is 1 additional hospitalization per 10,000 people. The study also found a moderate relationship (r = 0.434, adjusted R-squared = 0.19, p-value = 0.001) between the days of ozone exceedances per year and asthma-related hospitalization rates. For every 100 additional days per year of ozone exceedance, there is 1 additional hospitalization per 10,000 people.

CONCLUSIONS: Our study shows moderate correlations between asthma hospitalization rates and (1) median AQI and (2) days of ozone exceedance per year. However, future investigations might include patients' age, social economic status, and medication list. Other confounding variables such as geography, agriculture, and industries in each California county can also affect asthma hospitalizations.

Understanding the connections between environmental conditions and asthma symptoms will enable physicians and public health officials to prepare for asthma exacerbations and hospitalizations before they occur. Furthermore, proper health education and action among community members can allow medical personnel to divert resources and improve patient outcomes.

THE LONG-TERM RELATIONSHIP BETWEEN α-KLOTHO WITH ALL-CAUSE AND CAUSE- SPECIFIC MORTALITY

Nargiza Kurbanova, Cynthia Avila, Waleed Kassabo, Ayeman Basith, Hannah Chung, Simrah Siddiqui, Rehan Qayyum

Internal Medicine, Eastern Virginia Medical School, Norfolk, VA. (Control ID #3876452)

BACKGROUND: The relationship between α-Klotho (αK) and all-cause and cause-specific mortality is controversial. We investigated the association of serum αK levels with all-cause and cause-specific mortality in the 2007-16 National Health and Nutrition Examination Survey.

METHODS: Serum αK levels were measured for participants aged 40-79 years. Associations between mortality and αK levels as a continuous variable and in quintiles were examined using Kaplan-Meier (KM) survival and Cox proportional hazard models. To examine the non-linear relationship, we included two variables in models: a continuous αK variable and its squared αK variable. Adjusted models included age, gender, race, hypertension, diabetes, smoking, alcohol use, BMI, serum cholesterol, estimated GFR, educational status, and poverty threshold to income ratio.

RESULTS: Of the 13747 participants, 1569(11%) died, 7092(52%) were female, and 5,918(43%) were Caucasian. Mean (SD) age was 58(11) years, BMI 29.7(6.7) Kg/m2, and αK was 0.85(0.31) ng/mL. Individuals in the lowest quintile had the highest mortality (Figure). The adjusted Cox proportional hazards model found a U-shaped relationship; initially all-cause mortality decreased with increasing αK level, but the rate of decrease slowed until mortality risk started rising (continuous αK HR=0.58, 95%CI=0.38, 0.88; squared-αK HR=1.24, 95%CI=1.10, 1.40). A similar U-shaped relationship was noted between αK and cancer-mortality (continuous αK HR=0.46, 95%CI=0.20, 1.07; squared αK HR=1.31, 95%CI=1.07, 1.61). However, no relationship was noted with cardiovascular- or other-cause mortality. Examining αK as quintiles, we found no difference between the 1st vs. 5th quintiles while the middle three quintiles were significant, confirming a U-shaped relationship (2nd vs. 1st=0.76, 95%CI=0.59, 0.97, 3rd vs. 1st=0.77, 95%CI= 0.62, 95, and 4th vs. 1st=0.72, 95%CI= 0.56, 0.93). No association was found between αK quintiles and cause- specific mortality.

CONCLUSIONS: In this large diverse cohort representative of the US population, we report a U-shaped relationship between αK and all-cause and cancer mortality. Further research elucidating the underlying biological mechanism of the observed relationships is needed.

THE OFFICE-GUIDELINES APPLIED TO PRACTICE OFFICE-GAP PROGRAM: INTERVENTIONS TO IMPROVE DIABETIC PATIENTS' MEDICATION ADHERENCE

Adesuwa B. Olomu¹; Joseph C. Gardiner²; Aaron Nichols¹; Nephertiti Efeovbokhan³; Richard Pellizzari⁵; Raqhuel D. Williams¹; Karen Kelly-Blake¹; William Hart-Davidson⁴

¹College of Human Medicine, Department of Medicine, Michigan State University, East Lansing, MI; ²Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; ³Cardiology, NEA Baptist Memorial Hospital, Jonesboro, AR; ⁴College of Arts & Letters, Michigan State University, East Lansing, MI; ⁵College of Human Medicine, Michigan State University, East Lansing, MI. (Control ID #3876383)

BACKGROUND: Timely and continuous use of prescribed medications is key to effective chronic disease management. Yet as many as half of 187 million patients in the United States do not take medications as prescribed. 21-42% of diabetic (DM) patients are not adherent to their medications. Medication nonadherence in DM patients leads to poor DM and BP control with increased risk for hospitalization, disability, and death. Our objectives were 1) determine the impact of combined patient activation (using our Office Guidelines Applied to Practice {Office-GAP} Program) and evidence-based text messages (Way to Health program) interventions compared to text messages only on improving medication adherence in patients with diabetes mellitus type 2, in Federally Qualified Healthcare Centers (FQHCs); and 2) evaluate the differences by gender of combined Patient Activation + Text messaging versus Text messaging intervention only in improving diabetic patient medication adherence in FQHCs.

METHODS: Patients at 12 FQHCs in Michigan were randomized to two groups: Intervention (Arm 1): Office-GAP + Texting vs Texting only (Arm 2). Office-GAP is a patient activation intervention to improve communication and patient-provider partnerships through brief training in shared decision-making and use of a guideline-based checklist. Way to Health program is a two-way text messaging platform developed at the University of Pennsylvania for health communication interventions. Adherence to one prescribed primary medication was assessed with eCAP electronic monitoring. We report adherence rates for 78 patients who completed 3 months in an ongoing cluster randomized controlled trial. Adherence rate per patient is calculated as a proportion of distinct eCap open dates within the time window of 92 consecutive days. Generalized linear models with Beta regression on the continuous proportion was used to estimate group and gender effects.

RESULTS: Seventy-nine patients completed their 3-month assessment, Arm 1 (n=53, 71.7% female), Arm 2 (n=26, 76.9% female). A total of 5044 eCAP openings were within the time window, 70.6% were in Arm 1 and 29.4% in Arm 2. From Beta regression, the estimated adherence rate (as percent) was 68.4% (95% CI: 61.4-74.8) in Arm 1, and 54.8% (95% CI: 44.5-64.7) in Arm 2. The difference between arms is significant (p=.027). There was no significant difference in adherence by gender: Female 65.2% (95% CI: 58.3-71.5), male 66.0% (95% CI: 55.1-75.5).

CONCLUSIONS: Adherence rate was significantly higher in patients randomized to combined Patient Activation + Text messaging compared to patients receiving only text messaging. Patient activation and mHealth interventions hold promise as a feasible support strategy to improve patient medication adherence in FQHCs.

THE PRESSURE DOESN’T LET UP: A VIRTUALLY-DELIVERED HYPERTENSION PROGRAM DURING COVID

Karen Goldstein^2,1; Allison Lewinski^2,3; Abigail Shapiro²; Tiera Lanford²; Courtney White-Clark²; Madison Burns²; Julie Schexnayder⁴; Leah Zullig^2,5; Jennifer Gierisch^2,5; Hayden Bosworth^2,5

¹Division of General Internal Medicine, Duke University School of Medicine, Durham, NC; ²Durham VA Medical Center, Durham, NC; ³n/a, Duke University School of Nursing, Durham, NC; ⁴The University of Alabama at Birmingham School of Nursing, Birmingham, AL; ⁵Population Health Sciences, Duke University, Durham, NC. (Control ID #3875188)

BACKGROUND: Even prior to COVID-19 hypertension control has been declining, especially among historically marginalized populations. During the pandemic, clinic shutdowns and social distancing further worsened hypertension control. Virtually-delivered chronic disease management programs provided critical support during the pandemic and offer a promising approach to supplement the efforts of busy primary care teams to improve the health of diverse patient populations with hypertension. Our multi-site, quality improvement program, Team-supported, EHR-leveraged, Active Management (TEAM), rolled out over a year prior to COVID-19 and has continued steadily through the evolution of the pandemic. We report the impact of TEAM on hypertension control among a diverse, largely rural Veteran population surrounding the COVID-19 pandemic.

METHODS: TEAM is a population health-based, virtually-delivered hypertension program designed to provide supplemental support to patients with uncontrolled hypertension. Eligible patients were identified via the electronic health record or referred by their primary care provider. Patients were sent a letter with personalized information about their blood pressure (BP) followed with a phone call from the population health manager. The call focused on patient identification of individualized goals and specific action steps around hypertension management via motivational interviewing and ordering of blood pressure cuffs if needed. One to 2 follow-up calls (with or without video-enabled connection) assessed progress towards Veteran’s goals and self-monitoring of home BP measurement. Patient primary care teams received information about patient goals, potential regimen changes, and woman-tailored CVD risk information. We evaluated the impact of our program with a mixed methods approach using quantitative EHR data and participant and staff interviews.

RESULTS: Since 2019, TEAM has been implemented at 16 geographically diverse rural sites and enrolled 917 patients. Of the total enrolled, 119 were enrolled prior to COVID-19. In total, 27.4% of patients are women, 45.6% are Black and 50.7% White. Seventy-six percent live in rural areas. Mean age is 64.9 years (s.d. 9.3) and mean BP at program entry pre-COVID was 150.5/85.6mmHg and post-COVID was 154.3/84.6mmHg. Mean reduction in BP from program entry to completion was 5.5/3mmHg. Mean change in BP for women was 6/2.3mmHg and for Black patients was 4/2.5mmHg. Themes from patient qualitative interviews included appreciation for outreach from the population manager, convenience of remote counseling during COVID-19 restrictions, and improvement in self-management behaviors

CONCLUSIONS: Virtually-delivered hypertension control programs are an effective way to improve blood pressure control in a diverse population of patients and are feasible during pandemic-related conditions despite worse blood pressure control. Next steps are to ensure sustainability during evolving health care and social-environmental stressors.

THREE-MONTH OUTCOMES FOR PATIENTS TREATED IN AN ACADEMIC MEDICAL CENTER LONG COVID CLINIC FOR COGNITIVE SYMPTOMS

Andrew Schamess¹; Kathleen Woschkolup¹⁰; Laura J. Rush⁶; Erin McConnell⁵; Aaron Friedberg³; Taru Saigal³; alexa meara¹¹; Susan Bowman Burpee⁸; Stacy Stanwick⁷; Jennifer Eramo^2,6; Dana Hodges⁹; Vandana Ohri⁷; Jodi Grandominico¹; Ann S. McAlearney⁴

¹Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²Family Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ³Internal Medicine, The Ohio State University, Bexley, OH; ⁴Family and Community Medicine, The Ohio State University, Columbus, OH; ⁵General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ⁶CATALYST, The Ohio State University, Columbus, OH; ⁷General Internal Medicine, The Ohio State University, Columbus, OH; ⁸Physical Medicine and Rehabilitation, The Ohio State University Wexner Medical Center, Columbus, OH; ⁹Neurology , Dianne Collins Neuroscience Institute, Greenville, SC; ¹⁰Neurology, Bon Secours Mercy Health, Cincinnati, OH;¹¹internal medicine, The Ohio State University, Columbus, OH. (Control ID #3873611)

BACKGROUND: Post-Acute Sequelae of COVID-19 (PASC or "Long COVID") is a new chronic multisystem condition resulting from the COVID-19 epidemic and affecting as many as 200 million persons worldwide. Among the symptoms are cognitive slowing and mental fatigue, commonly known as “brain fog.” Specialized clinics have emerged at many academic medical centers to care for PASC patients. There is paucity of evidence about the treatments offered in these clinics or their impacts on patient outcomes. Our PASC clinic is staffed by general internists collaborating with subspecialists and rehabilitation professionals. We report on the use of behavioral, rehabilitative and pharmacologic treatments in the first 70 patients seen for neurocognitive symptoms (NCS) in our clinic, and on change in patient quality of life and functional status (QoL/FS) in the 3 months following initial clinic visit.

METHODS: Electronic medical records were searched for specified ICD-10 codes to identify patients with PASC and NCS who had completed the PROMIS29 QoL/FS inventory at the initial clinic visit (t1) and again 3 months later (t2). Data extracted by manual review and entered into a REDCap database included demographics, medication history, treatment recommendations, and PROMIS29 scores at t1 and t2. The primary outcome was change in any PROMIS29 T-score. Exact 95% confidence intervals (CIs) were calculated by binomial proportion. Comparisons were made using Fisher’s exact test. The study was approved by the University Institutional Review Board.

RESULTS: Of 70 patients identified for this study, 70% were female, 25% were non-white, and 27% had public insurance. Patients received a variety of treatments including workplace accommodations (25%), cognitive rest (21%), cognitive rehabilitation (30%), rehabilitation psychology (25%), and pharmacotherapy (25%). The frequencies and CIs of clinically significant improvement in QoL/FS (at least 5-point increase in PROMIS29 T-score) in each domain were: physical function: 19% (11-30), anxiety: 41% (4-63), depression: 39% (28-51), fatigue: 44% (40-64), sleep disturbance: 42% (30-55), ability to participate in social roles and activities: 16% (13-33). In this small sample, most subgroup comparisons were not statistically significant. However, 50% of patients treated with N-methyl-D-aspartate (NMDA) inhibitors (primarily amantadine) showed improvement in their ability to participate in social roles and activities compared with 18% of those not treated with NMDA inhibitors (2.7 times greater rate of improvement, p=0.033).

CONCLUSIONS: While a substantial number of patients showed clinically significant improvement in quality of life in several PROMIS29 domains after 3 months of treatment, many did not improve. More work is needed to establish effective, evidence-based treatments for PASC patients with NCS. NMDA inhibitors are a promising class of drug for these symptoms and warrant further study.

TRENDS IN THE BURDEN OF RISK FACTORS FOR CHRONIC DISEASE AMONG US ADULTS

Benjamin G. Mittman^1,2; Michael B. Rothberg¹; Phuc H. Le¹

¹Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; ²Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH. (Control ID #3874712)

BACKGROUND: Half of US adults suffer from chronic disease. Unhealthy alcohol use, obesity, low physical activity, poor diet, and current smoking are major preventable risk factors. An understanding of the national burden of these risk factors is essential for guiding continued surveillance and intervention. We examined temporal trends in the prevalence of risk factors for chronic disease in US adults.

METHODS: We completed a retrospective analysis of the continuous 1999-2018 National Health and Nutrition Examination Survey, including adults aged 18-79 years old. Five risk factors were defined according to appropriate national guidelines. We estimated the proportion of US adults meeting each criterion and the proportion of people with 0-5 risk factors. We used logistic regression to examine temporal trends and Poisson regression to determine socioeconomic and demographic characteristics associated with greater number of risk factors. We used R 4.2.1 and accounted for survey weights.

RESULTS: The final sample included 54,947 participants. From 1999-2018, the prevalence of current smoking and unhealthy alcohol use decreased significantly, whereas that of obesity increased by 50%. The prevalence of low physical activity decreased significantly from 2007-2018 while that of poor diet decreased from 2005-2012 and then increased again (Figure). Between 2007 and 2018, 20% of people had 0 risk factors, approximately two-thirds had 1-2, and 15% had ≥3. Compared to those without any risk factors, people with ≥1 risk factor were older (mean age 45.5 years vs. 43.3 years) and more likely to be female (51.9% vs. 49.1%) and Black (12.7% vs. 7.9%). In the multivariable model, lower income-poverty ratio and poor self-reported general health were associated with higher rates of risk factors, whereas higher education and private insurance coverage were associated with lower rates.

CONCLUSIONS: From 1999-2018, unhealthy alcohol use, low physical activity, and current smoking became less prevalent, whereas obesity and poor diet (more recently) increased in prevalence. Women, minorities, and people with low socioeconomic status had a higher burden of risk factors for chronic disease. Surveillance and intervention efforts should address the increasing rates of obesity and poor diet and focus on more vulnerable populations.

UNDERDIAGNOSES OF OBESITY/OVERWEIGHT IN ACADEMIC OUTPATIENT SETTING

Anu Satheeshkumar¹; Barath Rangaswamy²; Hina Tariz¹; John Garza³; Kejal Shah¹; Rahul Atodaria¹

¹Internal Medicine, Texas tech university of health sciences - Permian basin, Odessa, TX; ²internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ³Mathematics, The University of Texas Permian Basin, Midland, TX. (Control ID #3877321)

BACKGROUND: Obesity is a growing epidemic in USA. Despite high prevalence, underdiagnosis of obesity/overweight remains a significant problem. Body mass index (BMI) is a reliable predictor of obesity and overweight, but is under acknowledged by physicians. The primary purpose of this study is to examine whether obese or overweight patients receive an obesity or overweight diagnosis and weight-related counseling from their physician at a West Texas academic outpatient Internal Medicine Clinic.

METHODS: This study is a single center retrospective cross sectional analysis of 299 patients with BMI > 25 who visited Internal Medicine Clinic from October 1st 2020 to October 31st 2021. We collected body mass index, diagnosis of obesity and the diagnosis of overweight in the problem list of the office visit note documented by physicians. We evaluated if patients with BMI > 30 had a documented diagnosis of obesity and if patients with BMI from 25 to 30 had a documented diagnosis of overweight. Inclusion Criteria: Both male and female patients of age: 20 - 89 years on October 1, 2020. Exclusion criteria included pregnant patients, amputee, patients with diagnosis of hyperthyroidism, hypothyroidism, heart failure, radiation or chemotherapy treatment, or metastatic cancer prior to Oct 1, 2020.

RESULTS: Among 299 patients, 204 patients were qualified for the diagnosis of Obesity due to their BMI> 30. However only 48.52 % (99 patients) had a diagnosis of Obesity in the problem list. 95 patients were qualified for the diagnosis of Overweight due to their BMI > 25 but less than 30. However, only 3.15 %( 3 patients) of the patients had a diagnosis of overweight in their problem list. Majority of patients with obesity and overweight are not diagnosed in our outpatient clinic setting. Effect sizes (Cramer V) and p values (chi- squared test) for the difference of sample proportions for overweight, obese, and morbidly obese are summarized in table. The data provide strong evidence that overweight and obese patients are under diagnosed and under counseled regarding diet and exercise.

CONCLUSIONS: There is a great need to educate the physicians for early screening and identification of obesity and overweight. If we are not making the diagnosis in the problem list, then we are not acknowledging the disease process and are not subsequently treating this epidemic. Routine screening and accurate diagnosis are among the first steps leading to proper treatment. Underdiagnosing of obesity is an important barrier to treatment initiation

UNDERSTANDING CORE VALUES OF PATIENTS WITH A HISTORY OF OBESITY: CONSIDERATIONS FOR PROVIDERS WHEN TALKING ABOUT GREEN PHYSICAL ACTIVITY

Michelle E. Carfagno1; Katherine Tinco3; Andrea Aquines3,2; Coral Aquino3; Allison Squires4,3; Melanie Jay3,2; Stephanie L. Orstad3

¹Medicine, Stony Brook University Renaissance School of Medicine, Stony Brook, NY; ²VA NY Harbor Healthcare System, New York, NY; ³Division of General Internal Medicine and Clinical Innovation, New York University Grossman School of Medicine, New York, NY; ⁴Nursing, New York University, New York, NY. (Control ID #3870259)

BACKGROUND: Physical activity (PA) has long been used to help patients with a history of obesity lose weight, but patients are often unable to maintain that weight loss. PA that takes place in natural environments such as parks, or green PA, presents an opportunity for a cost-effective and scalable intervention design for lower-income communities, while providing a myriad of health benefits. Some physicians recommend and prescribe green PA through nature prescription programs. However, more research is needed to enhance patient-provider conversations about green PA, such as through the consideration of patient values. Using data from a qualitative pilot study, the purpose of this sub-analysis was to explore the interplay of patient values, specifically within the 8 Dimensions of Wellness, to inform future patient-provider interactions about green PA.

METHODS: We recruited 30 individuals who reside in the same urban community, have a history of obesity (BMI >25 prior to weight loss), and have lost at least 3% of their body weight in the last 24 months. Patients were recruited through targeted mailings, physician referrals, in-person recruitment at a partnering community health center, health fairs, and snowball sampling. Semi-structured interviews were conducted in English and Spanish in a “walk-along” format in the local park, audio recorded and professionally translated and transcribed to English. 15 participants who were between the ages of 21-53, majority Latina, and had an average BMI prior to weight loss of 37.8 were included in the sub-analysis. Using a pragmatic lens, analysis was conducted using a combination of inductive values coding and deductive coding based on the 8 Dimensions of Wellness Model. Analytic code memos were synthesized throughout the coding process to uncover how participants valued each of the dimensions of wellness.

RESULTS: Analysis uncovered patient values around four Dimensions of Wellness: Physical, Emotional, Environmental, and Social. The importance of promoting physical and emotional wellness for loved ones (e.g., children) arose in addition to individual physical and emotional wellness. Participants place significant importance on connecting with and helping their local community, with some citing group green PA as a means to help motivate each other to exercise. Patients enjoy the benefits of fresh air, open space, and greenery when spending time/exercising outdoors in parks but note that park and community safety is a principal consideration when being outdoors. The other four Dimensions of Wellness, Financial, Intellectual, Occupational, and Spiritual, were not as prominent in discussion.

CONCLUSIONS: We identified multiple dimensions of wellness that individuals value in general and in the context of green PA. Although these findings are community-specific, future research can focus on surveying a broader population to see if these findings may be generalizable to patient populations like this one to further inform conversations about green PA.

UNDERSTANDING THE CHALLENGES AND COPING STRATEGIES OF PERSONS LIVING WITH NON-COMMUNICABLE DISEASES DURING CLIMATE-INDUCED DISASTERS IN THE US VIRGIN ISLANDS: A MIXED METHODS APPROACH

Saria M. Hassan¹; Stephen Perez²; Michelle Teresa Wiciak¹; LaVerne Ragster³; Tess Richards⁵; Maxine Nunez³; Marcella Nunez-Smith⁴

¹Internal Medicine, Emory University, Atlanta, GA; ²Emory University School of Public Health, Atlanta, GA; ³University of the Virgin Islands, Saint Thomas, Virgin Islands (U.S.); ⁴General Internal Medicine, Yale University, New Haven, CT; ⁵St. Thomas East End Medical Center, St Thomas, Virgin Islands (U.S.). (Control ID #3876864)

BACKGROUND: At least 30% of mortality after severe weather events are due to poorly controlled non- communicable diseases (NCDs). With the advent of climate change the US territories including the US Virgin Islands (USVI) will experience more climate-induced disasters that are bound to worsen territorial health disparities. We sought to understand the experience of persons living with NCDs (PLNCDs) in the setting of climate-induced disasters in the USVI to inform future interventions.

METHODS: We conducted a concurrent mixed methods approach to document the impact of severe weather events on PLNCDs who are patients at a Federally Qualified Health Center in the USVI. Survey and interviews were conducted during the 2022 hurricane season (June-October 2022). Quantitative: we used convenience sampling to conduct a survey of PLNCDs to determine the impact of recent severe weather events on their mental health and document the challenges they experienced in the aftermath of the disaster. Descriptive and summary statistics were produced using SPSS. Qualitative: Purposive sampling was used to recruit 13 respondents with varied age, sex, and chronic disease for in-depth interviews to understand effective coping strategies for managing their NCD. Thematic content analysis was conducted with 3 coders to identify emergent themes. Integration: A joint display is used to integrate the quantitative and qualitative data.

RESULTS: Out of 87 survey respondents , 85% were female with an average age of 52.14 (sd=16.18) and

13% had no health insurance, 23% had 3 or more NCDs, with 30% having high blood pressure and 12% having diabetes. Twenty percent satisfied criteria for mild anxiety, with 8% having moderate to severe anxiety. Eighteen percent had mild depression with 8.6% moderate to severe depression. Despite experiencing a severe hurricane, 39% were not very prepared for another disaster. Thirty percent of respondents had experienced challenges managing their chronic disease during a past disaster. Emergent themes from the qualitative work included: NCDs were often not the biggest priority in the aftermath of a disaster, mental health poses an immense challenge due to the stress and trauma after a storm, there is a need for resources to strengthen the capacity of patients to self-manage their disease, and the importance of comprehensive and reliable information dissemination on NCDs in preparation for severe weather events

CONCLUSIONS: Our work has documented the challenges of PLNCDs in disasters in a vulnerable population. The work has identified areas for intervention at the individual, institutional, and policy level that can improve outcomes for the most vulnerable in the aftermath of a disaster. We will work with our FQHC partners to develop and test interventions at the individual and organizational level in preparation for the next hurricane season.

‘I AM RELUCTANT TO CONTINUE, YET KNOW SHE COULD GO INTO WITHDRAWAL’: A QUALITATIVE ANALYSIS OF PROVIDER REQUESTS FOR OPIOID MANAGEMENT ECONSULTS

Laila Khalid¹; Sharon Rikin²; Dana Watnick⁵; Tiffany Lu³; Ana Valle²; Joanna L. Starrels⁴

¹General Internal Medicine, Montefiore Medical Center, Bronx, NY; ²Internal Medicine, Montefiore Medical Center, Brooklyn, NY; ³Medicine, Montefiore Medical Center, Bronx, NY; ⁴Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY; ⁵Albert Einstein College of Medicine, Bronx, NY. (Control ID #3876839)

BACKGROUND: Primary care providers lack training in opioid management for chronic pain and access to pain specialists is limited. Electronic consultation (eConsult) offers a platform for providers to request specialist input about individual patients’ care. To inform dissemination of opioid management eConsults at other institutions, we sought to understand provider motivations for requesting an eConsult and to identify which provider questions could be addressed through eConsult without requiring direct specialist assessments.

METHODS: We conducted an inductive thematic analysis of the text of providers’ eConsult requests for opioid management from July 1, 2019 to September 30, 2020. Two researchers independently identified recurrent themes, compared findings and developed an initial codebook. In team discussions (LK, SR, DW, JS), code matrices were used to discuss emergent themes, and to explore themes by eConsult outcome.

RESULTS: Forty eConsults were requested by 29 unique providers. Respondents practiced general internal medicine (42%), family medicine (27%), hematology (20%) gynecology/obstetrics (8%), and geriatrics (3%). We identified four themes. (1) providers were motivated to reduce harm, but approaches varied from seeking reassurance to wanting to hand off opioid management entirely. (2) Providers needed help assessing and diagnosing opioid misuse and use disorder, including under-diagnosing despite describing the elements of misuse or, conversely, diagnosing and treating OUD with little evidence. (3) Providers had difficulty articulating questions, evidenced by absence of a specific question or overly broad requests, e.g. needing help with pain management. (4) Providers had misconceptions about common opioid management practices including short vs. long acting opioids, tapering drug testing urinalysis. Reducing harm and misconceptions were prominent among requests that were deemed to require direct assessments as compared to those that did not require direct assessments by specialists.

CONCLUSIONS: Providers use opioid eConsults to seek support and reassurance for balancing pain management with worries of OUD. However, providers’ lack of ability to assess for opioid use disorder (OUD) or misuse, difficulty articulating questions and miconceptions about opioid management may reduce the efficiency of the econsult model. Future econsult programs should train providers in not only diagnosing opioid misuse but also to articulate questions differently to maximize scarce specialist resources in a timely manner.

Scientific Abstract - Clinical Informatics and Health Information Technology

A DECISION SUPPORT TOOL’S IMPACT ON INTERPRETATION OF AND RESPONSE TO URINE DRUG TESTS FOR PATIENTS PRESCRIBED OPIOID ANALGESICS: A RANDOMIZED VIGNETTE-BASED NATIONAL SURVEY

Marc LaRochelle¹; Radhika Puppala¹; Sarah Kosakowski¹; Shapei Yan¹; Ziming Xuan²; Ricardo Cruz¹; Karen E. Lasser¹; Mari-Lynn Drainoni³; Erin E. Krebs⁴; Daniel P. Alford¹; Jeffrey H. Samet¹; Jane Liebschutz⁵

¹General Internal Medicine, Boston Medical Center, Boston , MA; ²Boston University School of Public Health, Boston, MA; ³Medicine, Boston University School of Medicine, Boston, MA; ⁴Medicine, Minneapolis VA Health Care System, Minneapolis, MN; ⁵Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #3874218)

BACKGROUND: Urine drug tests (UDT) are a recommended monitoring tool for patients prescribed opioids. However, UDT are difficult to interpret, and it is unclear how they impact clinical decision-making.

METHODS: We conducted a randomized vignette-based survey. We recruited physicians who completed a national educational safer opioid prescribing program. We randomized participants to one of three UDT conditions: Group 1 (standard report); Group 2 (standard report plus interpretation); and Group 3 (standard report plus interpretation and clinical guidance). We presented 4 vignettes that ranged from low to high concern of opioid misuse. Participants rated their concern for opioid misuse on a 7-point scale (1 = not concerned, 7 = highly concerned), and identified changes to opioid treatment plan in three domains: monitoring strategy, opioid dosage, and referral or treatment for opioid use disorder. We used ANOVA to test differences in concern for opioid misuse and chi-squared tests to identify treatment plan differences by group.

RESULTS: We invited the first 140 physicians meeting enrollment criteria to participate, and 121 (86%) completed the survey. Of the respondents, 56 (46%) identified as female, 67 (55%) completed residency within 5 years or were still residents, and 36 (30%) completed residency more than 10 years ago. The median (IQR) concern for misuse for the four vignettes was 2 (1,4), 4 (3,5), 5 (4,6), and 6 (5,7). Concern for misuse varied by Group in only the vignette with highest concern for misuse. Compared to Group 1, Group 2 chose different treatment plan changes in 5 of 12 decisions, each consistent with clinical guidance (p<0.05; Table). We did not identify differences in treatment plans between Groups 3 and 2.

CONCLUSIONS: In this randomized vignette survey, physicians provided UDT interpretation modified opioid treatment plans to be more consistent with clinical guidance. However, providing clinical guidance in addition to UDT interpretation did not influence clinical decision-making.

A MACHINE LEARNING APPROACH TO PREDICT ENGAGEMENT FOR A DIGITAL DIABETES PREVENTION PROGRAM

Danissa V. Rodriguez¹; Ji Chen¹; Ratnalekha V. Viswanadham²; Katharine Lawrence³; Devin Mann³

¹Population Health , NYU Langone Health, New York, NY; ²Pediatrics, NYU Langone Health, New York, NY; ³Population Health, NYU Langone Health, New York, NY. (Control ID #3874291)

BACKGROUND: Digital diabetes prevention programs (dDPPs) through mobile applications have been used as “digital prescriptions” within healthcare delivery systems. Despite their effectiveness, dDPPs suffer from high attrition rates and non-completion. Previous research focuses on the development of PAMS, a personalized automatic messaging system that leverages SMS and data integration into clinical workflows to help enhance patient-provider communication and increase engagement with a dDPP. Although preliminary data for PAMS show positive results, we propose ML-PAMS, a machine learning (ML) approach to predict individual engagement for a more personalized content experience to develop an optimized messaging system. This abstract describes our methods for building this ML model and our preliminary results.

METHODS: We partnered with a dDPP app to obtain daily engagement data from 2384 users (704,242 engagement records) external to the original PAMS study who did not receive personalized messaging. We aim to predict next-day engagement in four individual activities (steps, exercise, meal logs, and weigh-ins) and general activity (engagement in any activity) based on previous short-term and long-term activity in the application. We use the gradient-boosted forest model. The data was split into a 70% training set, a 15% validation set, and a 15% test set. the models were trained with η= 0.1 for 1000 rounds with early stopping. Area under ROC (AUROC) and Area under Precision-Recall curve (AUPRC) were used to measure model performance. Shapley values were calculated to reflect feature importance of the models.

RESULTS: The model accurately predicted future engagement and obtained similar results when predicting any of the four activities, and each individual activity (Figure 1.A). Using Shapley values (Figure 1.B), we found that the short-term frequency of various activities was the most informative feature for all five models. However, it could mean that the model is vulnerable to short-term disruption of user behavioral patterns. Additional social factors have the potential to better capture short-term pattern changes in advance and mitigate this issue.

CONCLUSIONS: ML approaches that allow engagement prediction represent an acceptable mechanism to improve messaging interventions to support patient adherence to digital prescriptions. Next, understanding user engagement phenotypes based on their predicted engagement; we can then develop a messaging intervention based on our findings.

AN EVALUATION OF DIAGNOSTIC ERRORS IN PRIMARY CARE TELEMEDICINE VISITS FOR ABDOMINAL PAIN

Jorge A. Rodriguez, David W. Bates, Anuj Dalal

General Internal Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #3876921)

BACKGROUND: The risk of diagnostic error (DE) is potentially heightened in telemedicine. Telemedicine allows synchronous video and audio-only visits. While telemedicine can improve care access, it also introduces challenges to a timely and accurate diagnosis. The goal of our study was to explore and characterize DEs after telemedicine visits for abdominal pain.

METHODS: We evaluated an enriched cohort of adult patients presenting to primary clinics at an academic medical setting in Boston, MA from March 2020 to February 2022. The cohort included patients who were likely to have DE based on presentation to the emergency department or inpatient setting for “can’t miss” abdominal pain diagnoses (e.g., appendicitis) within the 30 days after an index telemedicine visit. We performed a chart review using validated tools: Safer Dx instrument to assess the likelihood diagnostic error, and the DEER Taxonomy to identify diagnostic process failures. Two clinicians reviewed the charts, then met to adjudicate outcomes. All discrepancies were reconciled by a third clinician. We used a t-test to compare the mean number of diagnostic process failures in cases with DEs compared to those without.

RESULTS: The enriched cohort include 40 cases (29 audio-only, 11 video visits). Patients had a mean age of 60, were 69.4% female, and 66.6% White, 16.7% Black, 5.6% Hispanic, and 11.1% were of Other/Unknown race/ethnicity. We found a DE in 8 cases (20 %) (Table). Of these cases, 3 were harmful/potentially harmful. The missed diagnoses for these cases were: ischemic colitis and pancolitis. Diagnostic process failures were more likely in cases with vs without a DE. (6.3 vs. 1.3, p < 0.001). The most common significant diagnostic failure points in cases with a DE were: failure/delay in considering correct diagnosis (5/8, 62.5%), suboptimal weighing of a piece of history (3/8, 37.5%), failure to perform physical exam (3/8, 37.5%%), suboptimal weighing/prioritizing of diagnoses (3/8, 37.5%), and too much weight given to lower probability diagnosis (3/8 , 37.5%).

CONCLUSIONS: We demonstrate the challenges of evaluating abdominal pain using telemedicine, a difficult condition for this modality. While the lack of physical exam is cited as a limitation of telemedicine, our findings highlight additional diagnostic challenges (e.g., history-taking). As telemedicine use increases, we will need to develop best practice for diagnostic safety.

A NOVEL RISK PREDICTION ALGORITHM FOR ELDERLY PATIENTS AT HIGH RISK OF MEDICATION-RELATED ADVERSE EVENTS

Michelle Frits²; Diane L. Seger³; Christine Iannaccone¹; Aqsa Mugal¹; Frank Chang³; Lynn A. Volk⁴; Stuart R. Lipsitz⁵; Lisa Rotenstein⁶

¹General Internal Medicine, Brigham and Women's Hospital, Boston, MA; ²General Internal Medicine, Brigham and Women's Hospital, Somerville, MA; ³IS- Clinical and Quality Analysis , Partners Healthcare System, Wellesley, MA; ⁴Clinical and Quality Analysis, Partners HealthCare, Wellesley, MA; ⁵Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA; ⁶Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #3875950)

BACKGROUND: Adverse drug events contribute to 10-30% of hospitalizations in the elderly. Leveraging medication related information in risk stratification algorithms can facilitate identification of the patients at highest risk for preventable utilization and medication regimen modification. We evaluated the ability of the FeelBetter machine learning algorithm to identify elderly, multimorbid patients cared for by Brigham and Women’s Hospital (BWH) who were at highest risk of emergency department (ED) visits and hospitalizations.

METHODS: The FeelBetter algorithm uses patient medications, demographics, social history, diagnoses, lab results, procedures, allergies, ED and hospitalization patterns, and costs to stratify patients’ risk of ED visits and hospitalizations in the subsequent 1, 3, and 6 months. The algorithm was trained using data from BWH patients ages ≥65 with at least 1 chronic disease and ≥3 active medications as of 7/1/2016.

After algorithm training, patients were assigned 1 of 20 risk-levels based on risk percentile of either ED visits or hospitalizations as of 7/1/2019. These levels were then divided into risk quintiles (80%–100%, 60%–<80%, 40%–<60%, 20%–<40%, 0%–<20%).

We summarized demographics, mean problem list diagnoses, and mean number of medications for patients in each risk quintile and quantified their average ED visits and hospitalizations at 1-, 3-, and 6-months post algorithm prediction. We used an interval variable representing the 20 risk levels in two Poisson regression models to quantify increases in ED visits or hospitalizations uniquely predicted by the FeelBetter risk-levels over other covariates used to predict healthcare utilization (age, sex, medication count, and problem count).

RESULTS: The 108,817 patients had a mean (SD) age of 77.1 (6.6) years, a mean of 15.3 (9.3) problem list diagnoses and were taking an average of 9.0 (6.4) medications. Mean (SD) utilization at 6 months was .10 (.44) for ED visits and .09 (.40) for hospitalizations. Each risk quintile had distinct patterns of ED visits and hospitalizations, with patients in the 80-100% quintile having the highest mean ED and hospitalization rates at 1, 3, and 6 months.

In the Poisson model including the above covariates predicting 6-month utilization, each 1 of 20 increase in the patient’s FeelBetter risk level predicted a 14.2% increase in ED visits. In the hospitalization model, each 1 of 20 increase in the risk-level was associated with an 18.4% increase in hospitalizations. The top 5% of patients identified by FeelBetter were predicted to average 3.7 times the ED visits of the overall cohort and 4.1 times the admissions.

CONCLUSIONS: A novel machine learning algorithm that incorporates information about elderly, multimorbid patients’ medication regimens effectively stratifies patients’ risk of ED use and hospitalizations. Use of this model can help value-focused healthcare systems focus medication optimization efforts and facilitate avoidance of unnecessary healthcare utilization.

A QUALITATIVE ASSESSMENT OF A DIGITAL HEALTH NAVIGATOR PROGRAM IN A PRIMARY CARE CLINIC

Jorge A. Rodriguez¹; Angela Rui¹; Ronen Rozenblum¹; Lipika Samal²

¹General Internal Medicine, Brigham and Women's Hospital, Boston, MA; ²Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #3877094)

BACKGROUND: The 21^st Century Cures Act and the rise of telemedicine led to a focus on patient portals. However, portal use disparities persist and are in part driven by limited digital literacy. To address digital disparities, we implemented an integrated digital health navigator (DHN) program to support portal use by patients. The DHN is a dedicated clinic member who enrolls/trains patients on using the portal. Our objective was to assess the perceived value and experience of program organizers and staff member end users of the program.

METHODS: The DHN program was a piloted from March to July 2021 at a primary care clinic in Boston, MA. We conducted semi-structured interviews to allow for exploration of participant experiences. The interview guide was developed based on literature review and expert opinion. Two researchers independently conducted a qualitative analysis using the grounded theory inductive approach. In cases of disagreement, the other researchers assisted in reaching consensus. The researchers coded the transcripts to identify, categorize and sort key concepts. Codes were then grouped into emergent themes and relationships after iterative review and discussion.

RESULTS: We interviewed 13 staff members, 4 who organized the program (i.e., 1 director, 1 practice manager, and 2 administrative assistants) and 9 who were staff end users of the program (i.e., 3 physician assistants, 1 pharmacist, 1 medical assistant, 1 resident, and 1 primary care physician). Interviews with the organizers highlighted that the DHN program: 1) required integration into existing workflows and changes to the clinic space to allow the DHN to interact with patients and 2) helped the organization understand patient’s digital needs, and 3) supported patients that needed extra support to use the portal (Table). Interviews with the staff end users revealed that the DHN 1) provided a dedicated support for portal training, 2) integrated well into the workflow of a primary care visit, especially due to the multiple ways to contact the DHN, 3) facilitated the integration of technology into care (i.e., sending glucose readings using the portal), and 4) aligned with the health equity efforts of the clinic.

CONCLUSIONS: A DHN program can be integrated into a primary care clinic workflow. Digital health navigation offers a promising model for healthcare organizations to take a proactive approach to digital health equity in the primary care setting.

ARE FEWER CASES OF DIABETES MELLITUS DIAGNOSED IN THE MONTHS AFTER SARS- COV-2 INFECTION? A POPULATION LEVEL VIEW IN THE EHR-BASED RECOVER PROGRAM.

Neha V. Reddy¹; Steven G. Johnson³; MICHAEL D. EVANS⁴; Jeremy Harper⁵; Carolyn Bramante²

¹General Internal Medicine, University of Minnesota Medical School Twin Cities, Minneapolis, MN; ²Medicine, University of Minnesota Twin Cities, Minneapolis, MN; ³Institute for Health Informatics, University of Minnesota Twin Cities, Minneapolis, MN; ⁴Clinical and Translational Science Institute, University of Minnesota Twin Cities, Minneapolis, MN; ⁵Owl Health Works, Indianapolis, IN. (Control ID #3876852)

BACKGROUND: Long-term sequelae of severe acute respiratory coronavirus-2 (SARS-CoV-2) infection may include an increased incidence of diabetes. Our objective was to describe the temporal relationship between new diagnoses of type 2 diabetes mellitus and SARS-CoV-2 infection in a nationally representative database.

METHODS: We conducted a cross-sectional analysis to portray the temporal relationship between new- onset type 2 diabetes and SARS-Co-V-2 infection, among persons diagnosed with diabetes after September 2019.

RESULTS: There appears to be a sharp increase in diabetes diagnoses in the 30 days immediately surrounding SARS-CoV-2 infection, followed by a decrease in new diagnoses in the post-acute period, up to 360 days after infection (Figure 1).

CONCLUSIONS: These results underscore the need for further investigation, as understanding the timing of new diabetes onset after COVID-19 has implications regarding potential etiology and screening and treatment strategies.

BARRIERS AND FACILITATORS OF DIGITAL HEALTH SERVICES: QUALITATIVE FINDINGS FROM PATIENTS IN FEDERALLY QUALIFIED HEALTH CENTERS

Allison Pack¹; Stacy Bailey¹; Paula Rusca²; Josephine Llaneza²; rodolfo zuleta¹; Wei Huang¹; Guisselle Wismer³

¹General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ²Erie Family Health Center, Chicago, IL; ³General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #3876202)

BACKGROUND: As a result of the COVID-19 pandemic, digital health services (i.e., patient portals and video telehealth visits) have become ubiquitous. To examine potential disparities in the use of these services, we previously conducted a survey of 500 English or Spanish-speaking adults. Survey participants had attended ≥1 visits (in person or via telehealth) for themselves or their child over a 12-month period within one large federally qualified health center network in and around Chicago, IL. Using a sequential, mixed- methods design, we then conducted qualitative interviews to solicit explanations for survey findings.

METHODS: Interview participants were eligible based on prior survey completion, and purposive sampling ensured a mix of ‘users’ and ‘non-users’ of digital health services. A bilingual research coordinator (RC) telephoned participants and conducted audio-recorded interviews using a semi-structured interview guide. Questions explored barriers and facilitators to use of the patient portal and video telehealth visits. Analyses were conducted using a modified version of the Rapid Identification of Themes from Audio Recordings (RITA) procedures. Themes and illustrative quotes, transcribed verbatim, and translated into English when necessary, were identified.

RESULTS: A total of 24 participants were enrolled (12 users and 12 non-users of digital health services). Enrolled participants were diverse by language (English and Spanish), age, sex, and caregiver status. Barriers to portal uptake included a lack of knowledge, with some non-users reporting limited awareness of the portal itself, limited understanding of how to use it, and/or how the portal can be personally beneficial. Barriers to sustained use of the portal, reported among users, included challenges with the password reset feature and difficulties linking multiple children to a single account. Participants in both groups viewed in-person support, supplemented with written materials, as a valuable facilitator of portal uptake. Flexible scheduling of appointments and viewing of lab results were perceived as compelling features. For video telehealth visits, barriers to uptake were similar to those reported for the portal. Several non-users were unfamiliar with the option, while some participants in both groups expressed a general preference for in-person visits. On the other hand, users found video telehealth visits easy to access and join, and participants in both groups noted the benefit of increased flexibility with scheduling and transportation.

CONCLUSIONS: Results revealed key recommendations for enhancing the uptake and sustained use of the patient portal and video telehealth visits. Consideration should be given to enhancing awareness of digital health services, with educational materials or in-person support highlighting when and how such services can be personally beneficial. Enhancing the user-experience of portal security and profile features may facilitate sustained use.

BUILDING PATIENT-PROVIDER RELATIONSHIPS AND PROMOTING SELF-MANAGEMENT: A QUALITATIVE STUDY OF SECURE MESSAGING IN THE ECLIPPSE COHORT

Hannah Wilson³; Dean Schillinger¹; Mary E. Reed²; Nicholas Duran⁴; Wagahta Semere¹

¹General Internal Medicine at Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA; ²Division of Research, Kaiser Permanente, Oakland, CA; ³University of Central Florida College of Medicine, Orlando, FL; ⁴Arizona State University, Tempe, AZ. (Control ID #3876412)

BACKGROUND: Secure messaging (SM) via online patient portals allows asynchronous two-way communication between patients and physicians, which can be especially beneficial for patients with chronic diseases who have substantial inter-visit care needs. Recent estimates suggest nearly 1/3 of patients with type 2 diabetes engaged in patient portal use. Among patients with diabetes, prior studies have reported higher rates of patient satisfaction and improved self-management associated with use of SM. Yet, little is known about how this communication platform is used by patients with type 2 diabetes and comorbidities, and the role that secure messaging plays in their longitudinal care.

METHODS: This is a sub-study of the Employing Computational Linguistics to Improve Patient-Provider Secure Emails (ECLIPPSE) study. We conducted an exploratory, in-depth qualitative analysis of all SMs involving a random sample of patients and their PCPs from the ECLIPPSE cohort who sent ≥ 1 English- language SM between July 1, 2006, and Dec. 31, 2015. Applying reflexive thematic analysis, two researchers independently analyzed and coded all patient SM threads (defined as SMs sent and received under the same subject heading) regarding management of diabetes and comorbidities, moving from specific observations to describe broader themes. Through regular meetings and iterative input, the research team established consensus to develop a codebook applied to the entire patient sample of SMs/threads.

RESULTS: The sample included 25 participants with mean age of 58 yrs (SD 7.9); 11 were women, 7 identified as Asian, 5 as Black, and 2 as Hispanic. We examined all SMs patients authored over the study period. Among all patients, we analyzed a total of 1,354 SMs embedded within 455 threads, and identified five overarching major themes describing the role of SM communication in management of patients’ diabetes and other comorbidities: (1) Clarifying and updating care plans between visits, (2) Developing partnered strategies to address emergent health concerns, (3) Building rapport and trust, (4) Promoting patient self-management and health empowerment, and (5) Coordinating care between primary care and specialty providers.

CONCLUSIONS: Patients with diabetes use SM communication with their PCPs to support their health care over time, allowing patients to engage in self-management, deal with emergent health concerns, and invest in their relationship with their PCP. Future research should aim to further investigate the impact of secure messaging engagement on patient’s diabetes care and outcomes.

CAN SOCIAL MEDIA SENTIMENT ANALYSIS (SA) PREDICT POPULATION SENTIMENT TOWARD THE COVID-19 VACCINE?

RAJMOHAN RAMMOHAN¹; Atul Sinha²; Melvin Joy¹; Dilman K. Natt¹; Tulika Saggar¹; Charlene Curtis- Thomas¹; Susan Bunting¹; Prachi Anand¹; Sai Greeshma Magam²

¹INTERNAL MEDICINE, NASSA UNIVERSITY MEDICAL CENTER, East Meadow, NY; ²Internal Medicine, Nassau University Medical Center, East Meadow, NY. (Control ID #3875170)

BACKGROUND: Covid 19 vaccination is one of the debatable topics in today's societies. The COVID pandemic fueled one of the fastest vaccine developments in history. However, one major drawback we face is the skepticism and public opinion regarding the new vaccines. In the study, we analyze the public sentiments towards the Covid vaccine during the pandemic and its current state. The social media platform has a rich data source that can analyze population sentiment during a crisis. Positive sentiments are likely attributed to data showing less infectivity rate and hospitalizations. The negative sentiments could be due to vaccine side effects, lack of knowledge, specific cultural backgrounds, and social media misinformation.

METHODS: We used the Twitter application programming interface (API), Hypertext preprocessor (PAP), and Response capture interface (RAI) to collect the response across Twitter, YouTube, Reddit, and Facebook. Lexicon-based sentiment analysis of the tweets was done using the VADER sentiment analysis tool. Descriptive statistics were used to summarize absolute numbers, frequencies, means, and standard deviations (SD). Independent t-tests were used to compare the average positive and negative sentiment. Finally, correlation analysis was used to examine the relationship between the sentiment across the three years. The data were analyzed with SPSS

RESULTS: We recorded 2,001,450 responses from December 2020 - March 2020, 1,920,872 responses between September 2021-November 2021, and 1,987,590 responses between September 2022-October 2022. Positive sentiment toward the Covid vaccine has declined significantly from 2020 to 2021 and 2022 (68% vs.55% vs. 31%, P=0.021 95% CI). Negative sentiment toward Covid vaccine has increased significantly between 2020 to 2021 and 2022 (18% vs. 25%vs. 47%, p<0.01 95%CI). No change in Neutral sentiment (15% vs. 20% vs. 23% p=0.67).

CONCLUSIONS: Sentiment analysis using a response from social media platforms is helping to understand the general population's ideology. In our study, a time-based assessment of Social media response has shown a reduction over time in the frequency of Positive sentiment toward a Covid vaccine. Furthermore, the polarization in the Social media users, based on sentiment polarity, showed that the users were well connected, highlighting that such issues bond our society rather than segregate it.

CONTRIBUTORS TO VARIATION IN EHR TIME AMONG PRIMARY CARE PHYSICIANS

Lisa Rotenstein¹; A Jay Holmgren²; Daniel M. Horn³; Russell Phillips⁴; Stuart Lipsitz¹; Richard S. Gitomer⁵; David W. Bates¹

¹Medicine, Brigham and Women's Hospital, Boston, MA; ²Medicine, University of California San Francisco School of Medicine, San Francisco, CA; ³Medicine, Massachusetts General Hospital, Boston, MA; ⁴Center for Primary Care, Harvard Medical School, Boston, MA; ⁵Internal Medicine, Brigham Health, Boston, MA. (Control ID #3873898)

BACKGROUND: Primary care physicians (PCPs) spend the most time on the EHR of any specialty, and increased EHR time, particularly after-hours, has been associated with physician burnout. It is unclear how PCP, panel, schedule, messaging, clinic, and teamwork factors influence EHR time.

METHODS: Our sample consisted of PCPs who practiced at Brigham and Women’s Hospital and Massachusetts General Hospital in 2021. Using Epic Signal data, we calculated physician-level daily averages of total EHR time, time outside of scheduled hours, and time spent on the electronic inbox, all normalized to 1.0 clinical full time equivalent (FTE). We also calculated PCP-level averages of percent of orders with team contribution (signed orders pended by a different team member) and the number of appointments and messages completed in 2021.

We descriptively analyzed PCPs’ demographic, panel, schedule, and message volume characteristics and EHR time during 2021. We additionally described clinic staffing ratios and supports. We then built multivariable linear regression models with standard errors clustered by clinic to determine the association of PCP, panel, schedule, message volume, clinic, and teamwork characteristics with total daily EHR time, EHR time outside scheduled hours, and daily time spent on the electronic inbox, all normalized to 1.0 clinical FTE.

RESULTS: We evaluated 307 PCPs (60% female). PCPs’ mean (SD) clinical FTE was 0.5 (0.3). PCPs had completed residency a mean (SD) of 20.9 (11.3) years prior. Mean (SD) panel size was 883.9 (510.7), mean panel risk score was 1.9 (0.5), and a mean (SD) of 58.9 (22.6%) of PCPs’ panels were female. PCPs had completed a mean (SD) of 1154 (605) visits and received a mean (SD) of 12,475 (5,622) messages during 2021.

Per clinical FTE, PCPs spent a mean (SD) of 308.5 (135.5) total daily minutes on the EHR, 173.5 (153.3) minutes daily outside scheduled hours on the EHR, and 67.8 (34.5) minutes daily on the electronic inbox, with significant variation by clinic.

Female PCP gender and greater total message volume per clinical FTE were associated with significantly greater daily time in all categories (p<0.05). In contrast, PCPs with greater team contribution to orders and above median medical assistant to provider ratios in their practices had significantly lower daily total EHR time, time outside scheduled hours, and electronic inbox time (p<0.05).

CONCLUSIONS: We assessed EHR use patterns of more than 300 PCPs and found significant associations between modifiable primary care practice factors and time spent on the EHR in total, outside of scheduled hours, and on the electronic inbox. These results suggest the potential value of increasing team contributions to orders and medical assistant staffing, as well as reducing the burden of messages from all sources, to optimize PCPs’ EHR time.

DEVELOPING A MODEL TO PREDICT INPATIENT HYPOGLYCEMIA

Sarah R. Stern¹; Richa Bundy¹; Lauren Witek¹; Adam Moses¹; Cynthia Burns¹; Matthew A. Gorris¹; christopher kelly¹; Ajay Dharod²

¹Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC; ²Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC. (Control ID #3870102)

BACKGROUND: Inpatient hypoglycemia is associated with increased length of stay and mortality.¹ Prior work has shown predictive models which include logistic regression models including the variables, weight, creatinine clearance, basal insulin dose and whether the patient is receiving mealtime and sliding scale insulin, can predict which patients are at high risk of developing hypoglycemia during their hospitalizations^2,3,4Application of this equation, when paired with a system in which charge nurses were trained to assess the hypoglycemia score and recommend changes to the prescribing teams’ insulin regimens, was able to reduce inpatient hypoglycemic episodes.⁵ We wanted to apply a similar model without altering nurse workflow by allowing providers to view the hypoglycemia risk score in the EHR.

METHODS: A logistic regression model was trained on inpatient hospitalizations of diabetic patients receiving insulin at Wake Forest Baptist Hospital from January 2020 to December 2021. The model was developed to predict a hypoglycemic event (glucose < 70 mg/dL), within 24 hours of a borderline-low glucose measurement (70-90 mg/dL). Predictors were defined a priori based on previous predictive models and input from our clinical team. We split 60% of the dataset for model training and 40% for testing. We are currently building the final risk score into our EHR to display as a print group on the Glucose Management Tab, which displays a patient’s blood sugar trends and insulin administration.

RESULTS: The full dataset included 8,545 inpatient admissions, of which 1,307 (15%) had an outcome of hypoglycemia within 24 hours of a borderline- low glucose result. The most predictive model parameters included maximum insulin doses, a prior episode of severe hypoglycemia, and a diagnosis of type 1 diabetes. The model area under the curve (AUC) was 0.69 on the validation dataset.

CONCLUSIONS: We trained a logistic regression model to predict which patients are at high risk of hypoglycemia and found the model was moderately predictive. We are currently prospectively validating the model after building it into our EHR. We then plan to pilot the risk score on several inpatient medicine services, with associated clinical decision support recommendations.

EFFECTS OF BEHAVIORAL INTERVENTIONS ON OVERUSE IN OLDER ADULTS SIX MONTHS AFTER STOPPING INTERVENTIONS: EXTENDED FOLLOW UP OF THE BEHAVIORAL ECONOMIC APPLICATIONS TO GERIATRICS LEVERAGING ELECTRONIC HEALTH RECORDS (BEAGLE) RANDOMIZED CONTROLLED TRIAL

Stephen Persell¹; Tiffany Brown²; Jason N. Doctor³; Craig R. Fox⁴; Noah J. Goldstein⁵; Ji Young Lee⁶; Jeffrey A. Linder⁷; Daniella Meeker⁸; Yaw A. Peprah⁹; Lucia C. Petito¹⁰; Theresa A. Rowe¹¹

¹Medicine, Northwestern University, Evanston, IL; ²Department of Medicine; Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; ³University of Southern California, Los Angeles, CA; ⁴Anderson School of Management, UCLA, Los Angeles, CA; ⁵UCLA, Los Angeles, CA; ⁶School of Medicine, Northwestern University, Chicago, IL; ⁷Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; ⁸Preventive Medicine, Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA;⁹General Internal Medicine, Northwestern Universiry, Chicago, IL; ¹⁰Preventive Medicine , Northwestern University, Chicago, IL; ¹¹Department of Internal Medicine and Geriatrics, Northwestern University, Chicago, IL. (Control ID #3875128)

BACKGROUND: Overtesting and overtreatment of older adults may lead to harm. Redirecting attention to possible harms of overuse and social and reputational concerns using behavioral-science-informed decision support may be effective ways to change clinician behavior.

METHODS: We performed a pragmatic cluster-randomized controlled trial randomizing clinics to a behavioral-science-informed clinical decision support intervention designed to reduce overtesting and overtreatment in older adults based on Choosing Wisely or standard of care. The intervention targeted 3 co- primary overuse outcomes: 1) prostate-specific antigen (PSA) screening in men 76y and older; 2) urine testing for non-specific reasons in women 65y and older and 3) overtreatment of diabetes in patients 75y and older (HbA1C<7% and treated with insulin or sulfonylurea). These alerts drew attention to possible harms of overuse; 2 alerts further required written justification in the encounter document or else the statement “No justification was given” was added, appealing to social and reputational concerns. The study was conducted in 60 primary care practices with 371 clinicians in northeastern Illinois. The intervention period lasted 18 months starting September 1, 2020 and we assessed outcomes for an additional 6-months post-intervention cessation. To adjust for secular trends, we estimated a piecewise hierarchical mixed effects logistic regression model with a knot at month 0 (start of intervention) with treatment indicators and clinician-level random effects.

RESULTS: At baseline, annual rates of overuse were 28.1% (2,490 / 8,865) for prostate cancer screening, 30.7% (3,391 / 11,051) for urinary testing for non-specific reasons, and 20.8% (1,155 / 5,553) for diabetes overtreatment. Overuse of all three clinical targets was significantly reduced during the study period by the decision support interventions: for prostate cancer screening (adjusted OR at 18 months compared to control, 0.61; 95% CI, 0.51 to 0.74), urine testing for non-specific reasons (aOR, 0.69; 95% CI, 0.59 to 0.80), and diabetes overtreatment (aOR, 0.75; 95% CI, 0.59 to 0.96). The differences persisted after incorporating an additional 6 months of post-intervention data: prostate cancer screening, aOR 0.69 (95% CI, 0.55 to 0.87); urine testing, aOR 0.63 (95% CI, 0.52 to 0.77); and diabetes overtreatement, aOR 0.71 (95% CI, 0.52 to 0.97).

CONCLUSIONS: Clinical decision support tools informed by behavioral science that were designed to increase clinicians’ attention to possible harms and to draw on social and reputational concerns to reduce overuse and overtreatment in older patients moderately reduced overuse of diagnostic testing, a finding that persisted 6 months post-intervention.

EPIC SECURE CHAT PRACTICES AND EXPERIENCES AT A LARGE TERTIARY CARE CENTER

Frans J. Beerkens¹; Amanda Owens¹; Nikola Kocovic¹; Aleesha Shaik¹; Aviv Alter¹; Amit Blumfield¹; Brandon Needelman¹; Brian Hsia¹; Vinh-Tung Nguyen¹; Beth G. Raucher¹; David C. Thomas¹; Jonathan L. Halperin²

¹Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Medicine, Cardiology, Mount Sinai Medical Center, New York, NY. (Control ID #3872191)

BACKGROUND: Miscommunication in healthcare is a source of medical error, increases provider stress, and interrupts patient care. Epic Secure Chat (ESC) is an instant messaging system integrated within the electronic medical record that allows for immediate communication between members of the healthcare team. We investigated the burden and experiences with ESC among care team providers at a large urban academic hospital.

METHODS: An online survey was sent to multidisciplinary care team members who regularly use ESC, including physicians, nurses, pharmacists, social workers, case managers, nutritionists, speech language pathologists, radiologists, and physical and occupational therapists. The primary outcome was satisfaction with current ESC use, measured with a Likert scale 1-5 with 5 indicating greatest satisfaction. Secondary endpoints included the perceived burden of ESC measured by Likert scale, estimated number of messages sent and received daily, frequency and characteristics of appropriate and inappropriate messages, and perceived professionalism.

RESULTS: Responses from 155 care team members are included in this analysis. Of surveyed users, almost all (n = 126) were satisfied (scale 4/5 or 5/5) with ESC communication (Figure 1). The majority (n = 44) found that ESC posed an average burden (scale 3/5) with an estimated send/receive message volume 20-50 per day (n = 56). The daily number of messages care team members estimated exchanging varied by discipline, with pharmacists and nutritionists estimating <20 messages compared with nurses and physicians estimating 50-100 messages daily. Despite high satisfaction with ESC, many (n = 60) reported occasionally receiving inappropriate ESC messages, and some (n = 15) noted they often or always receive inappropriate messages. Common themes characterizing inappropriate communication included critical or urgent messages, unprofessional tone, and high frequency messaging.

CONCLUSIONS: Satisfaction with ESC was high but perceived burden varied among care team members. Many reported at least occasional inappropriate messaging. These results highlight a need to educate users on appropriate ESC practices.

EVALUATING ACCEPTABILITY AND FEASIBILITY OF COMMSENSE, A NOVEL WEARABLE TECHNOLOGY TO IMPROVE CLINICIAN-PATIENT COMMUNICATION

Virginia LeBaron¹; Tabor E. Flickinger²; David Ling²; James Edwards¹; David Lee²; Anant Tewari²; Anna Marie Kutcher¹; Zhiyuan Wang³; Hassan Nusayer³; Laura Barnes³

¹University of Virginia School of Nursing, Charlottesville, VA; ²University of Virginia School of Medicine, Charlottesville, VA; ³University of Virginia School of Engineering and Applied Science, Charlottesville, VA. (Control ID #3875818)

BACKGROUND: Evaluating the quality of clinician-patient communication during real clinical encounters is challenging. Technology offers novel opportunities to provide clinicians with actionable feedback to measure, track, and improve their communication skills, but assessing end-user perspectives is critical to ensure successful implementation. Our team has developed and piloted CommSense technology to address this need.

METHODS: This prospective, descriptive study evaluated the acceptability and feasibility of CommSense, a novel wearable technology designed to record and extract key metrics of communication performance from

real-time conversations. Nursing and medical students and practicing clinicians were recruited from an academic medical center. Participants wore a smartwatch with the CommSense application and read 2-4 scripts with a ‘patient’ (member of our study team). Scripts focused on conveying difficult news, discussing prognosis, and managing pain and contained examples of positive (e.g., active listening) or negative (e.g., interruptions, medical jargon) communication skills. Conversations were recorded by CommSense, de- identified and off-loaded for analysis. Participants completed an electronic exit survey (Qualtrics) to assess their experience with CommSense and opinions about its potential application in clinical practice; survey results were exported to SPSS and descriptive statistics calculated.

RESULTS: Forty (n=40) participants (5 clinicians; 19 nursing students; 16 medical students) pilot tested CommSense, the majority aged 18-24 (n=29, 72.5%); female (n=32, 80%), and White (n=24, 57.1%). Most participants reported having ‘a little’ experience communicating with seriously ill patients (n=33, 55%) and formal communication training (n=21, 52.5%). Over 90% of participants (n=38, 95%)‘strongly agreed’ or ‘agreed’ that CommSense could improve compassionate communication between patients and clinicians and help healthcare organizations deliver high quality care (n=39, 97.5%). 87.5% (n=35) ‘strongly agreed’ or ‘agreed’ they were comfortable with CommSense recording clinical conversations; 92.5% (n=37) ‘strongly agreed’ or ‘agreed’ they would be willing to use CommSense in the future; 47.5% (n=19) ‘strongly agreed’ or ‘agreed’ to concerns regarding privacy/confidentiality. 100% (n=40) ‘strongly agreed’ or ‘agreed’ they were interested in seeing information from CommSense about their communication performance

CONCLUSIONS: Overall, our pilot demonstrated strong feasibility and acceptability of CommSense. Participants positively evaluated its potential to help improve patient-clinician communication and healthcare delivery. Although participants expressed willingness to use CommSense and openness to feedback from it, there were concerns regarding privacy and confidentiality; attention to data protection will be critical in future studies of CommSense with real patients. It will also be important to test CommSense with a more diverse sample and with more practicing clinicians.

EVALUATION OF PROVIDER CLINICAL DECISION SUPPORT SYSTEM ADOPTION RATES BY PATIENT RACE

Ratnalekha V. Viswanadham¹; Simon Jones²; Kellie Owens²; Safiya Richardson^3,4

¹Pediatrics, New York University Grossman School of Medicine, New York, NY; ²Population Health, New York University Grossman School of Medicine, New York, NY; ³Deparment of Population Health, NYU Langone Health, New York, NY; ⁴Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #3876433)

BACKGROUND: Best practice alerts (BPAs) are a type of clinical decision support (CDS) within electronic health records (EHRs). Meta-analyses of the effects of CDS like BPAs have shown that providers who use decision support are more likely to order appropriate treatments and provide preventive care services. However, it is unknown whether there are differences in CDS adoption based on patient race. Differences in CDS adoption could contribute to health inequities. This is a critical gap in the literature for two reasons. First, differences in CDS and BPA adoption could contribute to health inequities. Second, understanding heterogeneity in using BPAs can help determine how CDS can be effectively designed to improve patient care. This study aimed to determine whether differences in BPA utilization by patient race exist and, if so, the underlying reasons for these differences.

METHODS: We retrospectively analyzed over 3 million BPA firings in the EHR with the corresponding patient, provider, encounter, and BPA information during outpatient primary care encounters at a large academic health system from July 1, 2018, to June 30, 2019, and from July 1, 2021, to June 30, 2022. We used linear mixed models to assess the probability of BPA adoption based on patient race, adjusting for random effects at the patient, provider, BPA, and encounter levels.

RESULTS: In the unadjusted analyses, we found that the percentage of BPAs responded to during a visit varied by patient race. Patients of non-white races had fewer BPA responses during an outpatient visit (-7% for African American/Black patients, - 8.06% for Asian patients, and -0.86% for patients of other or multiple races) compared to White patients (intercept, 16.3% (SE = 0.00025, p < 0.0001). The significant differences in BPA responses remained consistent when controlling for patient, provider, and encounter-level random effects. However, when controlling for BPA-level random effects (i.e., controlling for any possible characteristic of a BPA, like its content, how it appears in the EHR workflow, and the actions a provider can take after a BPA), patients of non-White races had more BPA responses during an outpatient visit (2.58% for African American/Black patients, 2.75% for Asian patients, and 5.15% for patients of other or multiple races) compared to White patients (intercept, 18.3% (SE = 0.0344), p < 0.01).

CONCLUSIONS: BPA design variables, like the types of BPAs, their placement in the EHR workflow, and the content disseminated in them, contribute significantly to providers using clinical support less for patients of color. Future directions will include machine learning and other statistical learning-based methods to estimate what set of BPA-related factors best predicts the probability of a BPA response based on patient race and assess how these factors may impact racial health inequities.

EXPANDING AND ENHANCING MY DIABETES CARE: A USER-CENTERED DESIGN STUDY

Elsa Rodriguez¹; Shilo Anders¹; Carrie Reale¹; Amber Hackstadt¹; Zhihong Yu¹; Lyndsay Nelson¹; Lindsay Mayberry¹; S. Trent Rosenbloom¹; Audriana Nigg¹; Adam Wright²; Tom Elasy¹; Lipika Samal³; William Martinez¹

¹Vanderbilt University Medical Center, Nashville, TN; ²Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN; ³Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #3868884)

BACKGROUND: My Diabetes Care (MDC) is a SMART on FHIR patient portal app designed to help patients better understand their diabetes health data while promoting and supporting self-management. Our prior research suggested MDC may improve patients’ understanding of diabetes health measures (eg, HbA1c) and increase diabetes self-efficacy. We aimed to expand the diabetes health data displayed in MDC beyond HbA1c, blood pressure, and cholesterol, to include urine microalbumin and body weight, and enhance access to Spanish-speaking patients.

METHODS: We applied user-centered Design Sprint methodology to design a prototype of a revised MDC user interface to include urine microalbumin and body weight. We conducted two iterative rounds of prototype usability testing. We used purposive sampling to ensure representation of participants aged ≥65 and with limited health literacy. Participants were asked to review the prototyple and perform standardized tasks (eg, interpret values) using ‘think-aloud’ procedures to understand their user experience. Participants’ statements were qualitatively analyzed to inform revisions. Participants rated overall satisfaction and ease of use from 1-worst to 5-best and completed the 10-item System Usability Scale (SUS) scored 0-worst to 100- best. To inform a planned Spanish version of MDC, we conducted a community engagement studio (CES) with Spanish-speaking patients.

RESULTS: Prototype usability testing participants (n=12) had a mean HbA1c of 7.9; 6 (50%) were female, 3 (25%) were age ≥65, and 4 (33%) had limited health literacy. Round 1 participants' (n=6) statements indicated confusion on how to enter and edit goal weight and whether home or clinic weight was displayed. The mean overall ease of use and satisfaction were 4.8 and 4.2, respectively. Participants appreciated the green, yellow, and red color coding and labeling of health data values (eg, HgbA1c) to indicate values in the goal, caution, and high ranges, respectively. Among round 2 participants (n=6), the mean ease of use remained high (4.7), and overall satisfaction rose to 4.7. SUS scores were high in both rounds, consistent with excellent usability (mean SUS was 92 and 95, respectively). CES participants (n=3) felt the direct translation of the app title (“mi Cuidado a la diabetes”) was awkward. They shared that “Cuidado” is not very positive and may be interpreted as “caution.” Participants also recommended including resources to assist patients in discussing diabetes with their family and friends to engage their support in self-care (eg, diet)

CONCLUSIONS: Participants were able to use MDC with ease and highly rated its usability. Revisions led to an improved user interface for body weight. These findings suggest that the fully programmed version of MDC will likely meet the needs of target users. CES findings highlighted the need to translate app language with an awareness of cultural nuance. Further research is underway to test the usability of fully programmed, English and Spanish, versions of MDC.

EXPERIENCES USING AT-HOME VIRTUAL REALITY FOR CHRONIC PAIN: A QUALITATIVE STUDY

Genevieve Bryant¹; Hector R. Perez²; Lesly Sanchez Alvarez³

¹General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY; ²Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY; ³Internal Medicine, Albert Einstein College of Medicine, Bronx, NY. (Control ID #3876608)

BACKGROUND: Virtual reality (VR) is a promising nonpharmacological option for chronic pain management. However, little is known about the quality and depth of patients’ experiences with at-home VR for chronic pain. As part of an ongoing pilot clinical trial, we sought to elucidate patients’ experiences using an at-home VR device for pain management in a qualitative study.

METHODS: We conducted a qualitative survey of participants in the Bronx, NY who used a VR device for chronic pain at-home for one week. Patients were eligible if they were English-speaking adults with at least moderate chronic pain. Patients were excluded if they had contraindications to using the device, including epilepsy. Participants were recruited from electronic medical record databases and from prior pain clinical trials. The study utilized a device marketed for chronic pain and used in prior clinical trials, the RelieVRx (AppliedVR, Van Nuys, CA). The RelieVRx uses immersive mindfulness and cognitive behavioral interactive visuals and VR activities, including breathing exercises with visual cues, to reduce pain. After using the device for a week, we conducted a qualitative interview focused on how patients used the device, their thoughts and feelings during use, and how they thought VR helped or hindered their pain. Interviews were coded and analyzed by two authors using thematic analysis.

RESULTS: Of 5 people that completed the at-home study, 4 participants agreed to a qualitative interview. Median age was 55, 3 were female, 1 was non-Hispanic Black, and 3 were Hispanic. The median pain level was 4.8/10. All participants had never used VR prior to the study. In interviews, participants reported an overall positive experience. All participants described how the immersion provided by the device facilitated relaxation (“It’s like I’m a part of [nature] as I do those exercises, because I breathe along with the flow and the movement of the picture inside the VR.”) Three participants also elaborated on how relaxation had beneficial effects on mood and sleep (“It’s teaching you how to breathe, to relax your muscles, your nerves. I did feel good when I was doing it.”). Lastly, two participants reported how the device led to positive effects on pain and relaxation even when not using the device (“Any time my body experienced pain I can go right to that state of mind and start to visualize that I am wearing the machine.”). In contrast, one participant felt that while the device induced relaxation, there were limited effects on pain and the novelty decreased over time.

CONCLUSIONS: In this small sample of participants who piloted VR for chronic pain at home, participants noted positive overall experiences with some potentially durable effects. Further research with more participants to elucidate potential mechanisms for the effectiveness of VR in chronic pain.

EXPERIENCES USING AT-HOME VIRTUAL REALITY FOR CHRONIC PAIN: A QUALITATIVE STUDY

Genevieve Bryant²; Hector R. Perez¹

¹Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY; ²General Internal Medicine, Montefiore Health System, Bronx, NY. (Control ID #3877401)

BACKGROUND: Virtual reality (VR) is a promising nonpharmacological option for chronic pain management. However, little is known about the quality and depth of patients’ experiences with at-home VR for chronic pain. As part of an ongoing pilot clinical trial, we sought to elucidate patients’ experiences using an at-home VR device for pain management in a qualitative study.

METHODS: We conducted a qualitative survey of participants in the Bronx, NY who used a VR device for chronic pain at-home for one week. Patients were eligible if they were English-speaking adults with at least moderate chronic pain. Patients were excluded if they had contraindications to using the device, including epilepsy. Participants were recruited from electronic medical record databases and from prior pain clinical trials. The study utilized a device marketed for chronic pain and used in prior clinical trials, the RelieVRx (AppliedVR, Van Nuys, CA). The RelieVRx uses immersive mindfulness and cognitive behavioral interactive visuals and VR activities, including breathing exercises with visual cues, to reduce pain. After using the device for a week, we conducted a qualitative interview focused on how patients used the device, their thoughts and feelings during use, and how they thought VR helped or hindered their pain. Interviews were coded and analyzed by two authors using thematic analysis.

RESULTS: Of 5 people that completed the at-home study, 4 participants agreed to a qualitative interview. Median age was 55, 3 were female, 1 was non-Hispanic Black, and 3 were Hispanic. The median pain level was 4.8/10. All participants had never used VR prior to the study. In interviews, participants reported an overall positive experience. All participants described how the immersion provided by the device facilitated relaxation (“It’s like I’m a part of [nature] as I do those exercises, because I breathe along with the flow and the movement of the picture inside the VR.”) Three participants also elaborated on how relaxation had beneficial effects on mood and sleep (“It’s teaching you how to breathe, to relax your muscles, your nerves. I did feel good when I was doing it.”). Lastly, two participants reported how the device led to positive effects on pain and relaxation even when not using the device (“Any time my body experienced pain I can go right to that state of mind and start to visualize that I am wearing the machine.”). In contrast, one participant felt that while the device induced relaxation, there were limited effects on pain and the novelty decreased over time

CONCLUSIONS: In this small sample of participants who piloted VR for chronic pain at home, participants noted positive overall experiences with some potentially durable effects. Further research with more participants to elucidate potential mechanisms for the effectiveness of VR in chronic pain.

EXPLORING THE BURDEN OF MESSAGES IN EHR INBOX AMONG PRIMARY CARE PHYSICIANS

Richa Bundy²; Adam Moses²; Elisabeth Stambaugh⁴; Paschal Stewart⁴; Lauren Witek²; Lindsey E. Carlasare³; Gary Rosenthal^1,2; Christine Sinsky³; Ajay Dharod^1,2

¹Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC; ²Informatics and Analytics, Wake Forest University School of Medicine, Winston-Salem, NC; ³Professional Satisfaction, American Medical Association, Chicago, IL; ⁴Atrium Health Network, High Point, NC. (Control ID #3875895)

BACKGROUND: Physicians spend a substantial portion of their workday in the Electronic Health Record (EHR) and have cited time spent within their inbox to be particularly burdensome (Arndt et al, Annals of Family Medicine, 2017). Measures of inbox time have been mainly characterized and presented in aggregate (Melnick et al, Journal of the American Medical Informatics Association, 2021; Moore et al, Applied Clinical Informatics, 2021) However, understanding types of messages that contribute most to inbox burden is imperative for the development of interventions to target those message workflows and ultimately reduce time spent in the inbox. To our knowledge, no studies have characterized and quantified the types of messages received in the inbox across provider characteristics or by time on inbox.

METHODS: We collected one year of primary care physicians’ inbox volume and time by message type from the EHR data warehouse and the EHR vendor. The volume and time datasets were merged and aggregated by provider, message type, and calendar week. Providers scheduled less than 250 total hours were excluded from the analysis. We used descriptive statistics to assess overall volume and time per message by inbox message type. We also used Wilcoxon Rank-Sum tests to assess differences in median message volume and time by physician sex.

RESULTS: We included 326 primary care physicians’ inbox messages received between November 2021 and October 2022. Of the 69 unique message types in the inbox, three contributed to 54% of the message volume and 77% of the total time spent in the inbox: patient calls, patient medical advice request (PMAR), and results. Female physicians had a significantly higher median volume of PMAR messages than males, adjusted for scheduled hours. However, female physicians spent the same time per message as their male colleagues for these message types (Table 1).

CONCLUSIONS: Most of the time spent in the inbox can be attributed to only three message types. Many message types contribute to inbox volume but involve limited physician time. Additionally, female physicians received a disproportionate volume of messages from patients but spent similar amounts of time per message as their male colleagues.

GAPS IN OSTEOPOROSIS INFORMATION ONLINE

Irvind Buttar, Simran Parmar

Internal Medicine, Lenox Hill Hospital, New York, NY. (Control ID #3869329)

BACKGROUND: Patients are able to access an abundance of health care information via the internet. Online health information that is available should be comprehensive and inclusive. Osteoporosis is a condition effecting 500 million men and women all over the world. It is well established and noted that post menopausal women are affected. However, there is a significant population of patients who take immunosuppressants, have cancer, or metabolic conditions that place them at risk of developing osteoporosis. These populations should be included on osteoporosis informational pages to properly inform those at risk and help increase necessary screening.

METHODS: A review of fifty-eight academic Internal Medicine hospital systems was performed. We initially sought out if the hospital system had a patient education section on Osteoporosis. Out of the systems with patient education sections, we performed a cross sectional review to see if they mentioned screening/diagnostic methods and if they comprehensively included patient populations at risk. The primary outcomes were as follows: patient education section available, diagnostic testing information available, susceptible patient populations mentioned, and susceptible patient populations other than post menopausal women mentioned.

RESULTS: There were fifty-eight academic internal medicine hospital centers with accessible online information analyzed. Out of the fifty-eight main hospital centers, fifty-three (91%) had accessible osteoporosis websites with general information. Out of the fifty-three with these websites, forty-five (81%) mentioned screening/diagnostic modalities. Further, out of the forty-five hospital centers with diagnostic information, twenty-six (58%) mentioned the patient population of post menopausal women, and nineteen (42%) mentioned all other susceptible populations.

CONCLUSIONS: It is imperative to have accurate and comprehensive health care material available for our patients to promote literacy. Specifically focusing on osteoporosis, the above data search showed that only 42% of hospitals with websites convey extensive information on osteoporosis to patients who are at risk other than post menopausal women. This condition can be so lifechanging and limiting if not properly screened for and diagnosed. Proper patient education can increase screening, doctor -patient conversations while creating more informed patients.

HOW MUCH DOES INTRAVENOUS FLUID CAUSE HEMATOCRIT TO DROP?

Nabeel Qureshi^1,2; Joshua Pevnick²; Johan Carrascoza-Bolanos²; Matthew Bloom²

¹RAND Health, RAND Corporation, Santa Monica, CA; ²Cedars-Sinai Medical Center, Los Angeles, CA. (Control ID #3876042)

BACKGROUND: Hematocrit often drops after surgery. To differentiate drops from post-operative bleeding vs intravenous fluids, we sought to estimate expected post operative hematocrit (post-OH) values accounting for net fluid intake and intraoperative estimated blood loss (EBL).

METHODS: We reviewed patient-level data from the electronic health record (EHR) of an academic medical center in the California-Hawaii region for all non-pregnant adults undergoing elective knee or hip arthroplasty from November 2013 to September 2022. We used ordinary least squared regression to evaluate the association between an outcome variable of post-OH and predictors including: clinical [pre-operative hematocrit (pre-OH), intraoperative fluid inputs and outputs, and blood volume]; surgical (time from surgery to lab testing, EBL); and patient height and weight. We only included patients with a pre-OH result in our EHR within 7 days of the scheduled surgery date. We conducted sensitivity analysis using different specifications for estimated circulating blood volume.

RESULTS: 6,648 patients met the inclusion criteria. Of those, 58.6% were female. Mean BMI was 25.5 (SD=6.5). Mean net fluid intake was 1,121.6 mL (SD=795.6). Mean EBL was 143.3 mL (SD=178.1). Our model had an R2 of 0.553 compared to a model of pre-OH only of 0.280. Pre-OH was the strongest predictor of post-OH. Each 1% increase in pre-OH was associated with a 0.70% increase in post-OH. More time between the surgery and the post-OH collection reduced the strength of the relationship between pre-OH and Post-OH. On average, estimated blood loss and a positive fluid balance were associated with a decrease of 5.15% and 0.24% in post-OH, respectively. Our estimates were robust to sensitivity analyses and all variables included in the model were statistically significant with p-values < 0.005.

CONCLUSIONS: Compared to using the pre-OH alone, expected post-OH values may be better estimated by accounting for patient-specific EHR data. Unexpected drops in post-OH should prompt further clinical investigation.

IMPACT OF ARTIFICIAL INTELLIGENCE ON COVID 19 VACCINATION

RAJMOHAN RAMMOHAN¹; Tulika Saggar¹; Atul Sinha²; Melvin Joy¹; Dilman K. Natt¹; Charlene Curtis- Thomas¹; Susan Bunting¹; Prachi Anand¹

¹INTERNAL MEDICINE, NASSA UNIVERSITY MEDICAL CENTER, East Meadow, NY; ²Internal Medicine, Nassau University Medical Center, East Meadow, NY. (Control ID #3875196)

BACKGROUND: Artificial Intelligence is a device that responds to human voices and can be commanded to do various tasks. Artificial Intelligence can be found on smart speakers, smartwatches, mobile phones, tablets, and other devices. The most well-known are Alexa (Amazon), Siri (Apple), Google Assistant (Google), and Cortana (Microsoft). AI is being used to obtain health information, which has become a critical point of analysis for researchers in terms of question understanding and quality of response. Particularly, the COVID-19 pandemic has and still is severely affecting people worldwide, which demands studies on how VAs can be used as a tool to provide useful information.

METHODS: Universal Artificial Intelligence software Apple Siri, Amazon Alexa, Google Assistant, and Microsoft Cortana, were tested for medical information reliability. Voice recordings were done for 5 commonly asked questions in four different languages, English, Spanish, Mandarin, and French, regarding COVID vaccination. Likert’s scale was used to grade the response depending on the credibility of two blinded authors. The study was performed in two phases; (I) Comparisons between 4 AI were performed for the English language; (II) Comparing the outcome between different languages. The accuracies of each answer provided through audio output and the quality of the source supporting each answer were analyzed. The authors decided if each of the four AI provided clinically reliable advice.

RESULTS: Regarding the English language, Apple Siri’s responses were significant for reliability compared to other peers (95% vs. 70% vs. 65% vs. 15%, P: 0.012). Reliability was significant in AI using English as the Primary language as compared to the other Languages (73.2% vs. 60% vs. 55% vs. 10% p<0.01)

CONCLUSIONS: Artificial Intelligence continues to remain an important part of the development of Humanity. Most of the AI performed well in our study when English was the base language, but we believe there is a need for improvement for AI in other languages, especially with the technology becoming more ingrained in our everyday lives.

IMPACT OF EARLY TELEMEDICINE FOLLOW-UP ON 30-DAY HOSPITAL READMISSIONS

Anne Grauer¹; Talea Cornelius¹; Marwah Abdalla¹; Nathalie Moise²; Ian Kronish¹; Siqin Ye³

¹Medicine, Columbia University Irving Medical Center, New York, NY; ²Department of Medicine , Columbia University Medical Center, New York, NY; ³Medicine, Columbia University Medical Center, New York, NY. (Control ID #3868684)

BACKGROUND: Telemedicine is increasing in popularity but the impact of this shift on patient outcomes has not been well described. Prior data has shown that early post-discharge office visits can reduce readmissions. However, it is unknown if routine use of telemedicine visits for this purpose is similarly beneficial.

METHODS: We conducted a retrospective observational study using electronic health records data to assess if the rate of 30-day hospital readmissions differed between modality of post-discharge follow-up visits.

RESULTS: A total of 1,295 index discharges from 1,170 patients were included for analysis. Of these, 397 (31%), 481 (37%), and 417 (32%) discharges had telemedicine, in-person or cancelled/no-show follow-up visits within 7 days of discharge, respectively. The 30-day readmission rate for discharges with in-person, telemedicine, or cancelled/no-show follow-up visits within 7 days were 16%, 15%, and 17% (P=0.64), respectively. Compared to discharges with completed in-person follow-up visits, the adjusted odds of readmission for those with telemedicine follow-up visits was not significantly different (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.53 to 1.25, P=0.34) (Table 1).

CONCLUSIONS: Our study is among the first to examine the impact of primary care telemedicine use on 30 day readmission rates when used for post-discharge follow-up after hospitalization in the general population. Our study showed that 30-day readmission rate did not differ significantly according to the modality of visit. These results provide reassurance that telemedicine visits are a safe and viable alternative for post-hospitalization follow-up. Future studies, including larger randomized controlled studies, will need to confirm our findings.

IMPACT OF SOCIAL MEDIA SENTIMENT ANALYSIS (SA) TO PREDICT POPULATION OPINION TOWARDS ANNUAL SCREENING COLONOSCOPY

RAJMOHAN RAMMOHAN¹; Melvin Joy¹; Atul Sinha²; Tulika Saggar¹; Dilman K. Natt¹; Charlene Curtis- Thomas¹; Susan Bunting¹; Prachi Anand¹

¹INTERNAL MEDICINE, NASSA UNIVERSITY MEDICAL CENTER, East Meadow, NY; ²Internal Medicine, Nassau University Medical Center, East Meadow, NY. (Control ID #3875287)

BACKGROUND: Sentiment analysis is an emerging trend to understand patients’ thoughts in multiple situations, especially in healthcare settings, regarding patients undergoing screening procedures such as colonoscopy. Given the growing use of social media, public health interventions to improve cancer screening are being widely implemented. The primary aim is to analyze the population response toward the annual colonoscopy, and the secondary goal is to analyze the population sentiment toward earlier colonoscopy screening.

METHODS: We used the Twitter application programming interface (API), Hypertext preprocessor (PAP), and Response capture interface (RAI) to collect the response across Twitter, YouTube, Reddit, and Facebook. Lexicon-based sentiment analysis of the tweets was done using the VADER sentiment analysis tool. Descriptive statistics were used to summarize absolute numbers, frequencies, means, and standard deviations (SD). Independent t-tests were used to compare the average positive and negative sentiment. Finally, correlation analysis was used to examine the relationship between the sentiment across the three years. The data were analyzed with SPSS.

RESULTS: We recorded 7,651,350 responses from December 2017 - November 2022. 3,520,673 responses between December 2018 - November 2020 and 4,130,677 responses between January 2021 - November

2022. Positive sentiment toward the Annual colonoscopy has improved significantly from 2018 to 2022 (59% vs. 69% P=0.022 95% CI). Positive sentiment increased from annual colonoscopy from age 50 to age 45 between 2018 to 2022 (53% vs. 67% p<0.01 95%CI).

CONCLUSIONS: Our study showed an increase in the frequency of Positive sentiment toward Annual Colonoscopy and Earlier colonoscopy surveillance. Positive sentiments are likely attributed to data showing that the population favors the benefit of earlier colonoscopy screening. The negative sentiments could be due to side effects, lack of knowledge, specific cultural backgrounds, and social media misinformation. Furthermore, the polarization in the Social media users, based on sentiment polarity, showed that the users were well connected, highlighting that such issues bond our

IMPLEMENTING A STANDARDIZED PROGRESS NOTE TEMPLATE TO REDUCE NOTE LENGTH

Peter Kleinschmidt¹; Adam Rule²; Heidi Twedt¹

¹School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI; ²Information School, University of Wisconsin-Madison, Madison, WI. (Control ID #3871960)

BACKGROUND: Progress note length in the US far exceeds that of notes in other countries. Note length has increased dramatically over the last decade which is driven largely by duplication of redundant information. Introduction of new evaluation and management (E/M) guidelines in January of 2021 provided an opportunity for reducing extraneous information yet adjusting decades-old habits has been slow to occur. Operational tools such as providing standard documentation templates for notes may encourage this transition to shorter and, hopefully, more readable notes.

METHODS: We developed a standard note template designed to reduce duplication of data, increase readability, and streamline note writing while also providing embedded tools to assist with coding and compliance. The template was made available to general internists writing office progress notes in July of 2021. Adoption of the note was optional but encouraged on a regular basis with involvement of physician informaticists, division heads, and executive-level clinical leadership. Twelve months after implementation of the template we analyzed impacts on progress note length and compared this the 12 months prior to implementation of the template. Inclusion for analysis required authors being staff physicians or advanced practice providers, having data available for at least 3 months in both pre and post change periods, and having completed at least 100 encounters both pre and post change.

RESULTS: Among the 80 users included in this analysis, 29 were frequent users (>50% of encounters written with template), 18 were moderate users (1-50% of encounters), and 33 were non-users (i.e. <1% of encounters). Overall adoption of the template plateaued at 37% of encounters written with the standard template. Frequent users reduced median note length by 902 characters (95% confidence interval: 782,1080), moderate users reduced by 343 characters (28, 879) and non-users reduced by 101 characters (24,162). Frequent users reduced note length significantly more than non-users (P=0.00008, Mann-Whitney U test)

CONCLUSIONS: An active campaign implementing a standard note template for provider documentation substantially shortened documentation length among frequent users of the template. Interestingly, note length shortened even in users who did not adopt the standard template. Although some shift in note characteristics could be attributed to the change in evaluation and management guidelines that occurred in January 2021, previous work has shown that this change had no impact on note length at least in the early months after the changes were put in place. While policy changes alone may not change note writing behaviors, a focused project involving note template standardization can set the tone for an organizational culture on reducing note length, hopefully reducing extraneous or duplicative information, and thereby making notes easier to read and write. Future study will focus on improvement in time to document, readability, and provider satisfaction.

INLINE CLINICAL DECISION SUPPORT: DOCUMENTATION OF PAIN MANAGEMENT WITHIN CLINICAL NOTES

Matthew K. Lee, Archana Saxena, Katherine Moawad, Eduardo Iturrate, Jonathan Austrian, Hardev Randhawa, Roland Casem, Adam J. Goodman, Katherine A. Hochman, Joseph Weisstuch

Jonah Feldman NYU Langone Health, New York, NY. (Control ID #3834245)

BACKGROUND: Pain is a ubiquitous experience across inpatient settings that can greatly shape patients’ hospital course and overall quality of life. This project aimed to provide inline clinical decision support (CDS) for documentation of a pain management assessment and plan. Thorough documentation enhances interdisciplinary therapeutic treatment for pain and allows for frequent provider re-assessment of inpatient pain management. Given that pain may vary in its clinical presentation and responsiveness to treatments, a CDS intervention was designed keeping a broad spectrum of patients in mind. This study aims to increase provider documentation addressing patients’ pain management assessment and plan.

METHODS: An inline CDS disappearing tip was developed to appear in the Assessment and Plan (A&P) section of note templates. The tip is populated in notes for all admitted medicine/surgery patients who had a pain score ≥ 5/10 or received pain medication within the last 24 hours. The tip prompts the provider to document a pain management assessment and plan. On 2/17/22 tracking of the tip commenced across four hospitals using an Epic smart data element.

After tracking, 2703 notes met tip criteria from 2/17/22 to 3/4/22 and were categorized into one of two groups depending on if the CDS was used or not. Retrospective chart review was performed on a random sample of 400 notes (200 from each group), excluding those that did not have an A&P section. Clinical notes were primarily evaluated for documentation of the source of pain and the plan for pain management. Additional information regarding specific features of pain management plans and author role was collected.

RESULTS: After implementation of CDS within clinical notes, 63.5% (127/200) of notes documented a source of pain compared to 59.5% (119/200) without the integrated CDS tip (p=0.206). With the integrated CDS tip, 37% (74/200) of notes explicitly documented a pain management plan compared to 44.5% (89/200) without the integrated CDS tip (p=0.937). All clinical notes with and without CDS tip integration had similar rates of pain management plans that addressed pain severity, breakthrough pain, and consultation.

CONCLUSIONS: In this pilot study of 400 inpatient notes, the pain management inline CDS tip was associated with an increase in the rate of pain documentation. The labeling of notes from the study will facilitate a natural language processing (NLP) evaluation over thousands of published notes. This NLP evaluation will be powered to more definitively assess the impact of the CDS tip on documentation outcomes and identify opportunities for provider education and optimization of the tip. Clearer documentation of a patient’s pain source, assessment, and management plan helps providers address pain more attentively and effectively.

NECESSARY BUT NOT SUFFICIENT: IMPLEMENTATION AND EFFECTIVENESS OF VA’S DIGITAL DIVIDE INITIATIVE DURING THE COVID-19 PANDEMIC

Donna Zulman^1,2; James Van Campen²; Jacqueline M. Ferguson²; Zainub Dhanani³; Alison L. Greene^2,1; Rachel Kimerling^4,2; Cindie Slightam²

¹Medicine, Stanford University, Stanford, CA; ²Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA; ³Health Policy, Stanford University School of Medicine, Stanford, CA; ⁴National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, CA. (Control ID #3877092)

BACKGROUND: Virtual care holds promise for overcoming access barriers, but the "digital divide" impedes many individuals' use of technology. We sought to evaluate the implementation and effectiveness of VA’s national initiative to distribute video-enabled tablets to Veterans with access barriers during the COVID-19 pandemic.

METHODS: The VA began distributing video-enabled tablets to Veterans in 2016, but demand for this resource increased dramatically during the COVID-19 pandemic. In response, the VA implemented a Digital Divide consult in order to scale up tablet distribution and direct tablets and subsidized data plans to Veterans with documented access barriers and care needs. Guided by the RE-AIM Framework, we evaluated this initiative's Reach (i.e., number and characteristics of tablet recipients), Adoption (i.e., rates and volume of video-based service use among tablet recipients), and Effectiveness (i.e., patient-reported experiences with tablets, based on a mailed and phone survey of 3,399 tablet recipients with subsequent video visits). We assessed Implementation by examining reasons for tablet referral and changes over time in the percentage of Veterans who had a video visit within 90 days of tablet receipt.

RESULTS: Between 2020-2022, >130,000 Veterans received VA-issued video-enabled tablets, one-third of whom resided in rural locations. Tablet recipients (compared to the general VA population) were more likely to be <65 yrs (53% vs 47%), non-white (34% vs 28%), and have >5 chronic conditions (45% vs 18%), a mental health condition (70% vs 33%), priority status for high disability (52% vs 41%), and a history of homelessness (19% vs 4%). The most common criteria cited in tablet referrals were a mental health diagnosis (64%), social isolation (24%), and distance from VA >30 miles (23%). Following implementation of the Digital Divide consult, the percentage of tablet recipients who had a video visit within 90 days of tablet receipt rose from 57% in October 2020 to 74% in April of 2022. After consult implementation, we observed that many high-need patient populations had high rates of video visit engagement (i.e. ≥4 video visits in six months after tablet receipt) including 51%, 40%, and 42% of Veterans at high-risk for suicide, with substance use disorder, and with a hospitalization in the 90 days prior to tablet receipt, respectively. However, a moderate proportion (22-30%) did not have any video visits in the six months after tablet receipt. Among 1,000 survey respondents (response rate 35.7%), 91% reported that video visits helped them get care in a timely manner and 80% reported receiving the same quality of care during video-based and in-person visits

CONCLUSIONS: Although VA’s tablet initiative successfully targeted Veterans with complex medical and social needs during the pandemic, video visit rates remained low for many recipients. Future implementation strategies should focus on facilitating tablet adoption and use for high-value virtual care services.

NOVEL LARGE LANGUAGE ARTIFICIAL INTELLIGENCE MODEL ACCURATELY DIAGNOSES CLINICAL CASE VIGNETTES DESPITE NOT BEING DESIGNED FOR MEDICAL CARE

John T. Menchaca, Sara Turbow

Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #3868723)

BACKGROUND: Patients are increasingly turning to the internet to research their health questions and concerns. The utility of online symptom checkers (ex. WebMD) has been limited by their deficits in accurately diagnosing and triaging medical conditions. Novel artificial intelligence (AI) language models trained with expansive textual data may provide a new means of facilitating self-diagnosis and triage for the general public. The goal of this analysis is to evaluate the diagnostic and triage accuracy of ChatGPT, a publicly available large language AI model designed to helpfully interact with users on a wide range of topics.

METHODS: Forty-five standardized patient vignettes previously used in the literature to evaluate online symptom checkers were provided verbatim to ChatGPT. The model was sequentially asked to provide 1) the most likely diagnosis, 2) the 5 most likely diagnoses, and 3) triage advice regarding urgency of care (emergent, non-urgent, self-care). The browser cache for the ChatGPT website was cleared between each vignette. Descriptive statistics were used to calculate percentages of correct responses across categories.

RESULTS: Of the 45 standardized patient vignettes, all vignettes provided symptoms with duration, 27% included comorbidities, and 78% included objective data such as vital signs. The most likely diagnosis provided by ChatGPT was the correct diagnosis for 89% (95% CI 76% to 96%) of vignettes. The top 5 most likely diagnoses included the correct diagnosis in 96% (95% CI 85% to 99%). ChatGPT accurately triaged the urgency of care in 15 of 15 (95% CI 78% to 100%) emergency cases, 14 of 15 (95% CI 68% to 100%) non-urgent cases, and 5 of 15 (95% CI 11% to 62%) self-care cases. All inaccurate triage recommendations for self-care cases were to seek non-urgent medical care. The single inaccurate triage for a non-urgent case recommended self-care and included a caveat about possible inaccuracy with an additional recommendation to discuss treatment with a healthcare professional.

CONCLUSIONS: A large language AI model was highly accurate identifying the correct diagnosis in 45 standardized patient vignettes despite not being designed for medical care. The model accurately triages conditions requiring emergency and non-urgent care, though is risk-averse in cases when self-care may be appropriate. These findings suggest that large language AI models may be a promising patient and provider resource in the future, particularly if finetuned for medical use. Many important steps must be taken prior to its practical use in healthcare, among them including 1) demonstration of accuracy in more varied and complex clinical cases and when responding to non-clinical language, 2) quantifying how risk-averse triage may affect healthcare utilization, and 3) better understanding patient and provider perceptions of such technology.

NUTRI: PRELIMINARY RESULTS FROM A FEASIBILITY PILOT TRIAL OF A CLINICAL DECISION SUPPORT FOR COLLABORATIVE DIET GOAL SETTING IN PRIMARY CARE

Brandon S. Altillo^3,1; Madalyn Rosenthal^1,2; William M. Tierney^5,4; Lola Okunade^6,1; Mariana Rendon Flores²; Eesha Nayak¹; Steven Andrews⁷; Marissa Burgermaster^1,2

¹Population Health, The University of Texas at Austin Dell Medical School, Austin, TX; ²Nutritional Sciences, The University of Texas at Austin, Austin, TX; ³Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; ⁴Indiana University School of Medicine, Indianapolis, IN; ⁵Indiana University Richard M Fairbanks School of Public Health, Indianapolis, IN; ⁶Lone Star Circle of Care, Georgetown, TX; ⁷University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #3877284)

BACKGROUND: Diet is a major driver of chronic disease, but primary care providers (PCPs) often lack the time and training to adequately address it during visits. We developed a clinical decision support, Nutri, that guides PCPs through efficient, data-driven, collaborative, behavioral science-based nutrition goal setting with patients. Nutri collects patients’ diet history via an Automated Self-Administered 24-Hour Dietary Recall and suggests goals based on the USDA Dietary Guidelines for Americans.

METHODS: We tested Nutri’s feasibility in a pilot randomized controlled trial in 10 high-volume primary care clinics of a federally qualified health center network. We randomized PCPs to receive Nutri or control (usual care) stratified by training (MD/DO vs NP/PA) and self-reported need for interpreter for Spanish- speaking patients. Both groups completed a validated diet counseling competency scale and self-efficacy items at baseline. English- or Spanish-speaking patients ages 18-64 with BMI ≥25 kg/m² plus a diet-related comorbidity were recruited via text message sent to patients with upcoming appointments. PCPs randomized to Nutri were trained and received Nutri reminders prior to and at the time of each appointment. Nutri PCPs reported their satisfaction after each encounter using Nutri and assessed usability with the System Usability Scale (SUS) at the trial’s conclusion. Both groups completed 3-month diet counseling self-efficacy and competency posttests. We used t-tests to assess pre-post differences in self-efficacy and competency between Nutri and control PCPs.

RESULTS: We randomized 12 PCPs (Nutri: 4 MD/DO, 2 NP/PA; 2 Spanish-speaking; mean 11.5 years practicing; control: 3 MD/DO, 3 NP/PA; 1 Spanish-speaking; mean 3.7 years practicing). Nutri PCPs used Nutri with a mean of 3 patients each (range 1-7). PCPs completed the Nutri workflow in 100% of 18 eligible encounters. In 78% of encounters, the PCP and patient chose a Nutri-recommended goal. Mean PCP satisfaction post-encounter was 3.7±0.7 (5-point scale) and SUS score was 75±17.0 (above average). Table 1 describes competency and self-efficacy results by group.

CONCLUSIONS: PCPs successfully completed the Nutri workflow and reported moderate satisfaction and high usability ratings. Diet counseling competency significantly increased among Nutri PCPs compared to control and self-efficacy trended positively. Nutri can play an important role in supporting efficient, evidence-based dietary counseling in primary care.

PREDICTORS OF TELEMEDICINE USE FOR PATIENTS WITH DIABETES IN TWO HEALTH SYSTEMS

Elaine Khoong¹; Magdalene Kuznia⁴; Elizabeth B. Sherwin²; Kathryn E. Kemper²; Sarah Nouri³; Courtney R. Lyles¹

¹Medicine, University of California San Francisco, San Francisco, CA; ²Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA; ³Medicine, University of California, San Francisco, San Francisco, CA; ⁴School of Nursing, University of California San Francisco, San Francisco, CA. (Control ID #3877306)

BACKGROUND: Few studies have investigated how health system telehealth implementation impacts use of telemedicine for vulnerable patients. Safety-net systems provide more audio-only visits, and low-income, older, or minoritized patients are more likely to use audio-only visits, but the interplay between system- and patient-level factors is understudied. Therefore, we assessed if system telehealth priorities were associated with disparities in telemedicine use.

METHODS: We studied patients with diabetes (DM) empaneled as of 3/19 to an academic (site A) or safety- net (site S) system in the California-Hawaii region. Telemedicine visits were >95% video at site A and >95% audio-only at site S. Using EHR data, we assessed: (1) if patients had 1+ visit in a “hybrid” period from 7/20-3/21 when in-person & telemedicine visits were available; (2)whether patients had 1+ telemedicine (telephone/video) visit. We performed multivariable logistic regression analyses (adjusting for sex, insurance, comorbidities, and baseline DM control) focused on four predictors associated with digital health inequities: age, race/ethnicity, language, and socioeconomic status. To evaluate system-level factors, we assessed for interactions between site and primary predictors.

RESULTS: We studied 15148 patients (5268 site A; 9880 site S). 1+ visit: 10201 (67.3%) had 1+ visit in the hybrid period. Relative to 75+ yo, 18-34yo had lower odds of 1+ visit and 50-74yo had higher odds of 1+ visit. Black and non-English speaking had higher odds vs white and English-speakers, respectively. There were no significant interactions. 1+ telemedicine visit: 8305/10201 (81.4%) had 1+ telemedicine visit. Site S and younger age were associated with higher odds of 1+ telemedicine visit while Non-Hispanic Asian and Hispanic race/ethnicity were associated with lower odds. Younger patients at site S had lower odds than those

at site A of having 1+ telemedicine visit, but non-Hispanic Asian and Chinese-speaking patients at site S had higher odds than those at site A. (See table.)

CONCLUSIONS: After considering patient-level factors, system-level factors impact telemedicine access for patients with similar demographic traits. We found that a system that prioritized telephone visits was associated with higher telemedicine use for Asian or Chinese-speaking patients but lower use for younger patients compared to a system that prioritized providing video visits. Patient-level predictors of telemedicine use should be considered in the context of the system where they receive care.

PREVALENCE AND NATURE OF CLINICIAN DISBELIEF IN ADMISSION NOTES OF HOSPITALIZED PATIENTS

Courtney R. Lee^1,2; Xinwei Chen^1,2; Ari Klein¹; Davy Weissenbacher³; Graciela Gonzalez-Hernandez³; Gary E. Weissman^1,2

¹University of Pennsylvania, Philadelphia, PA; ²Leonard Davis Institute of Health Economics, Philadelphia, PA; ³Cedars-Sinai Medical Center, Los Angeles, CA. (Control ID #3877192)

BACKGROUND: In ambulatory settings, electronic health records (EHR) of Black patients are more likely to contain language used by clinicians to communicate disbelief in their clinical history. However, less is known about the use of such language in hospital settings where time constraints and fatigue are more likely to contribute to bias. To characterize the prevalence of language used by clinicians to communicate disbelief of a patient’s history in admission notes and examine whether the use of such language varied by patient race and ethnicity.

METHODS: We conducted a retrospective cohort study using the Medical Information Mart for Intensive Care (MIMIC-III, version 1.4) study, a deidentified EHR database from patients hospitalized in intensive care units (ICU) between June 1, 2001 and October 31, 2012. Because no applicable lexicon reflecting clinician disbelief has been identified, we applied the linguistic construct epistemic stance, which refers to a writer’s commitment to the certainty of information. Using this construct, we manually assembled a list of terms from published sources. We identified a total of 62 terms (e.g., reports, claims), and used regular expressions, an exact string-matching technique, to identify these terms within our sample. Three coders separately annotated a random set of 25 snippets for each term, then a consensus-based gold standard was used to confirm the presence or absence of epistemic stance. Terms were eliminated if they were considered correctly identified <80% of the time. Thirteen terms were included in the final analysis. The main outcome was a binary indicator for presence of at least one term in a note. The primary exposure was patient race and ethnicity (non-Hispanic White [NHW], non-Hispanic Black [NHB], Hispanic, Asian/Pacific Islander, or Other), which reflected self-report or a determination by the administrator who registered the patient. We used a mixed- effects logistic regression model to account for clustering of notes within admissions and admissions within patients. We adjusted for age, sex, preferred language, and insurance provider.

RESULTS: The sample included 17,551 admission notes written about 5,079 patients in 5,996 unique admissions. Of these patients, the mean (SD) age was 64.5 (18.0), 2348 (46.2%) were female, 3798 (74.8%) were non-Hispanic White, 565 (11.1%) were non-Hispanic Black, 188 (3.7%) were Hispanic, and 134 (2.6%) were Asian/Pacific Islander. In comparison to NHW patients, NHB patients had similar odds of containing at least one disbelief term (OR 1.17, 95% CI 0.95-1.43; p=0.72), as did Asian/Pacific Islander patients (OR 1.20, 95% CI 0.76-1.89); p=0.44), and Other racial/ethnic groups (OR 0.85, 95% CI 0.52-1.39; p=0.52)

CONCLUSIONS: While patient race and ethnicity have been linked to greater prevalence of clinician disbelief in the outpatient setting, this study suggests that the prevalence of disbelief does not vary by race and ethnicity among patients in the hospital.

PRIMARY CARE AND TELEHEALTH VISITS ACROSS ENGLISH LANGUAGE DURING THE COVID-19 PANDEMIC IN THE LOS ANGELES SAFETY NET

Alejandra Casillas¹; Anshu Abhat³; Griselda Gutierrez²; Carmen Mendez³; Stefanie D. Vassar⁴; Yu-Chuang D. Huang⁴; Arleen F. Brown⁵

¹Medicine, David Geffen School of Medicine @ UCLA, Los Angeles, CA; ²Medical Administration, Harbor-UCLA Medical Center, Torrance, CA; ³Internal Medicine, Harbor-UCLA Medical Center, Torrance, CA; ⁴Division of Internal Medicine & Health Service Research, UCLA, Los Angeles, CA; ⁵Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #3875314)

BACKGROUND: Telehealth has the potential to expand health care in safety net health systems—settings which disproportionately serve racial/ethnic minority, low-income, and/or Limited English Proficient (LEP) persons, and other patients who already experience social barriers to health care services.

At the outset of Coronavirus-19 disease (COVID-19), the Centers for Medicare and Medicaid Services granted payment for video and telephone visits. However, little is known about telehealth trends during the pandemic among safety nets. We describe this in the Los Angeles County Department of Health Services (LAC DHS)— the second largest safety net system in the US.

METHODS: We aggregated electronic health record data, comparing visit types (in-person, video, telephone) for unique patients with primary care visits during three study periods: pre-pandemic (Mar 2019- Feb 2020, n=161,087), pandemic Year 1 (Mar 2020-Feb 2021, n=164,752) and Year 2 (Mar 2021-Dec 2022, n=185,592). We examined differences between patients with English as primary language in the record, versus those with non-English (LEP).

RESULTS: In the pre-pandemic period, English and LEP patients had a mean 3.09 and 3.64 primary care visits, with no significant changes in Year 1 or 2. Figure 1 shows monthly primary care visits per 1,000 patients: in-person declined during Years 1 and 2, with increasing telehealth (combined telephone/video; video less than 1%) for both language groups. In the pre-pandemic period 18% (English) and 17% (LEP) of patients in primary care had a telehealth visit. In Year 1, this significantly changed to 89% (English) and 91% (LEP). In Year 2, 74% (English) and 76% (LEP) patients in primary care had a telehealth visit.

CONCLUSIONS: Despite COVID-19, the LA safety net delivered stable primary care visits. LEP patients, who already face barriers that negatively impact health outcomes—did not experience decreases. Telephone visits made up a significant portion of primary care for English and LEP groups after March 2020. One policy implication is that eliminating telephone visits as a billable visit would disproportionately affect underserved populations and threaten the ability of safety nets to meet need.

PROTECTION CONFERRED BY DELTA AND BA.1/BA.2 INFECTION AGAINST BA.4/BA.5 REINFECTION AND HOSPITALIZATION: A RETROSPECTIVE COHORT STUDY

Nicole Winchester¹; Nabin Shrestha³; Priscilla Kim²; Larisa G. Tereshchenko⁴; Michael B. Rothberg⁵

¹Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; ²Education, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; ³Infectious Disease, Cleveland Clinic, Cleveland, OH; ⁴Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; ⁵Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH. (Control ID #3868122)

BACKGROUND: SARS-CoV-2 immunity has declined with subsequent waves and accrual of viral mutations. In vitro studies raised concern for immune escape by BA.4/BA.5, and a study in Qatar showed moderate protection, but these findings have yet to be reproduced.

METHODS: This retrospective cohort study included individuals tested for COVID-19 by PCR during Delta predominance (July 1, 2021 to December 25, 2021), or BA.1/BA.2 (December 26, 2021 to June 24, 2022) and then retested during BA.4/BA.5 (June 25, 2022- August 18, 2022). The preventable fraction (PF) was calculated as the ratio of the infection/hospitalization rate for initially positive patients divided by infection/hospitalization rate for initially negative patients, stratified by age, and adjusted for age, gender, comorbidities, and vaccination status using logistic regression.

RESULTS: 20,987 patients were tested during Delta and/or BA.1/BA.2 and retested during BA.4/BA.5. Prior Delta infection provided no significant protection against BA.4/BA.5 infection (Adjusted PF: 11.9% (95% confidence interval [CI], 0.8-21.8); p=0.036) and minimal protection against hospitalization (Adjusted PF: 10.7% (95%CI, 4.9-21.7); p=0.003). In adjusted models, prior BA.1/BA.2 infection provided 45.9% (95%CI, 36.2-54.1) (p <0.001) protection against reinfection with BA.4/BA.5 and 18.8% (95% CI, 10.3-28.3) (p<0.0001) protection against hospitalization with BA.4/BA.5. Older adults (>65 years of age) derived greater protection from BA.4/BA.5 by prior BA.1/BA.2 infection than younger adults (<65) (p<0.001). Up- to-date vaccination also provided modest protection against reinfection with BA.4/BA.5 and hospitalization.

CONCLUSIONS: Prior infection with BA.1/BA.2 and up-to-date vaccination provided modest protection against infection with BA.4/BA.5 and hospitalization, while prior Delta infections provided minimal protection against hospitalization, and no protection against reinfection.

RELATIONSHIP BETWEEN THE CLINICAL LEARNING ENVIRONMENT AND INTERNAL MEDICINE RESIDENT CLINICAL REASONING DOCUMENTATION PRACTICES

Verity Schaye²; Matthew Haller²; Ilan Reinstein²; Daniel Sartori²; David J. DiTullio²; Erin Geraghty²; Kevin Hauck¹; Benedict Guzman²; Jesse Burk Rafel²

¹Medicine, NYU Langone Health, New York, NY; ²NYU Langone Health, New York, NY. (Control ID #3872088)

BACKGROUND: The clinical learning environment (CLE) – the organizational structures and cultures that trainees encounter – can have a significant impact on resident performance which can be difficult to quantify. We explore the relationship between the CLE at one academic internal medicine program and resident clinical reasoning (CR) documentation assessed by a previously developed machine learning (ML) model that classifies CR documentation as high- or low-quality based on a validated gold standard.

METHODS: We conducted a retrospective cross-sectional analysis of trends in resident CR documentation quality determined by the ML model among all general medicine admissions on resident teams (n = 12,605 admissions, n = 302 residents) across four academic years (AY) (July 2018-June 2022). Descriptive statistics and chi squared testing, including tests for linear trend, were performed with the R statistical package.

RESULTS: Resident CR documentation quality was lower during day shifts (59% high-quality vs 66% high- quality during night shift (8pm-7:59am), p<0.001) and quality decreased with increasing number of notes in the shift (note #1 in shift 65% high-quality vs note #5 in shift 55% high-quality, p=0.01). There was a trend in improvement by AY from 2018 to 2022 with a decrease in AY 2019 which included the initial COVID-19 surge in NYC (63% high-quality AY 2018 vs 58% high-quality AY 2019 vs 64% high-quality AY 2020 vs 67% high-quality AY 2021). CR documentation quality during the initial NYC COVID-19 surge was significantly lower than other times (51% high-quality March-May 2020 vs 65% high-quality other times during study period, p<0.001).

CONCLUSIONS: In this retrospective analysis of trends in resident CR documentation, aspects of the CLE such as day shift (vs night), volume of admissions in a shift, and the COVID-19 surge all were associated with lower quality CR documentation. We hypothesize that quality was higher during the night shift as residents can focus more on new admissions without the workload of routine non-emergent care. We observed an increase in note quality by AY and one hypothesis for this observation is there was an increase in number of resident teams and a decrease in team caps during this time period. Limitations of this work include its cross-sectional design, which precludes causal claims, and absence of controls for confounding by patient factors. Next steps will be to analyze the relationship between CLE and CR documentation quality in a nested regression model accounting for patient comorbidities. Our findings highlight the utility of using an automated ML model to explore the relationship between the CLE and resident performance measures given the ability to create large datasets for analysis in minimal time with ML which would not be feasible with human review. Retrospective analyses such as this one could inform studies with causal design to further understand impact of the CLE and inform quality improvement efforts that target hypothesized root causes.

ROLE AND IMPACT OF REAL-TIME PHARMACY BENEFIT CHECK TOOLS IN THE INPATIENT SETTING

Bradley D. Very¹; Priyanka Solanki²; Kristian Feterik³

¹Medicine, University of Pittsburgh Department of Medicine, Pittsburgh, PA; ²Department of Medicine, UPMC, Pittsburgh, PA; ³Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #3877034)

BACKGROUND: Real-time pharmacy benefit check (RTPBC) tools estimate outpatient out-of-pocket (OOP) prescription costs, and have been integrated into electronic health records (EHR). These components are underutilized, and little is known about their application in the inpatient setting.

METHODS: We surveyed 250 internal medicine trainees at an academic center to assess the importance of accessing OOP costs, tool awareness, and its effect on workflow. A system-based educational effort followed the pre-test with a tutorial and demonstration. Two months later, trainees completed a post-test. Results were assessed for significance with an unpaired Wilcoxon test.

RESULTS: There were 38 and 22 respondents in the pre and post-test groups, respectively. Trainees felt that access to outpatient OOP prescription costs is valuable, and considering cost is important when selecting medications continued after discharge. Tool awareness increased, with 26.3% of pre-test respondents reporting familiarity, compared to 50% in the post-test group. There was a statistically significant improvement in the ease of access to OOP costs (pre Z = 1.97, 95% CI, 1.49-2.39; post Z = 2.72, 95% CI, 2.04-3.40), and an increase in utilization (pre Z = 1.94, CI, 1.49-2.39; post Z = 2.72, CI, 2.04-3.40). There was a non-statistically significant increase in the ability to integrate OOP costs into workflow (pre Z = 2.42, CI, 2.08-2.76; post Z = 2.95, CI, 2.44-3.46). See Figure 1.

CONCLUSIONS: While trainees agreed that considering outpatient OOP prescription costs for hospitalized patients is valuable, the role of RTPBC tools remains unclear. Further research is needed to assess how system-based implementation of RTPBC tools can improve workflow, and evaluate the potential effect on clinical outcomes, including prescription abandonment and adherence.

THE IMPACT OF WIDESPREAD TELEHEALTH IMPLEMENTATION ON PATIENT-CLINICAL TEAM INTERACTIONS AMONG TWO COHORTS OF PATIENTS WITH DIABETES

Elaine Khoong¹; Sarah Nouri²; Elizabeth B. Sherwin⁵; Magdalene Kuznia⁶; Anna D. Rubinsky^3,5; Kathryn E. Kemper¹; Oanh K. Nguyen¹; Urmimala Sarkar⁴; Dean Schillinger¹; Courtney R. Lyles¹

¹Medicine, University of California San Francisco, San Francisco, CA; ²Medicine, University of California, San Francisco, San Francisco, CA; ³Medicine, University of California, San Francisco, San Francisco, CA; ⁴Medicine, UCSF, San Francisco, CA; ⁵Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA; ⁶School of Nursing, University of California San Francisco, San Francisco, CA. (Control ID #3875214)

BACKGROUND: COVID-19 changed primary care utilization. Utilization studies focus on billed visits, but care of patients with chronic diseases includes visits with other team members or between-visit interactions. These non-billed interactions are understudied and are more frequent in safety-net settings. We evaluated the impact of telehealth implementation on patient-clinical team interactions for patients with diabetes (DM) at an academic and safety net health system.

METHODS: Using EHR data, we studied visits (in-person, telehealth) and between-visit interactions (telephone calls, patient portal messages) for adults with DM empaneled to an academic (site A) or safety-net (site S) system in the California-Hawaii region. We included encounters with any member of the primary care team (e.g., clinician, pharmacist, social worker) and divided our study period into three: pre-COVID (4/19-3/20), strict shelter-in-place (4-6/20), hybrid (7/20-3/21). We assessed four outcomes reported as mean per person per month: all encounters; all visits; billed visits; between-visit interactions. Using an interrupted time series analysis adjusted for sex, insurance, comorbidities, and baseline DM control, we evaluated changes over time and reported marginal means to assess differences in each period by race/ethnicity, language preference, socioeconomic status (SES), and age. Due to telehealth implementation differences (telephone vs video visits), we analyzed sites separately.

RESULTS: Among the 15148 patients (5268 site A; 9880 site S), most encounters were between-visit interactions (72% site A; 59% site S). There was a significant growth in total encounters from pre-COVID to hybrid (site A: 1.14 to 1.21; site S: 0.84 to 1.00), which was driven at both sites by between-visit interactions. At site A, patient messages increased (0.30 to 0.47) vs telephone calls at site S (0.47 to 0.54). In contrast, all visits and billed visits significantly decreased at site A (0.35 to 0.30; 0.31 to 0.26). At site S, all visits increased (0.36 to 0.39), but billed visits were stable (0.26 to 0.27). When evaluating differences by demographic traits, we found fewer differences in visit frequency by age, race/ethnicity, language, and SES in the hybrid period vs pre-COVID. However, when evaluating between-visit interactions, non-English speakers had significantly fewer than English speakers in the hybrid period vs pre-COVID.

CONCLUSIONS: Telehealth implementation changed patient-clinical team interactions. Between-visit interactions grew more than visits, but the modality of the interaction diverged in our cohorts (patient messages vs telephone). While differences in visit usage by race/ethnicity, language, age, and SES closed compared to pre-COVID, differences in between visit interactions by language preference persisted. To fully understand care utilization for patients with chronic diseases, studies should expand beyond billed visits, particularly since disparity patterns differ in billed visits vs between-visit interactions.

USE OF VIRTUAL SCRIBES ASSOCIATED WITH SIGNIFICANT DECREASES IN ELECTRONIC HEALTH RECORD TIME BY AMBULATORY PHYSICIANS

Lisa Rotenstein³; Jianyi Zhang²; Christine Iannaccone¹; Christopher Holland²; Michael Healey³; David Y. Ting⁴; Christine Sinsky⁵; David W. Bates²

¹General Internal Medicine, Brigham and Women's Hospital, Boston, MA; ²Brigham and Women's Hospital, Boston, MA; ³Medicine, Brigham and Women's Hospital, Belmont, MA; ⁴Medicine, Massachusetts General Hospital, Lexington, MA; ⁵Professional Satisfaction, American Medical Association, Chicago, IL. (Control ID #3873893)

BACKGROUND: Ambulatory physicians spend much of their days using the electronic health record (EHR) and on EHR-based documentation. Virtual documentation support, such as virtual scribes, has the potential to enhance the physician experience while reducing the barriers associated with in-person documentation assistance. We characterized the impact of virtual scribes on physician EHR use patterns at two large academic medical centers.

METHODS: We identified physicians who had used a virtual scribe at Brigham and Women’s Hospital or Massachusetts General Hospital (MGH) between 01/2020 and 09/2022. For each physician, we extracted data about EHR use patterns from the Epic Signal database.

We assessed physicians’ specialty and hospital affiliate, as well as whether they used a synchronous vs. asynchronous virtual scribe service. We then used paired t-tests to compare EHR time metrics pre- and post- virtual scribe use at a physician level. We compared each physician’s total EHR time per appointment, pajama time (5:30 PM-7 AM) per appointment, note time, percent of note written by physician, average note length, and percent of orders with team contribution in the three months pre- and post- use of virtual scribes.

RESULTS: Our sample included 116 physicians (89% from MGH). Scribe users were distributed across specialties, with 22% internal medicine, 17% family medicine, and 11% dermatology physicians.

On a per-physician basis, virtual scribe use was associated with significant decreases in EHR time per appointment, note time per appointment, and pajama time per appointment in the three months post versus the three months prior to virtual scribe use. Total average EHR time was 39.3 minutes pre-scribe use vs. 32.6 minutes post (p=0.02), average note time per appointment was 10.8 minutes pre-scribe use and 9.1 minutes post-scribe use (p<0.001), and pajama time per appointment was 10.1 minutes pre-scribe use vs. 8.6 minutes post-scribe use (p<0.001). The proportion of the note contributed by the physician significantly decreased with scribe use (80% prior to scribe use versus 50% after).

Note length significantly increased with scribe use (mean 6395.4 characters post-scribe vs 5953.0 characters pre-scribe use; p<0.001). There was no significant change in the proportion of orders with contribution from another member of the care team with scribe use.

CONCLUSIONS: In this longitudinal study across two academic medical centers, we demonstrate that use of virtual scribes is associated with significant decreases in multiple EHR time metrics, and slight increases in note length. Future studies should segment analyses by whether scribe offering is synchronous vs. asynchronous, qualitatively characterize physician and patient experiences with virtual scribes, and assess the quality of scribed notes.

VIRTUAL REALITY FOR CHRONIC PAIN IN A COMMUNITY WITH LOW ACCESS TO TECHNOLOGY: A USABILITY AND PILOT STUDY

Lesly Sanchez Alvarez¹; Genevieve Bryant²; Hajar Traiba¹; Hector R. Perez¹

¹Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY; ²General Internal Medicine, Montefiore Health System, Bronx, NY. (Control ID #3876048)

BACKGROUND: Evidence suggests virtual reality (VR) technology may be beneficial for reducing pain symptoms in patients with chronic pain. However, studies to date have yet to recruit from communities with low access to technology. We sought to conduct a usability study and to pilot test a VR device among participants recruited from a community with low access to technology.

METHODS: We conducted in-person usability testing and pilot testing of a VR device in patients with chronic pain in the Bronx, NY, whose inhabits have among the lowest access to technology in New York State. Participants were enrolled if they were English-speaking adults with at least moderate chronic pain. Participants were excluded if they had contraindications in using the VR headset, including epilepsy. Participants were recruited from electronic medical record databases and from prior pain clinical trials. The study utilized a VR device marketed for chronic pain and used in prior clinical trials, the RelieVRx (AppliedVR, Van Nuys, CA). The RelieVRx uses immersive mindfulness and cognitive behavioral interactive visuals and VR activities, including breathing exercises with visual cues, to facilitate improved pain. First, to measure usability, participants were asked to operate the device and researchers compiled notes on usability tasks (turning on/off the device, fitting the headset, operating the machine, completing activities). We rated performance on each usability task on a 0-3 point scale, with values 1 and below considered usability barriers; we report proportions here. Lastly, in our pilot study, participants completed VR activities

for 10 minutes and reported pain intensity (using a 10-point Likert scale) and mood (using the Brief Mood Introspection Scale) both before and after. Paired t-tests were used to calculate differences in pain intensity and mood before and after VR testing.

RESULTS: We recruited 16 participants (mean age: 58.2 years; female: 75%; non-Hispanic Black: 62.5%; high school education or lower: 53%). Almost all (94%) had never used VR. On usability tasks, participants had little difficulty with most tasks; where there were issues, these were easily remedied. While only 38% had no difficulty turning on the device, 87% of participants were able to fit and operate the device, and 100% had no difficulty completing VR activities. On pilot testing, participants reported large reductions in pain intensity after VR activities (32.0% mean reduction in pain intensity, p=0.005). Feelings of liveliness and calmness increased after VR activities (30% improvement, p=0.006; 16.2% improvement and p=0.05, respectively), while feelings of tiredness decreased (31.8% reduction, p = 0.01).

CONCLUSIONS: In this study of VR for chronic pain in a sample of patients recruited from a community with low access to technology, we found no major usability issues and large effects on pain and mood after one session. Further research can determine whether effects seen in this study are durable.

Scientific Abstract - DEI, Health Equity, and Social Determinants of Health

"SHIFTING THE CULTURE AND THE WAY THAT WE PRACTICE": PERINATAL CLINICIANS' COGNITIVE AND BEHAVIORAL CHANGES IN RESPONSE TO ANTIRACISM AND ANTIBIAS INTERVENTIONS

Sarah B. Garrett¹; Fiona Miller⁵; Linda Jones⁴; Julie Harris⁴; Breezy Powell⁴; Erica Chan⁶; Stephen Zamarripa¹; Daniel Dohan¹; Melissa Simon²; Brittany D. Chambers³

¹Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA; ²Northwestern University Feinberg School of Medicine, Chicago, IL; ³Department of Human Ecology, University of California Davis, Davis, CA; ⁴California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA; ⁵University of California San Francisco School of Medicine, San Francisco, CA; ⁶University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #3874037)

BACKGROUND: Many health systems are implementing interventions to address racism and bias in maternal healthcare. There is little research on their effects. We characterize how perinatal clinicians report they and colleagues have changed following antiracism/antibias interventions.

METHODS: As part of larger study about antibias training, we conducted in-depth interviews with perinatal clinicians (n=20) at two hospitals in Northern California. Using inductive/deductive thematic analysis, we developed a taxonomy of described changes.

RESULTS: Respondents were nurse midwives (6), physicians (6), registered nurses (5), and other staff (3). They self-identified as Black (4), multiracial (4), or white (12) women; two identified as Latinx or Hispanic. Twelve respondents discussed changes in themselves or colleagues following interventions such as antiracism talks, antibias trainings, and colleagues’ requests to reform biased behavior. We characterized these as: 1. Cognitive changes, including: Recognizing one’s own biased thinking and behavior (“It was a very subtle shift for me…Instead of saying, ‘I’m not a racist, I don’t have biases,’ saying, ‘Yes, you do, and that’s okay. Let’s acknowledge them… and then you can start shifting them’”); and better understanding the role of race and racism in disparities (“It’s made a deep impression on me to learn some of the data about the discrepant perinatal outcomes… It's not education and income. Blackness, that makes the difference in poor outcomes, and in not believing women”). 2. Individual behavior changes, including: Evaluating whether one is providing unbiased care (“I think for an extra second about, like, would I treat this patient differently were they to be more similar to me”); working to change biased speech and behavior (“[Colleague] told me about the things people have said that are actually showing levels of racism… I’m trying to un-train myself out of it because of the racial connotations”); communicating concern about colleagues’ biased speech or behavior (“If I hear something I definitely say something”); and identifying ways to better support patient autonomy. 3. Team behavior changes, including: More intra-colleague discussion of racism, bias, and respectful care; and collaborating to assess and optimize treatment for individuals in racial/ethnic groups with higher rates of perinatal complications (“The doctor stopped, ‘Is there anything that we’re not covering to make sure that we’re decreasing her risk?’ I hadn’t heard a doctor verbalize it before”).

CONCLUSIONS: Perinatal clinicians observe cognitive, behavioral, and individual- and team-level changes following antiracism/antibias interventions, some of which exceed mere allyship. Future research should investigate which type(s) of changes benefit the care and outcomes of patient populations disproportionately burdened by maternal health inequities, and identify which interventions, in which contexts, produce these.

DIVERSITY, EQUITY, AND INCLUSION PROGRAMS AT US MEDICAL SCHOOLS: A NATIONAL SURVEY

Melinique Walls²; Isra Hasnain²; Monica Vela³; Paulina Zajac³; Norma Poll-Hunter⁴; Wei Wei Lee¹.

¹General Internal Medicine, University of Chicago, Chicago, IL; ²University of Chicago Pritzker School of Medicine, Chicago, IL; ³Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; ⁴Association of American Medical Colleges, Washington, DC. (Control ID #3876866)

BACKGROUND:A diverse physician workforce strengthens health equity via improved healthcare access for underserved patients. Despite efforts to increase diversity at US medical schools, Black, Hispanic, and American Indian students remain underrepresented in medicine and are more likely than their white peers to experience mistreatment and bias. While many schools have diversity, equity, and inclusion (DEI) offices, little is known about the scope of these offices.

METHODS: Between Aug 2021-Feb 2022, 154 US medical schools were surveyed about their DEI offices. The survey assessed the presence of a DEI office, characteristics of leaders, budgets/FTE support, and programming. Chi square and Mann-Whitney U tests explored associations between budget, and FTE for staff and faculty by school type (public vs. private), size and diversity (%URM students enrolled).

RESULTS:Of 154 schools,103 responded (67%). 92% reported having a DEI office. Of 64 schools reporting an annual budget, 28% reported <$50,000, and the maximum was >$500,000; there was no difference by school type (p=0.45) and diversity (p=0.80).

Of 94 respondents who reported demographic data, 71% were faculty, 47% were deans, and 11% were directors. Of 61 respondents who identified as the “DEI leader,” 68% were women, 59% were Black, 69% were non-Hispanic, and 39% were in their roles for <5 years. Median FTE for DEI leaders was 0.50 (IQR 0.5-1.0) and 3.0 (IQR 2.0-4.5) for all DEI faculty/staff. Median faculty/staff FTE per URM student was 0.03 (IQR 0.01-0.05) and while no differences by school type (p=0.13) or diversity (p=0.40) were found, higher median FTE per URM student was found at smaller (<590 students) vs. larger schools (0.04 [IQR 0.02-0.07] vs. 0.02 [IQR 0.01-0.03], p=0.01) and at private vs. public schools (0.03 [IQR 0.02-0.06] vs. 0.02 [IQR 0.01-0.04], p=0.04). Schools with <20% URM students had higher FTE per URM student than those with greater diversity (0.04 [IQR 0.02-0.07]) vs. 0.02 [IQR 0.01-0.04], p=0.002). Median faculty/staff FTE per enrolled student was 0.005 FTE (IQR 0.003-0.009).

Of 95 respondents, most DEI offices promoted an inclusive culture (92%), advanced diversity of the medical profession (87%), and supported community service (71%). Of 81 responding schools, 31% evaluated their DEI office, with most using the AAMC graduate questionnaire diversity items (76%) and internal surveys of DEI events (68%).

CONCLUSIONS: To our knowledge, this is the first study to describe characteristics of DEI offices at US medical schools. Almost all responding schools had DEI offices, which were staffed by approximately 3 FTEs and approximately half had annual budgets of up to $100,000 to support a range of student and community based initiatives. Smaller schools, private schools, and those with less diversity devoted more FTE per URM student than larger, public, and more diverse schools. Few schools evaluate their DEI programming and we recommend more rigorous evaluation to guide resource allocation and strategic planning.

2022 PREVALENCE OF BURNOUT AMONG WOMEN RESIDENTS AND ASSOCIATION WITH DISCRIMINATION-BASED TRAUMA: A MULTI-INSTITUTIONAL STUDY

Tyra Fainstad¹; Adrienne Mann¹; Alexander Heilman¹; Pari Shah²; Christine D. Jones³; Lotte Dyrbye³

¹Internal Medicine, University of Colorado, Denver, CO; ²Graduate School of Social Work, University of Denver, Denver, CO; ³Medicine, University of Colorado Denver School of Medicine, Aurora, CO. (Control ID #3874489)

BACKGROUND: The Covid-19 pandemic has precipitated dramatic increase in physician burnout. Although physician burnout has been well documented, the current state of burnout among female residents remains underexamined.^1-3 Recent data shows mistreatment/discrimination by patients, families, and visitors in the workplace⁵ increases the odds of burnout among practicing physicians. Single specialty studies in residents suggest a similar relationship, but an understanding of the relationship between past experiences of discrimination outside of the workplace and burnout risk among residents is lacking. The purpose of this study is to describe the current prevalence of and risk factors for burnout amongst female physician trainees across multiple institutions and specialties.

METHODS: In September 2022, a baseline survey was administered to 1,017 female trainees who had volunteered to participate in a professional coaching program², across 26 GME training programs. The survey included demographics, the Trauma Symptoms of Discrimination Scale (TSDS),⁴ and the Maslach Burnout Inventory (MBI). The TSDS is a 21-item self-report measure that screens for trauma symptoms due to past discriminatory events. The scale includes questions about current symptoms including avoidance, negative cognitions, social fears, and worries about the future. Items are rated from 1 (never) to 4 (often) based on the amount of distress caused specifically by prior discriminatory acts.⁴ Burnout was defined as scoring >27 for emotional exhaustion (EE) and/or >10 for depersonalization (DP) on the MBI.

RESULTS: All 1,017 trainees responded to the baseline survey. The mean age was 31 years, 88% (843)

identified as heterosexual, 59.9% (573) identified as White. Most (81%) were non-surgical, and 20.7% (207), 19.8% (198) and 59.5% (596) were PGY-1, PGY-2, and >PGY-3, respectively. Overall, 66% had burnout, 66.0% had high EE, and 61.3% had high DP. Mean EE and DP scores were 30.58 and 11.83. Higher scores on the TSDS was associated with higher odds of burnout (OR, 1.30 for 10 units of change, 95% CI 1.11-1.53, p=0.001), high EE (OR 1.26 for 10 units of change, 95% CI 1.11-1.43, p<0.001), and high DP (OR 1.12 for 10 units of change, 95% CI 1.00-1.26, p=0.058). Multivariable analysis exploring independent predictors of burnout will be presented in the meeting.

CONCLUSIONS: Data from this large, multi-institutional, multi-specialty cohort show a higher level of burnout than reported in pre-pandemic large studies of US residents.^1,3 This study suggests that trauma from previous discrimination experiences increase burnout risk in female residents. Burnout among trainees is progressing. In addition to a GME-wide national wellbeing effort focused on system-level drivers, initiatives to help those who have suffered trauma from discrimination inside and outside the workplace may be useful. Future studies should explore how best to help trainees recover from previous experiences of trauma.

ACCESS TO CONTINUOUS GLUCOSE MONITORING SYSTEMS IN A RESIDENT RUN PRIMARY CARE CLINIC FOR UNDERSERVED MINORITY PATIENTS WITH TYPE 2 DIABETES: A PILOT STUDY

Rebecca G. Sgroi¹; Srikala Gumireddy¹; Wan Ying Tan¹; Leah Roseph¹; Diana Salama²; Rebecca Kaplan³; Yolande Milambwe³; Cynthia R. Feher¹; Nancy Rennert^4,51Internal Medicine, Norwalk Hospital Department of Medicine, Norwalk, CT; ²University of Vermont Larner College of Medicine, Burlington, VT; ³Primary Care Clinic, Norwalk Hospital, Norwalk, CT; ⁴Chief of Endocrinology, Norwalk Hospital, Norwalk, CT; ⁵Associate Clinical Professor, Yale School of Medicine, New Haven, CT. (Control ID #3868330)

BACKGROUND: Disparities in diabetes care are well documented. Continuous Glucose monitoring Systems (CGMs) have improved patient experience without the need for finger sticks and have been shown to effectively lower Hemoglobin A1C, decrease the number of hypoglycemic events and increase the serum glucose time in range. CGMs may also decrease clinical inertia and allow improved diabetes management. Medically underserved and historically marginalized persons are disproportionately affected by diabetes, yet limited data exist on use of CGMs in this population. We report a pilot initiative that brought CGM access (FreeStyle Libre 2) to our Federally Qualified Community Health Center (FQHC)’s resident physician primary care clinic. Our patients face unique challenges, as most are underinsured (with 40% having no insurance) and 50% report a preferred language other than English.

METHODS: We created a group of Clinical Champions (Resident Physicians, Attending physicians, Registered Nurses and Medical Assistants) to develop a Team Workflow and education plan for all clinicians and staff including CGM placement, trouble shooting and data interpretation. Patients with Diabetes Type 2 and an A1C >8.0% or on insulin were referred to be enrolled in CGM. Exclusion criteria were renal failure and pregnancy. The study visit schedule included an initial nurse visit for patient education and device placement of FreeStyle Libre (FSL). Follow up medical visits were scheduled at 2 weeks, 6-8 weeks, and 3-4 months where glycemic data was reviewed and shared decision making took place to make medication and behavioral changes. Baseline HBA1c was collected and repeated at the 3–4-month visit. Provider and patient surveys were distributed at each visit.

RESULTS: Fifty participants were enrolled in the CGM study and had FSL placed. The CGM active time was greater than 50% in 76% of participants and those who continued with CGM had an increase in active time. Initial mean A1C for the entire cohort was 9.64% and average glucose after 2 weeks was 195 mg/dl. Hypoglycemia, especially overnight, reduced over time. The use of CGM data was associated with clinician- initiated medication changes. Provider and patient surveys showed positive sentiment to using the device and revealed an increase in likelihood of medication changes based on glycemic trends. In addition, patients reported better understanding of their disease process overall.

CONCLUSIONS: This pilot study demonstrates the feasibility of utilizing diabetes technology (FreeStyle Libre 2) in underserved patients who often lack access and support required to manage their diabetes. CGM is becoming more common in outpatient settings to determine glycemic trends and make appropriate medication recommendations. This study shows that CGM can be successfully deployed during Primary Care visits by physicians in training who will likely continue to use CGM well beyond their training.

ACHIEVING EQUITY IN SCREENING MAMMOGRAPHY AMONG IMMIGRANT EAST AFRICAN WOMEN IN SEATTLE: ONE SIZE WILL NOT FIT ALL

Rebecca S. Gold¹; Rachel L. Yung³; ADELAIDE H. MCCLINTOCK²

¹Internal Medicine, University of Washington, Seattle, WA; ²Medicine, University of Washington, Seattle, WA; ³Oncology, University of Washington, Seattle, WA. (Control ID #3874130)

BACKGROUND: Compared to white women, Black women are diagnosed with breast cancer at advanced stages and have higher mortality rates. Decreased mammography utilization significantly contributes to breast cancer disparities. Immigrant Black women face additional barriers that compound these inequities; notably, mammography rates are among the lowest for recent immigrants. We aimed to describe experiences and preferences related to breast cancer screening among Somali and Ethiopian women, two growing immigrant populations in Seattle, to inform system-wide interventions to increase screening rates within a diverse patient population at a large, urban, academic medical center.

METHODS: Semi-structured focus groups with women who self-identified as Somali or Ethiopian, eligible for breast cancer screening in Seattle, WA. Each focus group discussed participant views on health care, breast cancer screening, and future outreach. Interviews were conducted in Somali or Amharic with a real- time certified bilingual interpreter and cultural mediator. Verbatim transcripts from audio recordings underwent constant comparison and iterative data reduction analysis by two authors.

RESULTS: 11 Somali women participated in 2 focus groups and 7 Ethiopian women participated in 2 focus groups. Several themes were shared between Somali and Ethiopian women: obstacles to screening (e.g., physical location of services, need for interpreters, competing caregiving responsibilities), the power and value of a doctor’s recommendation, the weight of information from within their own community, and the motivation to screen when hearing stories of people with cancer. Both groups recommended more presence in community outreach and recommended oral or visual materials as the primary mode of information sharing. Themes more common among Somali women included an expectation of pain, a cultural tradition of silence around health issues, and an emphasis on the role of religion in health (e.g., predestination). Ethiopian women described how although faith and religion including prayer were important in their lives or for coping with health issues, they desired more separation between religion and healthcare. Ethiopian women also described a desire for more information about breast cancer and screening and may place greater emphasis on the provider as a trusted source of information.

CONCLUSIONS: This study identified obstacles to screening and opportunities for developing tailored, culturally-relevant interventions to improve rates among East African communities in our region. Healthcare systems must be prepared to address the unique needs of both populations for interventions to meaningfully impact screening rates and ultimately reduce disparities in breast cancer outcomes.

ADAPTATION OF A BIDIRECTIONAL CRISIS AND EMERGENCY RISK COMMUNICATION FRAMEWORK BY COMMUNITY ENGAGED RESEARCH PARTNERSHIPS IN RURAL MISSISSIPPI DURING THE COVID-19 PANDEMIC

Rodney Washington⁷; Jane Njeru²; Lohr M. Abby²; Jennifer A. Weis⁹; Angela Omondi⁸; Mauda Monger⁴; Sandra Melvin⁵; Nakeitra Burse³; Caroline Compretta⁶; Irene G. Sia¹; Mark L. Wieland²

¹Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic Minnesota, Rochester, MN; ²Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic Minnesota, Rochester, MN; ³Six Dimensions, LLC, Ridgeland, MS; ⁴My Brother’s Keeper, Inc, Ridgeland, MS; ⁵Institute for the Advancement of Minority Health, Jackson, MS; ⁶Department of Preventive Medicine, The University of Mississippi Medical Center, Jackson, MS; ⁷School of Population Health, The University of Mississippi Medical Center, Jackson, MS; ⁸Department of Behavioral and Environmental Health, School of Public Health, College of Health Sciences, Jackson State University, Jackson, MS; ⁹Center for Clinical and Translational Science, Mayo Clinic Minnesota, Rochester, MN. (Control ID #3874056)

BACKGROUND: Crisis and emergency risk communication (CERC) frameworks have been used to promote public participation in coronavirus 2019 (COVID-19) mitigation efforts, but equitable implementation depends on reaching those who have been disproportionately affected by COVID-19 disparities. African American and Hispanic populations as well as immigrant and refugee populations have experienced disproportionate COVID-19 incidence, hospitalizations, and deaths due to pandemic-associated environmental and socioeconomic factors framed by structural racism. Community engagement is important for reaching populations at risk for health inequities in the COVID-19 pandemic.

METHODS: In March 2020, a community-engaged research partnership in Southeast Minnesota adopted a CERC framework to address COVID-19 prevention, testing, and socioeconomic impacts within health disparity groups. Bidirectional communication between Communication Leaders (trusted leaders in the community selected by community partners for their extensive social connections) and their social networks collaborated with the partnership to refine messages, leverage resources, and advise policy makers. This community-engaged risk communication intervention demonstrated high acceptability, feasibility, perceived efficacy, and sustainability. The framework was adapted by a community-academic partnership with rural African American populations in three Mississippi counties with high COVID-19 disparities. Intervention reach was assessed by the number of messages delivered by Communication Leaders to members of their social networks. Perceived scalability of the intervention was assessed by the Intervention Scalability Assessment Tool. Bidirectional communication between Communication Leaders and community members within their social networks was used by the partnership to refine messages, meet resource needs, and advise statewide decision makers.

RESULTS: Communication Leaders in all three counties used a variety of platforms to share information, reaching more than 8,482 individuals during the first 3 months, in the three counties. The intervention was deemed to be highly scalable by partnership members. Scalability was perceived to be facilitated by the magnitude and urgency of the problem, the high perceived efficacy of the intervention that is adapted for local contexts, high acceptability through the tailoring process and co-ownership by community partners, and the relatively low start-up costs of partnering with existing communication leaders in each region.

CONCLUSIONS: Adaptation of a community-engaged pandemic CERC intervention is feasible and scalable, and it has the potential to reduce COVID-19 inequities across heterogeneous populations. This approach may be incorporated into current and future pandemic preparedness policies for community engagement.

ADDRESSING 30-DAY READMISSION RATES FOR PNEUMONIA: WHAT ARE THE RISK FACTORS?

Elizabeth M. Jean-Marie, Kaniza Z. Abbas, Willie L. McClure, Jihane Faress

Medicine, University Hospitals, Cleveland, OH. (Control ID #3874490)

BACKGROUND: Pneumonia is a severe health problem in the United States (US), responsible for over a million annual hospital admissions and more than 140,000 annual hospital readmissions. Studies show that approximately 1 in 5 patients with pneumonia are readmitted to the hospital within 30 days of discharge. This leads to a severe burden on the healthcare system, both in terms of resources and costs. The goal of this study was to assess factors associated with 30-day readmission for patients admitted with pneumonia our Northeast Ohio hospital system.

METHODS: We obtained data from patients in our healthcare network through the EMR. Using 1CD-10 codes, we generated a list of patients with pneumonia as their admission diagnosis between September 2020 and August 2021. We then filtered the list to include patients with an additional encounter in the system within the next 30 days (an admission, ED visit, or observation). Patients without an additional encounter were compared as a control group. The medical charts for these patients were reviewed for information on demographics, comorbidities, readmission diagnosis, discharge, and follow-up appointments. These data points were collected and manually input into a secure RedCap database.

RESULTS: A total of 296 patient encounters were reviewed in our healthcare system–96 encounters for our 30-day readmission group (a rate of 32%) and 200 encounters for a comparison group. Readmission/ED visits were largely within 7 days (36, 42%) of discharge. Of the readmission encounters reviewed, only 19 were related to pneumonia (19.7%), while over 80% returned to the hospital for other reasons. Patients who were readmitted when compared to the control group were most likely to be Black (76%, 60%, respectively) and female (58%, 47%, respectively). The most common comorbidity in the readmission group was COPD (38.7%, 9.4%, respectively), whereas in the control group it was malignancy (33.9%, 53.7%, respectively).

CONCLUSIONS: At our large hospital network, nearly 1 out of 3 of our patients admitted for pneumonia return to the hospital within 30 days. Our study highlights at risk populations for pneumonia readmission at our institution are those who are Black, Female and/or have COPD. Special care and follow-up focused on pneumonia patients who fall into these high risk populations might result in decreased post-hospital readmissions.

ADVANCING HEALTH EQUITY THROUGH PARTNERSHIPS OF STATE MEDICAID AGENCIES, MEDICAID MANAGED CARE ORGANIZATIONS, AND HEALTH CARE ORGANIZATIONS

Anna L. Thorndike⁷; Lauren Peterson¹; Sivan Spitzer²; Shilpa Patel³; Anne Smithey³; Jennifer Moore^5,4; Marshall H. Chin⁶

¹Crown Family School of Social Work, Policy, and Practice, University of Chicago, Chicago, IL; ²Azrieli Faculty of Medicine, Bar-Ilan University, Tel Aviv, Israel; ³Center for Health Care Strategies Inc, Hamilton, NJ; ⁴Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI; ⁵Institute for Medicaid Innovation, Washington, DC; ⁶Department of Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ⁷University of Chicago Pritzker School of Medicine, Chicago, IL. (Control ID #3859661)

BACKGROUND: To reduce health inequities, care transformation to address medical and social needs, especially for marginalized populations including people with Medicaid insurance, should be supported and incentivized by payment reform methods. Further, collaboration across government agencies, managed care organizations, health care organizations, and communities is essential to overcome health system fragmentation and implement sustainable reform. This study examines how multi-stakeholder teams operationalized the Roadmap to Advance Health Equity model to (a) build cultures of equity and (b) integrate health equity into care transformation and payment reform initiatives.

METHODS: Advancing Health Equity: Leading Care, Payment, and Systems Transformation is a national program funded by the Robert Wood Johnson Foundation that brings together multi-stakeholder teams to design and implement initiatives to advance health equity. Each team consists of representatives from state Medicaid agencies, Medicaid managed care organizations, and health care organizations in seven U.S. states (DE, IL, ME, NJ, PA, TN, WA). Through didactic and technical assistance support, teams were encouraged to implement the Roadmap to Advance Health Equity model to build a culture of equity, identify a health equity focus, diagnose root causes of the health equity focus, implement care transformation, and reform payment to advance health equity. In 2021, semi-structured interviews were conducted with representatives (n=23) from all seven teams about experiences implementing the Roadmap. Interviews were coded for themes using NVivo Qualitative Data Analysis software.

RESULTS: Facilitators of building cultures of equity included 1) build upon preexisting intra-organizational cultures of equity, 2) recruit and promote diverse staff, and 3) train staff on health equity and anti-racism. Teams faced challenges building inter-organizational cultures of equity. Facilitators of identifying a health equity focus area and its root causes included 1) use data to identify health equity focus, 2) overcome stakeholder assumptions about inequities, and 3) partner with Medicaid members and community. Facilitators of implementing care transformation and payment reform were 1) tailor preexisting care delivery and payment structures to focus on health equity, 2) partner with Medicaid members and individual providers, and 3) incentivize equitable care transformation and payment reform. Facilitators of sustainability planning included 1) identify evidence of improved health equity focus and 2) maintain relationships among stakeholders. Teams faced challenges determining the role of the state Medicaid agency.

CONCLUSIONS: Multi-stakeholder teams shared practical strategies for implementing the Roadmap to Advance Health Equity that can inform future efforts to build intra- and inter-organizational cultures of equity and integrate health equity into care delivery and payment systems for Medicaid programs.

ADVERSE FINANCIAL OUTCOMES BEFORE AND AFTER COVID-19 INFECTION

Nora V. Becker¹; Carlton F. Erin⁶; Theodore Iwashyna²; John W. Scott⁴; Michelle H. Moniz³; John Z. Ayanian^5,1

¹Internal Medicine, University of Michigan, Ann Arbor, MI; ²Johns Hopkins University, Baltimore, MD; ³Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; ⁴Surgery, University of Michigan, Ann Arbor, MI; ⁵Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; ⁶Pediatrics, University of Michigan, Ann Arbor, MI. (Control ID #3874518)

BACKGROUND: Survivors of COVID-19 infection may experience financial hardship, and credit outcomes are increasingly recognized as a powerful way to assess patients’ financial wellbeing. Our objective was to compare credit outcomes between two cohorts of COVID-19 survivors, the first with credit outcomes measured before their infections, and the second with credit outcomes measured after their infections.

METHODS: We utilized medical claims from adult enrollees in a large state-level commercial insurance network linked to their Experian credit report data in January 2021. We identified two cohorts of COVID-19 survivors: a “post-infection” cohort with infections diagnosed during March-July 2020 (credit outcomes observed ≥6 months after infection), and a “comparison” cohort with infections diagnosed during February- October 2021 (individuals with credit outcomes observed prior to infection). The comparison cohort included individuals who had a COVID-19 infection, but whose credit outcomes could not have been affected by their infection because these outcomes were measured prior to infection. All patients with identified COVID-19 infections were characterized as either non-hospitalized or hospitalized for COVID-19.

Logistic regression models were used to compare financial outcomes between the post-infection and comparison cohorts. Primary outcomes included having medical debt in collections, non-medical debt in collections, or a low credit score (<660, range 300-850). All models adjusted for age group, gender, COVID-19 hospitalization, and four zip-code level covariates. All models included an interaction term between cohort and COVID-19 hospitalization to test whether changes in proportions of individuals with adverse credit outcomes between cohorts differed among patients who were hospitalized versus not hospitalized.

RESULTS: The study cohort included 132,109 patients with COVID-19 infections. We found significantly higher rates of adverse financial outcomes among individuals after COVID-19 infection compared with individuals prior to COVID-19 infection, and even greater increases among those hospitalized with COVID-19. Adjusted rates of adverse credit outcomes increased by 1, 1.7, and 3.5 percentage points for medical debt in collections, non-medical debt in collections, and low credit score for non-hospitalized COVID-19 patients, compared with absolute increases of 7.6, 6, and 9 percentage points for hospitalized COVID-19 patients, respectively (all p<0.001).

CONCLUSIONS: To our knowledge, our study is among the first to use credit report data to examine objective patient financial outcomes before and after COVID-19 hospitalization. We demonstrate that adverse financial outcomes were significantly more common among commercially-insured adults after compared to prior to COVID-19 infection, particularly among those hospitalized with COVID-19. Further research is essential to define the mechanisms of this association and design policies to improve financial outcomes for COVID-19 survivors.

AN EVALUATION OF RACE STRATIFICATION IN THE ATHEROSCLEROTIC CARDIOVASCULAR DISEASE POOLED COHORT RISK EQUATIONS USING A SEQUENTIAL MODELING STRATEGY

Arnab K. Ghosh¹; Sara Venkatraman¹; Monika M. Safford²; Parag Goyal³; Lisandro D. Colantonio⁴; Todd Brown⁴; Samprit Banerjee¹

¹Medicine, Weill Cornell Medical College, New York, NY; ²Department of Medicine, Weill Cornell Medical College, New York, NY; ³Medicine, Weill Cornell Medicine, New York, NY; ⁴Epidemiology, The University of Alabama at Birmingham, Birmingham, AL. (Control ID #3857055)

BACKGROUND: The 2014 atherosclerotic cardiovascular disease (ASCVD) Pooled Cohort risk equations (PCREs) employ race stratification. However, the use of race-specific risk prediction has been questioned due to increasing recognition of the specious relationship between race and the biology of disease, and that race differences in risk prediction may be a consequence of differences in social determinants of health (SDOH).

METHODS: We analyzed data from 13,198 REGARDS study participants aged 45-79 years, without ASCVD[SV1] [AG2] , and with low-density lipoprotein (LDL) cholesterol 70-189 mg/dL or non-high- density lipoprotein cholesterol (non-HDL-C) 100-219 mg/dL at baseline in 2003-2007. Participants were followed for up to 10 years for incident ASCVD, including myocardial infarction, coronary heart disease death, and fatal and nonfatal stroke. We analyzed the discrimination using C-statistics and calibration comparing observed to predicted events of the original PCREs based on baseline covariates. Then, we compared the discrimination and calibration of 3 versions of the PCRE: Model 1. Best-fit race stratified equations, Model 2. Best-fit equations without race stratification, and Model 3. Best-fit equations where race was replaced by indicators for SDOH.

RESULTS: Across all race-sex strata (Black females [BF], Black males [BM], White females [WF], and White males [WM]), C-statistics nor calibration did not improve after removal of race stratification in Model 2 (BF 0.7, 95% confidence interval [CI]: 0.67-0.74; BM 0.67, 95% CI: 0.63-0.71; WF 0.76, 95% CI: 0.72-0.79; WM 0.68, 95% CI: 0.65-0.7) nor after the addition of relevant SDOH variables in Model 3 (BF 0.72, 95% CI: 0.68-0.75; BM 0.68, 95% CI: 0.64-0.72; WF 0.76, 95% CI: 0.73-0.79; WM 0.68, 95% CI: 0.66-0.71) compared to Model 1 (BF 0.71, 95% CI: 0.68-0.74; BM 0.68, 95% CI: 0.64-0.72; WF 0.76, 95% CI: 0.73-0.79; WM 0.68, 95% CI: 0.65-0.71).

CONCLUSIONS: The removal of race-stratification from the PCREs is unlikely to impact performance, and thus the removal of race-stratified PCREs may be warranted

AN INNOVATIVE APPROACH TO COMBATING FOOD INSECURITY AT THE GRASSROOTS LEVEL

Shiva A. Nuti²; Vivek S. Patel²; Roshan B. Tom²; Jed Janecek²; Alicia Cano²; Jacob Alaniz²; Jenieve Chapa²; Nikhil Gogineni³; Sagar Kamprath¹

¹Department of Family Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX; ²The University of Texas Medical Branch at Galveston School of Medicine, Galveston, TX; ³Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX. (Control ID #3876689)

BACKGROUND: According to a nationwide database, our community has a food insecurity rate of 14.1%, higher than the national average of 11.8%. We hypothesize that though numerous nonprofits address food insecurity in our local community, our target population is largely unaware of them due to inadequate communication between the community and these existing nonprofits; and so naturally, one potential facet of the food insecurity issue in our city relates more to poor awareness rather than resource availability. To address this, we founded a student-led nonprofit where our focus is on community integration of existing food resources and direct delivery of food donations.

METHODS: Our organization is a nonprofit lead by 16 volunteers that connects underserved residents to food resources. We first identified 30 home-bound families who indicated that they were food insecure through established databases provided to us by free health clinics. We then collected goods in partnership with various nonprofits and major grocery chains. Furthermore, we compiled a comprehensive guide of available resources via online research to distribute during our food delivery drive. During our food drive, our goal was to connect these residents to existing resources and raise awareness about nearby resources to help bridge the gap between the underserved and those willing to help. Lastly, we distributed a survey to our residents, analyzing trends such as annual income, monthly rate of food scarcity, and their knowledge of organizations that can help.

RESULTS: We distributed a survey to our residents to determine the number of food-based organizations they were familiar with and then compare that number with the actual number of surrounding food-based organizations. We determined that in our city and its nearby areas, there are at least 11 food pantries, but our pilot survey (22/30 family responses) results show that a majority of our residents are scarcely aware of them - 16 families knew between 0-1 food organizations, and 6 families knew between 2-4 food organizations. This indicates that there is a gap between the available resources and knowledge of these resources among families.

CONCLUSIONS: Our organization behaves as a medium which facilitates communication and integration between the existing food-centric nonprofits and the population in need, thus bridging the knowledge gap regarding available resources.

To improve our organization, in the future, we would like to create a centralized database containing all of the available resources that encompass basic necessities ranging from food to medical care. Through this database, we can contact families about their needs and address them efficiently. Our goal of resource integration will be accomplished in partnerships with free clinics, churches, and volunteer physicians so that they can spread the word to the underserved. This model will hopefully reduce inefficiency in obtaining help in turn improving long-term health outcomes in our community.

A PILOT STUDY OF THE EFFECT OF PATIENT-PHYSICIAN LANGUAGE DISCORDANCE ON WEIGHT LOSS-RELATED OUTCOMES IN ADULT PATIENTS WITH OBESITY AND OVERWEIGHT ATTENDING A PHYSICIAN-SUPERVISED WEIGHT MANAGEMENT CLINIC IN NEW ENGLAND

Marina Spinelli¹; Varalakshmi Niranjan^2,1

¹University of Connecticut School of Medicine, University of Connecticut School of Medicine, Farmington, CT; ²Medicine, University of Connecticut, West Hartford , CT. (Control ID #3875158)

BACKGROUND: Patient-physician language concordance or discordance describes whether patient and physician speak the same or different languages. Several studies exploring patient-physician language concordance/discordance find worse health outcomes with discordance; others find no differences. To our knowledge, this study is the first investigating the relationship between patient-physician language concordance/discordance and weight loss. With obesity and overweight being prevalent and having serious comorbidities, we aim to understand impacts of patient-physician language concordance/discordance on weight loss and related outcomes.

METHODS: We randomly selected 80 language-concordant and 20 language-discordant patients (using documented “preferred language”) from the adults with obesity and overweight attending a physician- supervised weight management clinic in New England from January 2017 through August 2022. From chart review, we recorded weights and related variables, calculated changes from first to last visits, calculated mean changes for both groups, and compared group means by two-tailed independent Welch t-tests with alpha of 0.05.

RESULTS: Preferred languages were English (N=80), Spanish (N=17), Arabic (N=1), Punjabi (N=1), and American Sign Language (N=1). Analyses showed the following means (p-values) for the language- concordant versus discordant groups, respectively: number of appointments attended was 3.6 versus 2.8 (0.30); weight decreased by 2.5% (of initial) versus 1.5% (0.34); skeletal muscle mass decreased by 1.4% (of initial) versus 0.06% (0.06); body fat decreased by 1.5% versus 1.8% (0.76); systolic blood pressure increased by 0.2 mmHg versus 1.8 mmHg (0.47); diastolic blood pressure decreased by 1.6 mmHg versus 0.03 mmHg (0.47); hemoglobin A1c decreased by 0.13 versus 0.06 (0.81); total cholesterol decreased by 2 versus increased by 7 (0.20); LDL cholesterol decreased by 5 versus increased by 5 (0.09).

CONCLUSIONS: There were no statistically significant differences in weight loss or related outcomes between language-concordant and discordant groups. Lack of difference may reflect limited sample size and/or the clinic’s efforts (professional medical interpreters via telephone language lines, “after visit summaries” in preferred language, and culturally sensitive weight loss meal plans) to decrease potential impacts of patient-physician language discordance and potentially coexisting cultural differences. If further studies support that current practices effectively address potential impacts of patient-physician language discordance, the clinic should strive to continue these practices.

APPLYING CRITICAL RACE FEMINISM TO EXPLORE BARRIERS AND FACILITATORS TO POSTPARTUM PRIMARY CARE UTILIZATION AMONG BLACK WOMEN WITH CARDIOVASCULAR DISEASE RISK FACTORS: A QUALITATIVE STUDY

Serena M. Ogunwole¹; Habibat A. Oguntade²; Kelly M. Bower³; Lisa A. Cooper⁴; Wendy Bennett⁵.

¹General Internal Medicine, Johns Hopkins University, Baltimore, MD; ²University of Minnesota School of Public Health, Minneapolis, MN; ³Johns Hopkins University School of Nursing, Baltimore, MD; ⁴Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; ⁵Medicine, Johns Hopkins University, Baltimore, MD. (Control ID #3874253)

BACKGROUND: Black women with pregnancy complications, including excess gestational weight gain, gestational diabetes and hypertension, have a high risk for future chronic disease. Effective transitioning to primary care in the postpartum period may reduce chronic disease risk factors and thus improve racial disparities in maternal health and long-term health. Utilization of postpartum primary care is lower for Black (vs. White) women, but few studies have explored the unique experiences of Black postpartum women, while considering the intersecting influences of racism, sexism, and classism on their lived experiences. Our objectives are to: 1) identify barriers and facilitators to postpartum primary care utilization among Black women with cardiometabolic risk factor and 2) explore the cultural, social, and historical context that may influence postpartum primary care utilization among Black postpartum women with cardiometabolic risk factors.

METHODS: We recruited 18 Black women within one year of delivery with cardiometabolic complications prior to or during pregnancy (pre-pregnancy chronic hypertension, type 2 diabetes, obesity, preeclampsia, or

gestational diabetes) from early home visiting programs in Baltimore, Maryland. We conducted in-depth interviews from May 2020-June 2021. Two researchers trained in qualitative analysis conducted and analyzed the data. We created predetermined codes guided by critical race feminism theory and the research objectives. We used a hybrid inductive and deductive thematic analysis to identify codes and themes.

RESULTS: We identified eight main themes: 1) limited knowledge on the concept and need for postpartum primary care 2) gaps in care transitions and communication between the obstetric and primary care providers 3) pregnancy and childbirth as critical life experiences that influence postpartum health and future well-being 4) unique mental health and wellness needs that emerge postpartum 5) patient-provider relationship affecting care experiences 6) structural and personally mediated racism not explicitly articulated, but present and ubiquitous influences 7) intersectional experiences of Black motherhood/womanhood as sources of unique stress and resilience and 8) sociocultural ideals about health and healthcare influence care-seeking.

CONCLUSIONS: Black women’s experiences before, during, and after pregnancy provide valuable insights into facilitators and barriers to utilizing postpartum primary care. Interventions at the patient, provider, and system levels that are attentive to intersectional identities and lived expereinces, may promote health equity for Black women’s postpartum primary care and ultimately improve maternal and cardiovascular health.

A PRAGMATIC, STAKEHOLDER-INFORMED APPROACH TO PRIORITIZING SOCIAL RISKS FOR HEALTH CARE SYSTEM-BASED SCREENING AND INTERVENTION

Mayuree Rao^1,2; Matthew Maciejewski^3,4; Cindie Slightam⁵; Camila Chaudhary⁵; Karin Nelson^1,2; Donna Zulman^5,6

¹Health services research & development, VA Puget Sound Health Care System, Seattle, WA; ²Medicine, University of Washington, Seattle, WA; ³HSR&D, Durham VA Medical Center, Durham, NC; ⁴Duke University, Durham, NC; ⁵Health Services Research & Development, VA Palo Alto Health Care System, Palo Alto, CA; ⁶Medicine, Stanford University, Stanford, CA. (Control ID #3877272)

BACKGROUND: Screening for social risks – individual-level social and economic conditions – is increasingly common in clinical care. However, there exists little formal guidance on how to select among social risks for systematic screening within a health system.

METHODS: We developed and piloted a pragmatic approach for prioritizing social risks for screening

within a random sample of Veterans receiving care in the Veterans Affairs (VA) health care system. First, we identified social risks from existing screening tools and VA resources. Social risks were excluded if they did not meet our working definition of a social risk (from the US Preventive Services Task Force) or were not relevant to Veterans, based on duplicate review. Next, 15 VA stakeholders including researchers, operations leaders, and Veterans completed an online survey, rating the extent to which they perceived each social risk

1) impacts health outcomes, 2) impacts patient experience and 3) is actionable. Stakeholders were also asked to identify the 12 highest priority social risks. Survey results were presented to stakeholders during 2 hour- long meetings, serving as a basis for discussion of social risk prioritization. Finally, we used survey results and qualitative comments to identify high-priority social risks within and across criteria.

RESULTS: We identified 37 social risks, narrowed to 31 after exclusion based on definition and relevance to Veterans. Among the 31 social risks presented to stakeholders, discrimination experiences, health care access, housing instability, race/ethnicity, and transportation barriers were rated highly (i.e., were among the 12 highest rated social risks) across all 4 questions on the online survey. During discussion, stakeholders described challenges they faced in prioritizing social risks given varied clinical contexts; actionability was notably difficult to evaluate. Synthesizing the information from survey and discussion, we selected 21 high- priority social risks (Table).

CONCLUSIONS: Using a novel, pragmatic approach combining quantitative and qualitative data, we engaged diverse stakeholders to prioritize 21 social risks for health system-based screening and intervention.

This process highlights key criteria by which health care organizations may evaluate candidate social risks for systematic screening.

AREA DEPRIVATION AND WALKABILITY INFLUENCE CARDIOVASCULAR OUTCOMES AMONG INDIVIDUALS WITH HEART FAILURE WITH REDUCED EJECTION FRACTION Timothy M. Bober¹; Emily Guhl⁶; Scott D. Rothenberger²; Kwonho Jeong³; Kaleab Z. Abebe²; Amy Anderson²; Jared W. Magnani⁴; Bea H. Belnap²; Amber E. Johnson⁴; Bruce L. Rollman⁵

¹General Internal Medicine, UPMC Presbyterian-Shadyside, Pittsburgh, PA; ²Medicine, University of Pittsburgh, Pittsburgh, PA; ³Biostatistics, University of Pittsburgh, Pittsburgh, PA; ⁴Medicine, University of Pittsburgh, Pittsburgh, PA; ⁵Medicine, University of Pittsburgh, Pittsburgh, PA; ⁶Cardiology, Heritage Valley Health System, Sewickley, PA. (Control ID #3868804)

BACKGROUND: Neighborhood-level measures like Area Deprivation Index (ADI) and walkability are associated with increased cardiovascular disease (CVD) morbidity, higher utilization of health services, and mortality. We sought to understand the impact of these neighborhood-level factors on hospital readmissions and mortality among recently hospitalized depressed and non-depressed heart failure patients with reduced ejection fraction (HFrEF) enrolled in the NHLBI-funded Hopeful Heart Trial of telephonic collaborative care for HFrEF and depression in primary care.

METHODS: From 3/14-10/17, Hopeful Heart enrolled 756 hospitalized HFrEF patients (EF ≤45%) and NYHA class II-IV symptoms including 629 depressed (screen-positive 2-item Patient Health Questionnaire (PHQ-2) prior to discharge and score ≥10 on the PHQ-9 administered via telephone two weeks post- discharge) and 127 non-depressed HFrEF patients (PHQ-2 negative and PHQ-9 <5). We determined participants’ ADI score (0-100 scale, higher scores are worse) and Walk Score (0-100 scale, higher scores are better) using home addresses at the time of hospital discharge. We categorized participants into the top quartile (Q4) for ADI (most deprived) and Walk Score (most walkable) and then compared Q4 with all other quartiles (Q1-Q3). Methods included unadjusted nonparametric Kaplan-Meier analyses for survival curves, log-rank tests for differences in survival curves for 12-month mortality, and unadjusted Chi-Squared tests for 12-month readmission rate. Baseline depression status and treatment assignment did not predict readmission in our primary analysis and was not included in this subsequent analysis.

RESULTS: In all, 756 individuals with HFrEF participated (44% female; 73% white; mean EF: 28.3 +/- 9.1%) with mean ADI of 66.7 +/- 23.5 and mean Walk Score of 33.4 +/- 25.9. The mean PHQ-9 score for both ADI and Walk Score Q4 groups was similar to Q1-Q3. Participants in the Q4 group for worst ADI had a higher 12-month incidence of readmission that those in Q1-Q3 (81% vs. 70%, p=0.004), while those in Q4 for best Walk Score were readmitted at a similar level to QI-Q3. People in Q4 for ADI and Walk Score also had a similar 12-month incidence rates of cardiovascular (CV) (14% for Q4) and all-cause mortality (23% for Q4) versus Q1-Q3 quartiles.

CONCLUSIONS: Among a predominantly depressed cohort of people with HFrEF who enrolled in a clinical trial, worse ADI but not Walk Score is predictive of higher risk of 12-month hospital readmission. Neither ADI or Walk Score is predictive of 12-month CV or all-cause mortality. Further studies are needed to elaborate how neighborhood factors affect outcomes for people with heart failure such that interventions can be designed to address these disparities.

ASSESSING BARRIERS TO PRIMARY CARE FACED BY RESETTLED BHUTANESE REFUGEES THROUGH A QUALITATIVE ASSESSMENT

Amy Zheng¹; Swetara Joshi¹; Bhuwan Gautam²; Aditi Sharma²; Heather Costigan³; Morgan Loeffler³; Heather Stuckey³; Megan Mendez-Miller⁴; Tanuja Devaraj⁵

¹Penn State College of Medicine, Hershey, PA;²Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA; ³Qualitative and Mixed Methods Core, Penn State College of Medicine, Hershey, PA; ⁴Department of Family and Community Medicine, Penn State College of Medicine, Hershey, PA; ⁵Whitman Walker Health, Washington, DC. (Control ID #3872707)

BACKGROUND: The Nepali-speaking Bhutanese (NSB) community is one of the largest resettled refugee communities in the U.S. Resettled from 2007 to 2014, this population of 90,000 individuals has been reported to experience a high burden of chronic illness by several early studies. After almost a decade from their initial resettlement in the U.S, the NSB community continues to face disparities in health and challenges to receiving quality primary care. This study utilizes a qualitative approach to investigate the current barriers faced by the NSB community in receiving primary care.

METHODS: Participants who identified as NSB refugees were recruited from an Internal Medicine clinic at a tertiary medical center in Pennsylvania. Semi-structured interviews were conducted from August 2021 to March 2022. Questions reviewed demographics, socio-economic barriers, clinic visit experience, physician- patient relationship, care navigation and health beliefs. Interviews were conducted in Nepali, transcribed and coded via NVivo. Coded data were analyzed to identify significant emerging themes.

RESULTS: Eleven men and thirteen women participated in the study (N=24), with an average age of 50.3±17.8 years. The average number of years that participants spent in refugee camps was 18.5 years, and almost two-thirds (62.5%) of participants reported not completing high school. Major barriers identified included lack of communication in between appointments and miscommunication (e.g., abbreviated paraphrasing or dialectical differences) related to language interpretation. Many patients also described frustration with accessing appointments with their primary care physician, difficulty coordinating long wait times with other personal obligations, and lack of continuity of care with their providers. Positive facilitators to care involved helpful interpersonal relationships with staff and providers as well as strong family support (e.g., transportation, interpretation, scheduling appointments, and picking up medicine).

CONCLUSIONS: The resettled NSB refugee population faces unique experiences and barriers in primary care. Key considerations to provide effective primary care include language and culturally appropriate communication, continuity of care with primary care providers, and care navigation.

ASSESSMENT OF DEPRESSION AND ADHERENCE TO ORAL ANTICOAGULATION IN INDIVIDUALS WITH ATRIAL FIBRILLATION

Matthew Lapa³; Gretchen Swabe³; Jared W. Magnani^3,2; Matthew Muldoon³; Bruce L. Rollman¹

¹Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²Center for Research on Health Care, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; ³University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #3876000)

BACKGROUND: Depression is associated with decreased adherence to essential medication and poor clinical outcomes. However, there is a lack of literature investigating the association of depression with adherence to oral anticoagulants commonly prescribed to patients with atrial fibrillation (AF). We hypothesized that individuals with depression would have decreased adherence to direct-acting oral anticoagulants (DOACs) compared to those without.

METHODS: We analyzed claims from Optum’s de-identified Clinformatics® Data Mart Database to identify individuals with incident AF initiating either DOACs or warfarin between 2013-2019. We quantified adherence using proportion of days covered (PDC), categorized as limited (PDC <80%), adequate (PDC 80 to <90%), or optimal (PDC ≥90%). We used logistic regression to relate depression to 12-month adherence to anticoagulation in models adjusting for demographics, medical and psychiatric comorbidities, household income, educational attainment, and insurance type. We conducted a secondary analysis ascertaining adherence stratified by DOACs or warfarin between individuals with and without depression.

RESULTS: We identified 101,041 individuals (age 74.5±8.9, 49.3% female, 28.9% non-White) with a new diagnosis of AF who initiated anticoagulation. In those with depression (n=16,108) the odds of adequate adherence to DOACs was 0.89 (95% CI: 0.85-0.93) and optimal adherence was 0.88 (95% CI: 0.84-0.92) compared to individuals without depression. There was no difference in adherence to warfarin

CONCLUSIONS: Comorbid depression in individuals with AF is associated with around 11% to 12% lower adequate and optimal 12-month adherence respectively to DOACs. Recognizing depression as concomitant with AF may guide interventions to improve adherence to essential oral anticoagulants.

ASSOCIATION BETWEEN AGE AND HEALTHCARE UTILIZATION IN ADULTS WITH CRIMINAL LEGAL INVOLVEMENT (CLI)

Sanjay Bhandari¹; Laura Hawks²; Rebekah J. Walker³; Leonard E. Egede⁴

¹Internal Medicine, Medical College of Wisconsin, Milwaukee, WI; ²General Internal Medicine, Medical College of Wisconsin, Wauwautosa, WI; ³Medicine, Medical College of Wisconsin, Milwaukee, WI; ⁴Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3872186)

BACKGROUND: An exposure to the criminal legal system is associated with worse chronic disease control and increased healthcare utilization. While in the general population, older adults use acute and preventive services at higher rates than younger patients, little is known about the association between age and healthcare utilization in adults with CLI.

METHODS: Our sample included 37,279 US adults who participated in the National Survey of Drug Use and Health (2015–2019) and reported lifetime history of arrest or time spent on probation or parole. Our independent variable was age category: 18-49 years (younger adults); 50-64 years (middle aged adults); and 65+ years (older adults). Using negative binomial regression, we tested the association between these three age categories and healthcare utilization (ED, inpatient, and outpatient) controlling for relevant sociodemographic and clinical covariates.

RESULTS: Of the total participants, 59.9% were younger adults, 28.53% middle aged and 11.48% were older adults. Compared to the younger group, older adults were more likely to be male and identify as White race. Older adults had higher rates of most chronic noncommunicable diseases, but lower rates of past year substance use disorder or mental health condition. There were no difference in unadjusted mean number of ED visits between the three groups; older adults had more inpatient nights (1.2, 95% CI 0.9-1.4) than younger adults (0.5; 95% CI 0.4-0.5) and middle aged adults (0.8, 95% CI 0.7-0.9); there was a similar trend for outpatient visits. After adjustment, the older adults had lower frequency of ED visits (IRR 0.7, 95% CI 0.6-0.8) as compared to younger adults. The increased rate of inpatient utilization for older respondents compared to younger adults was completely attenuated in adjusted analyses (IRR 1.1; 95% CI 0.7-1.7). Middle aged respondents had higher outpatient utilization (IRR 1.1, 95% CI 1.1-1.2), whereas older adults had similar utilization pattern as compared to younger adults (IRR 1.0, 95% 0.9-1.1). Other independent predictors for higher acute healthcare utilization (ED visits and/or inpatient nights) included female gender, Black race, being widowed/divorced or never married, living in small- or non-metropolitan areas, insurance coverage by Medicaid or Medicare, and presence of various comorbidities.

CONCLUSIONS: Healthcare utilization patterns for adults with lifetime CLI are distinct, with younger and middle adults adults using more overall healthcare. After adjustment, younger adults are more likely to visit the ED than the older two groups, all three are equally likely to be inpatient and middle aged adults have highest rates of outpatient utilization. Interventions to reduce acute healthcare utilization in individuals with lifetime CLI should consider addressing the physical and behavioral health needs of young and middle aged adults with low education, low social support, residing in rural areas, and include multidisciplinary approach to manage their comorbidities.

ASSOCIATION BETWEEN FOOD INSECURITY IN YOUNG ADULTHOOD AND INCIDENT CARDIOVASCULAR DISEASE IN CARDIA: A LONGITUDINAL STUDY

Jenny Jia¹; Mercedes R. Carnethon²; Mandy Wong²; Cora E. Lewis³; Pamela Schreiner⁴; Namratha R. Kandula¹

¹Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ²Preventive Medicine, Northwestern University, Chicago, IL; ³Medicine, University of Alabama at Birmingham, Birmingham, AL; ⁴Epidemiology and Community Health, Regents of the University of Minnesota, Minneapolis, MN. (Control ID #3876822)

BACKGROUND: Food insecurity, a condition of inconsistent access to sufficient food for an active, healthy lifestyle, affects 1 in 10 Americans annually. Food insecurity is cross-sectionally associated with cardiovascular disease (CVD) and its risk factors, such as hypertension, obesity, and lifestyle behaviors. However, few studies have examined these relationships longitudinally.

METHODS: We included participants from the Coronary Artery Risk Development in Young Adults (CARDIA) study with food insecurity and other exposure data and no CVD event as of 2000-2001, baseline for this analysis. The primary exposure was food insecurity at year 15. Participants who endorsed “We have enough food to eat, but not always the kinds of food we want to eat”; “Sometimes we don’t have enough food to eat”; or “Often we don’t have enough food to eat” in the past year were categorized as having some food insecurity. The outcome was CVD events, a composite of coronary heart disease, stroke/TIA, heart failure, peripheral arterial disease and CVD death through August 31, 2020. Follow-up time was calculated as timefrom baseline to time at which CVD event was identified or censored at 2020. We used multivariable Cox proportional hazards models to estimate hazard ratios (HRs) and 95% CIs for incident CVD as a function of food insecurity, adjusted for age, sex, socioeconomic factors (education, marital status, income, and usual source of medical care), and race. We also assessed sex, education, and race as effect modifiers by including multiplicative interaction terms between the primary exposure and candidate modifiers in separate models.

RESULTS: In our sample of 3,626 adults at baseline, mean age was 40.2 years (SD 3.6), and 531 (14.6%) had some food insecurity. In those with some food insecurity, 360 (68%) identified as Black and 151 (31%) had household incomes <$16,000 per year, compared to 1341 (43%) and 184 (10%) in those with no food insecurity, respectively. Over 20 years of follow up, 272 CVD events occurred, with 208 (6.7%) in those with no food insecurity and 64 (12.1%) in those with some food insecurity. After adjusting for age, sex, and field center, food insecurity was associated with a greater risk of incident CVD (HR 1.46; 95% CI 1.09, 1.94). In subsequent models, this association was attenuated after adjusting for socioeconomic factors (HR 1.14; 95% CI 0.83, 1.58) but not appreciably different after further including race (HR 1.09; 95% CI 0.72, 1.65). We found no interactions between food insecurity and sex, education, or race in the relationship between food insecurity and incident CVD.

CONCLUSIONS: In CARDIA, food insecurity in young adulthood was not associated with CVD events in middle adulthood, after accounting for other socioeconomic factors. This relationship did not vary by sex, education, or race. Food insecurity appears to be a marker of socioeconomic status and is a useful single measure in screening for social determinants of health in clinical settings.

ASSOCIATION BETWEEN GOVERNMENTAL SPENDING ON SOCIAL SERVICES AND HEALTH CARE USE AMONG LOW-INCOME MEDICARE BENEFICIARIES

Carlos Irwin Oronce^3,1; Ninez A. Ponce²; Catherine Sarkisian^3,1; Yusuke Tsugawa^1,2

¹General Internal Medicine & Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA; ²Health Policy and Management, UCLA School of Public Health, Los Angeles, CA; ³Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA. (Control ID #3870245)

BACKGROUND: Low-income older adults experience a high burden of adverse social risk factors that contribute to worse access to primary care, frequent hospitalizations, and higher mortality. Governmental programs and social services mitigating these risks may lead to better outcomes. This study aims to evaluate the effect of county-level social spending on health care outcomes of dual-eligible Medicare beneficiaries.

METHODS: We analyzed a 20% random sample of Medicare beneficiaries 65 years and older dually enrolled in Medicaid from 2016 through 2018 linked to county-level governmental expenditures data from the US Government Finance Database. Four types of social spending comprised the exposures of interest: per capita spending on (1) public welfare, (2) housing and community development, (3) public transit, and (4) infrastructure. Outcomes included annual rates of primary care visits, emergency department (ED) visits, and preventable hospitalizations. We used separate multivariable negative binomial regression models with standard errors clustered at the county to measure the association between spending type and beneficiary- level outcomes, adjusting for individual and county covariates.

RESULTS: The analytic sample consisted of 607,857 low-income Medicare beneficiaries residing in 3,121 counties (mean age, 78.0 [SD 9.0] years; 66.1% female). Median county social spending in the four categories was $533 per capita (range: $312 to $1,016). On average, dual-enrollees had 3.5 (SD 3.8) primary care visits, 2.0 (SD 3.5) ED visits, and 0.2 (SD 0.5) preventable hospitalizations per year. After adjustment, higher welfare spending was associated with 12% higher primary care visits (adjusted incidence rate ratio [IRR] comparing the highest vs. lowest quintiles, 95% CI 1.04–1.20), 6% lower ED visits (IRR 95% CI 0.89–0.99), 8% lower preventable hospitalizations (IRR 95% CI 0.87–0.97) and 28% lower preventable hospitalizations from acute conditions (IRR 95% CI 0.75–0.90) per year. We observed that higher housing and community development spending was associated with 15% higher primary care visits (IRR 95% CI 1.07–1.23), 8% lower preventable hospitalizations (IRR 95% CI 0.87–0.98), and 14% lower preventable hospitalizations from acute conditions (IRR 95% CI 0.79–0.93) per year. Higher public transit spending was associated with 8% lower preventable hospitalizations (IRR 95% CI 0.88–0.96) and 14% lower preventable hospitalizations from acute conditions (IRR 95% CI 0.81–0.91) per year. Living in the highest quintile of infrastructure spending was not associated with any outcomes.

CONCLUSIONS: In a national sample of low-income Medicare beneficiaries, greater governmental spending on welfare, housing and community development, and public transit was associated with increased rates of primary care use and lower rates of acute care utilization. Public investments that address health- related social needs of low-income older adults may facilitate access to outpatient services while reducing costly acute care.

ASSOCIATION BETWEEN SOCIAL RISK PROFILES AND CLINICAL OUTCOMES IN ADULTS WITH TYPE 2 DIABETES: A LATENT PROFILE ANALYSIS

Rebekah J. Walker¹; Joni S. Williams²; Sebastian Linde³; Leonard E. Egede⁴

¹Medicine, Medical College of Wisconsin, Milwaukee, WI; ²Medicine, Medical College of Wisconsin, Milwaukee, WI; ³Medicine, Medical College of Wisconsin Department of Medicine, Milwaukee, WI; ⁴Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3876193)

BACKGROUND: Recent evidence suggests combining medical care with interventions that target social risk factors can improve health outcomes for adults with diabetes. However, no clear process exists for identifying how best to categorize social risks in a way that informs effective intervention development. In addition, it is unclear if combinations of different risks are important to target concurrently as opposed to addressing risks separately.

METHODS: The aim of this analysis was to investigate social risk profiles and associations of those profiles with clinical outcomes in adults with diabetes using latent profile analysis. 615 adults with diabetes completed validated questionnaires for 26 social risk factors within six domains of social determinants of health: socioeconomic, neighborhood and built environment, education access and quality, food environment, social and community context, psychological risk, and behavioral risk. A three-step latent profile analysis was used to identify different subgroups within the sample using Stata v16. Continuous variables were created for each social risk indicator. First, 2, 3, 4, 5, 6, and 7-class profiles were investigated with a 5-class profile identified as the best fit profile based on AIC and BIC scores. Second, posterior probability was used to classify individuals into their true latent class, with accuracy of classification determined by entropy score (0.94). Finally, based on marginal probabilities, we tested the profiles against the outcomes of HbA1c, blood pressure, and quality of life.

RESULTS: Five latent class profiles were identified. The lowest risk group accounted for 36% of the sample and had limited social risk but indicated concerns about their neighborhood. This group had significantly higher mental health related quality of life compared to the other four groups. The second group accounted for 34% of the sample and had overall low risk, but considered their neighborhoods to have low aesthetics, low food access, and high social isolation. This group had significantly higher blood pressure. Group 3 accounted for 6% of the sample and had high social risk in terms of neighborhood crime, violence, and financial instability but low psychological and behavioral risk. The fourth group accounted for 14% of the sample and had high psychological and behavioral risks but low socioeconomic and neighborhood risks. This group had significantly higher HbA1c (0.5%) and lower mental health related quality of life. The highest risk group accounted for 8% of the sample and indicated high risk in all domains. This group had significantly higher HbA1c (1%) and lower mental health related quality of life.

CONCLUSIONS: Social risk profiles can be identified that can guide development and implementation of interventions based on the social determinant domain of highest risk and the health outcome of concern in adults with diabetes.

ASSOCIATION OF FOOD INSECURITY AND CARDIOMETABOLIC DISEASE IN PATIENTS OF FEDERALLY-QUALIFIED HEALTH CENTERS: A CROSS-SECTIONAL STUDY

Jenny Jia¹; Andrew L. Owen²; Matthew J. O'Brien²

¹Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ²Center for Community Health, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #3876746)

BACKGROUND: Federally qualified health centers (FQHCs) are important sources of accessible medical care to low-income families in underserved areas. Many low-income families are affected by food insecurity, which is associated with chronic cardiometabolic diseases requiring primary care. Few studies have explored whether the association between food insecurity and cardiometabolic diseases exists in FQHC patients and whether it varies by sex.

METHODS: We included adult patients from community health centers in the Alliance of Chicago Community Health Services national network who were screened for food insecurity from 2017 to 2021. We measured the primary exposure, food insecurity, using the 2-question Hunger Vital Signs, categorizing responses of “yes,” “sometimes true,” and “often true” to either question at any time point as food insecure and “no,” “never true,” and “does not apply” at all time points as food secure. Outcomes were prevalent diabetes/prediabetes and cardiovascular disease (CVD), which we measured using diagnostic codes from electronic health records. To study the association between food insecurity and clinical outcomes, we used multiple logistic regression with food insecurity and sociodemographic covariates on the presence of each clinical outcome. In interaction models, we included multiplicative interaction terms between food insecurity and sex for each clinical outcome. We set statistical significance at α=0.05.

RESULTS: Our sample included 221,284 adult patients, 66% female, with mean age 36 years (SD 17.6). Food insecure patients, who accounted for 9% (n=20,460) of the sample, were more likely than food secure patients to identify as Black (49% vs. 41%) and less likely to have private health insurance (8% vs. 14%). In age- and sex-adjusted models, food insecurity was associated with diabetes/prediabetes (aOR= 1.09, p<0.001) and CVD (aOR=1.10, p<0.01). After further adjusting for health insurance, language, and race, which acted as a proxy for social determinants of health, food insecurity was associated with diabetes/prediabetes (aOR=1.07, p<0.01) but not with CVD (aOR=1.04, p>0.05). The interaction between food insecurity and sex on diabetes/prediabetes was significant, and food insecurity had a greater association with diabetes/prediabetes in women (aOR=1.17, p<0.001) than men. No interaction was found with CVD.

CONCLUSIONS: In a national sample of FQHC patients, food insecurity was associated with diabetes/prediabetes; this association was stronger in women than men. The association between food insecurity and CVD was null after accounting for proxies of social determinants of health. The magnitudes of these associations were lower than in prior similar studies in general populations, suggesting that further research should explore the interaction of social determinants of health and access to and use of FQHCs.

ASSOCIATION OF HIGH SENSITIVITY C-REACTIVE PROTEIN LEVELS WITH ELECTRONIC CIGARETTE USE COMPARED TO TRADITIONAL CIGARETTE, DUAL USERS, AND NON- SMOKERS AMONG US ADULTS.

Judith Gutierrez, Jacqueline Hirth, Roger Zoorob

Family and community medicine, Baylor College of Medicine, Houston, TX. (Control ID #3860528)

BACKGROUND: The use of electronic cigarettes (EC) has exponentially increased since their introduction to the US market in 2007, especially among young adults. Smoking is known to increase the risk of cardiovascular disease, but information on the impact of EC use on the cardiovascular (CV) system remains scarce. The purpose of this study is to evaluate differences in high sensitivity C-reactive protein (hs-CRP) levels, as a surrogate measure of cardiovascular risk, among EC users, traditional tobacco smokers (TTS), dual EC, and TTS as compared to non-smoking adults.

METHODS: This is a population-based secondary analysis of cross-sectional data from the country-wide representative, National Health and Nutrition Examination Survey (NHANES), which included data collected between 2016 and 2018. Each cycle, conducted across 2-year intervals, consisted of demographic, dietary,

and health-related data as well as a medical examination component in which physiological measurements are taken. We included all participants 21 to 60 years old in this study. Self-reported smoking and EC use were considered. Smoking status and nicotine-containing EC use were confirmed through serum cotinine levels. Serum hs-CRP was measured among patients who agreed to medical exam and blood draw. In addition to evaluating hs-CRP levels as continuous outcomes, we also created cutoff points that indicate low and moderate/high levels. Analyses were conducted using weights, clusters, and strata according to NHANES instructions to provide nationally representative estimates. Poisson regression was used to test the association between smoking and/or EC use and hs-CRP. Models were adjusted for covariates (age, gender, race/ethnicity, BMI, Diabetes, and hypertension).

RESULTS: A total of 6,219 participants were included. Low-level hs-CRP, indicating low CV risk, was present in 1,959 (32%) participants, and 4,260 (68%) had moderate/high CV risk. For nicotine product use, we found 508 (8%) smoked, 677 (11%) used ECs only, 823 (13%) both smoked and used ECs, and 4,211 (68%) were non-smokers. Smokers had the highest CV risk as indicated by hs-CRP [IRR=2.17 (95% CI= 2.17-2.18), p<0.001], and by dual smokers and EC users [IRR=2.17 (95% CI= 2.16-2.17), p<0.001], compared to non-smokers. E-cigarette smokers had a lower risk than both traditional and dual smokers, however, the risk was higher than non-smokers [IRR=2.08 (95% CI= 2.07-2.08), p<0.001].

CONCLUSIONS: Traditional tobacco and dual smoking are associated with increased CV risk, as indicated by hs-CRP. E-cigarettes are associated with lower CV risk than traditional smokers and dual smokers, but the risk is still higher than non-smokers.

ASSOCIATIONS BETWEEN SOCIAL DETERMINANTS OF HEALTH AND TOTAL HEALTHCARE COST IN AN INTEGRATED DELIVERY NETWORK

Ariel R. Silverman, Mark Duggan, Paul J. Chung, Robert Nocon

Health Systems Science, KaiserPermanente Bernard J Tyson School of Medicine, Pasadena, CA. (Control ID #3869414)

BACKGROUND: The U.S. is increasingly recognizing impacts of social risks on health and other outcomes. Meanwhile, healthcare costs are astronomically high, yet have not shown improved outcomes compared to peer nations with lower healthcare spending. Although social risk is widely believed to contribute to healthcare cost, this association has not yet been firmly established in a general population, as most research has focused on small, disease-specific populations or patients with high cost and high medical need. Additionally, research in this area has been challenging as there has not yet been standardized widespread adoption of social determinants of health (SDoH) screening. This study aims to identify associations between patient-reported social risk and total healthcare cost in an organization-wide sample of Kaiser Permanente (KP) members.

METHODS: A survey conducted by KP Social Needs Network for Evaluation and Translation (SONNET) was administered in 2020. Patients from all 9 states were surveyed using stratified sampling with oversampling for patients residing in census blocks with median household incomes at or below the 25^th percentile, Medicaid members, and applicants for financial assistance. The survey asked about a subset of SDoH including financial, housing, food, and transportation needs from the prior year. Survey data were linked to administrative electronic health record data including demographics, medical risk, and total direct healthcare cost for all services paid for by the health plan from 2019. Multivariable negative binomial regressions were performed to determine associations between social risk and total cost controlling for medical risk using DxCG, a widely used risk adjustment tool, and demographic variables.

RESULTS: Survey responses from 10,226 members were collected (23% response rate). Respondents were categorized into groups of no, moderate, or severe social risk based on existing literature, local operational team subject matter experts, and response to Likert-style questions. In a model without medical risk, moderate and severe risk were associated with healthcare cost 13% (p=0.02) and 48% (p<0.001) higher, respectively, than no risk, controlling for demographic covariates such as age group, gender, race, and region. When medical risk was added to the model, a 10% increase in medical risk was associated with 2.8% higher total cost (p<0.001), but the association between social risk and total cost was attenuated.

CONCLUSIONS: These results demonstrate a positive relationship between social risk and total healthcare cost, while confirming that medical risk is a potentially powerful mediator of this relationship. Further research is needed to better understand how medical risk might mediate the relationship, as well as potential impacts of social risk interventions. As payers, insurers, and providers build strategies to invest in SDoH at a broader scale, it is essential that we better understand relationships between social risk and healthcare cost.

AUTOMATED IDENTIFICATION AND DESCRIPTIVE ANALYSIS OF PATIENTS’ UNMET SOCIAL NEEDS IN CLINICAL TEXT: A CASE REPORT

Jane Njeru¹; Sungrim Moon²; Jay B. Doughty⁴; Mark L. Wieland¹; Jungwei W. Fan^2,3

¹Division of Community Internal Medicine, Geriatrics and Palliative Care, Mayo Clinic Minnesota, Rochester, MN; ²Department of Artificial Intelligence & Informatics, Mayo Clinic Minnesota, Rochester, MN; ³Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic Minnesota, Rochester, MN; ⁴Health Care Administration, Mayo Clinic Minnesota, Rochester, MN. (Control ID #3874360)

BACKGROUND: Social determinants of health (SDoH) influence health-related social needs, and are associated with suboptimal access to timely care, poor control of chronic diseases, and gaps in preventive care. Identifying patients with concomitant medical and social complexity is pivotal to funneling finite resources to address the needs of patients at the highest risk. However, systematically identifying patients who need assistance is difficult, and while data on medical comorbidities and prior healthcare utilization is easily accessible through electronic health records (EHR) and administrative databases, data on social complexity and unmet social needs are often buried in unstructured clinical text. The goal of this project was to develop natural language processing (NLP) solutions for identifying patients’ unmet social needs to facilitate referral to a community health worker (CHW) program for resource alignment.

METHODS: We sampled clinical notes and portal messages of 200 age/sex-stratified patients, retrieved from electronic health records. The base cohort consisted of adult patients seen at a large academic primary care practice in the midwest over a two-year period and referred to the CHW program for unmet social needs. Two nurse abstractors annotated five domains of unmet social needs in the clinical text. The annotations served as the gold standard for developing and evaluating a similarity- and a rule-based NLP program. We first explored a sentence similarity approach for efficiency of detecting the unmet social needs, and for comparison, a rule-based NLP algorithm was developed to identify the five domains of unmet needs. We evaluated the performance of both the approaches in identifying each as well as any of the five domains. Precision, recall, and F1-score were computed on the test set. Error analysis was performed at the patient level.

RESULTS: During the calibration stage, the two abstractors dually annotated 1,055 clinical notes and 100 portal messages. The annotated cohort consisted of 5,675 clinical notes and 475 portal messages, with an estimated kappa statistics agreement of 0.938. Among the 200 patients, 168 (84%) had at least one domain of the unmet needs annotated. The similarity- and rule-based NLP achieved an F1-score of 0.91 and 0.95, respectively. Patients identified through this AI/NLP algorithm will be referred to a CHW program for resource alignment related to the unmet need.

CONCLUSIONS: The clinical text contains rich information about patients’ unmet social needs. NLP can achieve satisfactory performance in identifying those needs and candidates for CHW referral.

BARRIERS AND FACILITATORS TO ACCESSING AND MAINTAINING PERMANENT SUPPORTIVE HOUSING FOR PEOPLE EXPERIENCING HOMELESSNESS WITH HIGH HEALTH NEEDS

Emily Scott¹; Thomas W. Gray³; Emma Allen-Morgan⁴; Alyssa Boral³; Sarah A. Stella²

¹Department ofMedicine, University of Colorado, Denver, CO; ²Department of Medicine, Denver Health, Denver, CO; ³Office of Research, Denver Health, Denver, CO; ⁴Quality Assurance, Colorado Coalition for the Homeless, Denver, CO. (Control ID #3875834)

BACKGROUND: People experiencing homelessness (PEH) have a large burden of both acute and chronic disease, and increased mortality rates compared to housed populations. A subset of PEH experience exceptionally high levels of unmet physical and behavioral health needs resulting in frequent utilization of high cost medical and other services. Permanent supportive housing is a critical foundation for addressing health and health-related social needs, yet PEH with high health needs may face additional barriers to accessing housing.

METHODS: We conducted semi-structured interviews with clients following entry into permanent supportive housing, and homeless service providers involved in the permanent housing process in the Mountain West region. Participants were recruited via snowball sampling through community and academic partners for both providers and clients. Interviews aimed to assess client and provider perspectives on barriers and facilitators to accessing and maintaining housing within our local coordinated entry system. Interviews were conducted by trained research staff using an interview guide. Interviews were audio-recorded, transcribed, and de-identified. Transcripts were coded in Atlas.ti and themes were inductively derived using grounded theory.

RESULTS: Interviews were completed with 15 service providers and 14 recently housed clients. Themes regarding the housing process for clients with high health needs included: 1) PEH with high health needs face increased barriers in accessing and navigating the coordinated entry system for housing services; 2) the standard assessment tool (i.e., VI-SPDAT) used to prioritize clients for housing does not adequately capture the vulnerability of many high needs clients, especially those with cognitive impairment; and 3) PEH with high needs are often placed with an inadequate level of support due to a lack of availability, have needs that exceed the level of care offered by the system, and/or experience housing loss rooted in a mismatch between client needs and preferences and services available. Recommendations for improvement included: 1) start the coordinated entry process during medical encounters (eg. hospitalizations) to improve access for PEH who frequently use medical services; 2) develop processes to utilize care team perspectives and existing contextual health data (in addition to self-report) to inform housing prioritization; and 3) partner with external agencies to address care gaps in supportive services in permanent housing.

CONCLUSIONS: PEH with the highest health needs face multiple barriers to permanent supportive housing and our findings highlight opportunities for improving the housing process for this at-risk group.

BEYOND SCREENING AND REFERRAL: A PRAGMATIC FRAMEWORK FOR HEALTH CARE SYSTEMS TO DETERMINE THE ACTIONABILITY OF SOCIAL RISKS

Mayuree Rao^1,2; Matthew Maciejewski^3,4; Karin Nelson^1,2; Leah M. Marcotte²; Donna Zulman^6,5

¹Health services research & development, VA Puget Sound Health Care System, Seattle, WA; ²Medicine, University of Washington, Seattle, WA; ³HSR&D, Durham VA Medical Center, Durham, NC; ⁴Duke University, Durham, NC; ⁵Medicine, Stanford University, Stanford, CA; ⁶Health Services Research & Development, VA Palo Alto Health Care System, Palo Alto, CA. (Control ID #3877226)

BACKGROUND: While health systems are increasingly screening patients for social risks, determining how to meaningfully address social risks identified through screening can be a challenge. Few frameworks exist to guide health system action in response to social risks.

METHODS: We conducted a narrative review of English-language literature indexed in PubMed from 2000 to 2021 that describes and classifies health system activities to address social risks. Based on critical appraisal and synthesis of the literature, we developed a pragmatic framework to characterize actionability of social risks within health systems.

RESULTS: The framework highlights 4 dimensions of social risk actionability: level of action, actor, purpose, and action (Figure). First, social risks can be addressed at several levels (e.g., during a patient’s visit, at the practice/institution level through programs, and at the community level through partnerships). Second, health system staff, or “actors” (including health professionals with direct patient contact, clinical and institutional leaders, and researchers) can take action in different ways depending on their role. Third, intervention on social risks can serve one or more purposes: to strengthen relationships with patients, tailor care, modify the social risk itself, and/or facilitate population health surveillance, research, and advocacy. Finally, specific actions on social risks vary by level, actor, and purpose. For example, at the encounter level, a primary care provider may schedule telehealth appointments for the purpose of tailoring care for a patient with a transportation barrier. At the institution level, an administrator may implement a program to provide transportation to medical appointments to reduce transportation barriers for all patients. At the community level, institutional leaders may advocate for public transit investment.

CONCLUSIONS: Drawing from the literature, the proposed framework offers a novel, structured approach to identify existing and potential actions to address social risks, for multiple purposes and across different roles and levels within a health care organization.

BUNDLING COLORECTAL CANCER SCREENING OUTREACH WITH SCREENING FOR SOCIAL RISK IN FEDERALLY QUALIFIED HEALTH CENTERS: A STEPPED-WEDGE IMPLEMENTATION-EFFECTIVENESS PILOT STUDY

Sanja Percac-Lima²; Gina R. Kruse¹; Daniel Gundersen³; Lynette Mascioli⁵; Deepinder Singh⁶; Mehezbin Munshi⁵; Karen Emmons⁴; Jennifer Haas^1,2

¹Medicine, Massachusetts General Hospital, Boston, MA; ²Division of General Internal Medicine, Massachusetts General Hospital, Boston , MA; ³Dana Farber Cancer Institute, Boston, MA; ⁴Harvard University T H Chan School of Public Health, Boston, MA; ⁵Massachusetts League of Community Health Centers, Boston, MA; ⁶University of Vermont Larner College of Medicine, Burlington, VT. (Control ID #3876061)

BACKGROUND: Bundling outreach for colorectal cancer (CRC) screening with screening for social determinants of health (SDOH) may enable patients to engage in preventive care by addressing SDOH and produce efficiencies in resource-constrained settings.

METHODS: In this clustered stepped-wedge trial, four Massachusetts federally-qualified health centers (FQHCs) were randomized to start implementation of a bundled outreach intervention over 8-week “steps” (10/2020-11/2021). The intervention consisted of outreach to 50-75 yr-olds not up-to-date on CRC screening to offer home fecal immunochemical testing (FIT) and SDOH screening. The implementation strategy used external facilitation and technical assistance for data reporting for each FQHC over two phases: 1) initial implementation (months 1-4) and 2) intervention adaptation guided by data to identify inequities in reach and effectiveness (months 5-8). The primary outcome was CRC screening completion by any guideline- recommended method. We compared screening rates in intervention and control FQHCs in each step by fitting generalized linear mixed effects models with random intercepts for FQHCs and patients to account for clustering of observations within FQHCs and multiple measurements among patients.

RESULTS: Each FQHC had a slightly different model of implementation and outreach depending on their unique infrastructure, workflows, capacity and pandemic-related staffing demands. Two implemented the pilot using population health approaches with outreach calls and two integrated the intervention within established teams and projects, such as pairing with high-risk patient community health worker programs and pre-visit planning. Of 32,524 unique patients who were not up-to-date with CRC screening in the 4 FQHCs, 53% were female; 22% Black, 14% Latino, 12% Asian, and 52% white; 48% were on public insurance, 33% private insurance, and 11% uninsured. The average rate of CRC screening completion was higher among intervention FQHCs than among control FQHCs. The odds ratio comparing CRC screening orders in intervention to control FQHCs was 2.5 (p<0.001), with an average marginal effect of 3 percentage point increase in CRC screening. A sensitivity analysis excluding pre-covid baseline periods found a slight attenuation of the effect but the same sign and significance at p<0.05.

CONCLUSIONS: This bundled intervention represents an effective, population-based solution to increase the delivery of cancer screening with consideration of the impacts of individual social risks. This strategy has potential to ameliorate CRC screening deficits associated with the pandemic.

BUT WHAT DOES INCLUSION LOOK LIKE?: INSIGHTS FROM HOSPITALISTS

Ashley Jenkins^1,2; Maya Narayanan³; Anne S. Linker⁴; Amelita Woodruff⁵; Archna Eniasivam^6,7; Benji Mathews⁸; David Sterken³; Gopi Astik⁹; Michelle Fletcher⁹; Nila Radhakrishnan¹⁰; Marisha Burden¹¹; Sarah Saari¹²; Andrew Auerbach⁶; Adriana Dhawan⁸; Areeba Kara¹³

¹Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY; ²Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY; ³University of Wisconsin-Madison, Madison, WI; ⁴Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ⁵Johns Hopkins Medicine, Baltimore, MD; ⁶Medicine, University of California San Francisco, San Francisco, CA; ⁷Pediatrics, University of California San Francisco, San Francisco, CA; ⁸University of Minnesota Medical School Twin Cities, Minneapolis, MN; ⁹Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ¹⁰Medicine, University of Florida, Gainesville, FL; ¹¹Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ¹²University of Washington, Seattle, WA; ¹³Department of Medicine, Indiana University School of Medicine, Indianapolis, IN. (Control ID #3861003)

BACKGROUND: Hospitalists often serve marginalized patients and have system-wide influence to promote diversity, equity, inclusion, and justice (DEIJ). Inclusion in particular has definition variability and no clear metrics of ‘success’. We sought to describe hospitalists’ perspectives about what constitutes an inclusive work environment.

METHODS: We conducted a rapid thematic analysis of open-ended questions from a cross-sectional electronically disseminated survey study examining DEIJ efforts in US hospital medicine groups. Survey participants were recruited from members of a US hospital medicine research collaborative in May 2021. Respondents were asked to elaborate upon survey item ratings (5-point Likert scale) related to their hospital medicine group’s inclusivity. Responses were summarized in a matrix and stratified by rating to allow for thematic analysis by a priori defined levels of self-rated inclusivity. High inclusivity (HI) contained extremely or moderately inclusive ratings. Low inclusivity (LI) comprised somewhat or not at all inclusive ratings.

RESULTS: Of the 436 respondents, 332 (76.5%) rated their site as having HI, 102 (23.4%) described their sites as having LI. 139 (32%) responded to the open-ended questions. Four themes emerged that informed perceptions of inclusion (Table): tangible efforts, diversity of the group, leadership, and personal experience and the workplace culture.

CONCLUSIONS: Frontline hospitalists identified investment in tangible efforts to further DEIJ for clinicians and patients as a necessary aspect of an inclusive hospital medicine group. Diversity within the ranks and leadership is valued as a marker of inclusivity. Workplace culture and day-to-day patient care experiences need alignment with the values of inclusion. Leaders play a significant role in furthering or thwarting these efforts.

CANCER INCIDENCE AMONG A SOMALI IMMIGRANT POPULATION IN MINNESOTA Ahmed A. Mohamed¹; Alanna M. Chamberlain²; Gregory Jenkins²; Lila J. Rutten^3,4; Jane Njeru¹; Mark L. Wieland¹

¹Department of Medicine, Mayo Clinic Minnesota, Rochester, MN; ²Quantitative Health Sciences, Mayo Clinic Minnesota, Rochester, MN; ³Exact Sciences Corporation, Madison, WI; ⁴Mayo Clinic Minnesota, Rochester, MN. (Control ID #3876771)

BACKGROUND: Somali immigrants and refugees constitute one of the largest African groups settling to the United States over the past three decades with the majority resettling in the state of Minnesota. In our primary care practice, we have documented significant disparity gaps in cancer screening among Somali patients compared to the general population. However, there is little known about cancer incidence among Somalis living in the US.

The objective of this study is to investigate cancer incidence among Somali patients as compared to non- immigrant patients in Olmsted County utilizing the Rochester Epidemiology Project (REP) medical records- linkage infrastructure.

METHODS: We determined the incidence of each cancer diagnosis using ICD-9 and ICD-10 codes and compared them between Somali and non-Somali populations during the years 2000-2020 in Olmsted County.

A person was defined as Somali if one or more of these conditions were met:

- one or more their records indicated that Somali was their country of origin

- one or more of their records indicated that they speak Somali

- one or more of their records indicated Somali race or ethnicity

- the text string “Somali” was found in a visit note from Olmsted Medical Center

Poisson regression was used to model the rate of a particular malignancy predicted by: year, age, gender and Somali descent. Relative risks for malignancy comparing Somali to the non-Somali Olmsted County population were calculated from the Poisson regression models.

RESULTS: Malignancies with statistically significant higher or lower incidence among Somali patients versus non-Somali patients are shown in Table 1. Liver and gastric malignancies have a higher incidence while hematologic, breast, cervical, lung, and melanoma have a lower incidence among the Somali population.

CONCLUSIONS: Malignancies related to infectious agents such as viral hepatitis have a higher incidence and prevalence in the Somali immigrant population of Olmsted County. Viral hepatitis is prevalent in the Somali population and is associated with hepatocellular carcinoma. Therefore, screening for and treating viral hepatitis can help reduce the incidence of liver cancer. There is a lower incidence and prevalence of malignancies related to lifestyle factors in the Somali population. Future studies on acculturation and cancer incidence in this population to evaluate this further are needed.

CAN HEALTH CONFIDENCE HELP PREDICT HOSPITAL LENGTH OF STAY OR READMISSION?

Ashley E. Brown, David O. Meltzer

Hospital Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #3873979)

BACKGROUND: It is well established that patients who are engaged or “activated” in their healthcare have better health outcomes and patterns of healthcare utilization. Additionally, patient activation may be associated with a range of socioeconomic factors affecting health outcomes and utilization. The Health Confidence Score (HCS) is a recently created tool that simply measures a component of health activation, health confidence. The HCS is a four-question survey at a basic literacy level, making it well-suited to monitor patient engagement within socio-economically vulnerable populations. We aim to understand if health confidence can help predict hospital readmission and length of stay.

METHODS: This prospective cohort study was performed at an urban academic medical center in the Midwest. The HCS was administered, as a part of a larger ongoing survey, to a sample of all inpatients admitted to the hospitalist service from January 21, 2022, to October 23, 2022. The survey data was combined with visit characteristics obtained from the electronic medical record. Population characteristics were defined by frequencies or mean and standard deviation (SD). We used bivariate analysis with a t-test to establish basic associations. Multivariate logistic regression controlling for sex, race, ethnicity, and age was used to assess the relationship of HCS with readmissions. Multivariate linear regression controlling for the same demographics was used to assess the relationship of HCS with hospital length of stay. Statistical significance was defined by p<0.05.

RESULTS: A total of 2,796 patients completed the HCS, of whom 55% were female, 76% were Black/African American, and 94% were not of Hispanic/Latino ethnicity. The mean age was 60 years (SD 17, range 19-105). During the study period, the mean HCS was 9.19 (SD 2.68, range 0-12) and 59% had an HCS≥9. Readmission occurred in 22% (601 patients) and the average length of stay was 7.32 days (SD 7.27, range 0-91). Patients with above average HCS (HCS≥9) had fewer readmissions (26% vs. 29%; p=0.162) with and without controlling for demographic confounders (OR 0.88; 95% CI [0.73, 1.06]; p=0.174), but these were not statistically significant. However, patients with an HCS≥9 had a significantly lower length of stay (6.71 vs. 8.33, p<0.001) compared to those with an HCS<9. This remained true when accounting for demographic confounders: patients with an HCS≥9 had an average length of stay 1.64 days (95% CI [2.2, 1.06]; p<0.001) shorter than those with an HCS<9.

CONCLUSIONS: To the best of our knowledge, this is the first study looking at the relationship between HCS, hospital readmission, and length of stay. While HCS was not significantly associated with readmission, we did find a strong association between HCS and hospital length of stay. We aim to assess whether HCS can have clinical utility in developing and targeting interventions to reduce hospital length of stay and improve outcomes for hospitalized patients.

CAN THE LANGUAGE BARRIER IMPACT THE READMISSION RATE IN COLON CANCER PATIENTS? – A SINGLE-INSTITUTION ANALYSIS

RAJMOHAN RAMMOHAN¹; Melvin Joy¹; Atul Sinha²; Tulika Saggar¹; Dilman K. Natt¹; Susan Bunting¹; Prachi Anand¹

¹INTERNAL MEDICINE, NASSA UNIVERSITY MEDICAL CENTER, East Meadow, NY; ²Internal Medicine, Nassau University Medical Center, East Meadow, NY. (Control ID #3875329)

BACKGROUND: Patients diagnosed with colon cancer face many challenges and need a good understanding of their diagnosis and proposed treatments to make informed decisions about their care. Health literacy is vital, and low health literacy may be associated with poorer outcomes. There is a concern that language barriers and literacy rates influence the readmission rate of colon cancer. We examine the 30-day readmission rate, 60-day readmission rate, and 90-day readmission rate regarding patients’ language and also to identify the health equity for any disparities.

METHODS: In our study, we performed a retrospective analysis of all Colon Cancer patients admitted to our hospital from 2009- 2022. Data on comorbidities, insurance status, surgical procedures, Cancer grade, colonoscopy reports, and baseline characters were collected. Patients were excluded if they died; Data was then divided based on the patient’s language. A Chi-Square test and odds ratio was performed on the entire cohort, and a matched subset was examined with propensity scoring matching to balance baseline characteristics.

RESULTS: A total of 701 patients were included in the study; 341(49%) were female, and the average median age group (was 55.6±5.9 years). Patients were divided into four groups based on their language. Propensity score matching was used to balance the baseline characteristics. Patients speaking English had significantly higher 30day readmission rates compared to the other Languages (47 vs. 7vs. 15 vs. 14, P=0.025, Correlation: 0.68). English had a significantly higher 60day readmission rate than the other Languages (25 vs. 3vs. 8 vs. 30, P<0.01, Correlation: 0.78). English had a significantly higher 90day readmission rate than the other Languages (10 vs. 2vs. 11vs. 10, P<0.01, Correlation: 0.55). Among Non- English speakers, Patients with insurance status had significantly higher readmission status than the non- insured patients (OR: 3.025, p<0.021).

CONCLUSIONS: This study is a promising start to study the impact of readmission rates in colon cancer patients based on language barriers. Understanding linguistic capabilities are crucial to bridge the gap between healthcare disparities. Further research on language discordance is needed to reduce the risk of language-discordant clinical encounters and the adverse health outcomes associated with these encounters.

CHALLENGES IN ACCESS TO COLONOSCOPY AT A STUDENT-RUN FREE CLINIC

Andrew B. Yang¹; Isaac A. Nathoo²; Ramia Rahman¹; Elizabeth K. Benitez²; Tiffany Merlinsky³; Ashita S. Batavia^2,5; Pamela Charney⁴

¹Weill Cornell Community Clinic, Weill Cornell Medicine, New York, NY; ²Medicine, Weill Cornell Medicine, New York, NY; ³Community Clinic, Weill Cornell Medicine, New York, NY; ⁴Internal Medicine, Weill Cornell Medical College, New York City, NY; ⁵Janssen Global Services LLC, Titusville, NJ. (Control ID #3875453)

BACKGROUND: This study looks at access to colonoscopies in an academic-based medical student-run free clinic that serves an uninsured population. Colonoscopy is critical for early identification of colorectal cancer, and delays in colonoscopy are associated with increased colorectal cancer (CRC) incidence and mortality. As such, we investigated referral and fulfillment rates at the clinic.

METHODS: This was a retrospective study of all colonoscopy referrals from 1/1/17 to 12/31/21. Demographic, colonoscopy referral, and colonoscopy procedure data were abstracted from the EHR by the authors. Up to May 2021, patients over 50 years were referred for screening colonoscopies, with the age changing to 45 years following a change in USPSTF guidance. Patients with a positive family history were referred for screening colonoscopies at age 40 or 10 years before the age that the immediate family member was diagnosed. Diagnostic colonoscopies, by contrast, are symptom driven. The time to procedure was defined as the number of days between the initial referral and the colonoscopy procedure.

RESULTS: During the study period, there were 150 referrals for 84 unique patients (33% male). 14 of these patients had a positive family history. The average number of referrals per patient was 1.8. 80% of referrals were diagnostic, and 55 referrals were repeats, meaning that multiple referrals were given for a single colonoscopy. This resulted in 95 remaining referrals, which we refer to as unique referrals. Amongst the unique referrals, 55% of diagnostic, 55% of screening, and 71% of referrals for a patient with relevant family history resulted in a colonoscopy. The median age at initial referral was 55 (interquartile range 50-61).

In total, 52 colonoscopies (79% screening, 21% diagnostic) were completed in 47 unique patients. 22 colonoscopies resulted in abnormal findings with a changed interval for a repeat colonoscopy, including 8 with tubular adenoma and 11 with polyps . There were 5 patients referred for 2 separate colonoscopies during the timeframe of the study due to a combination of family history of CRC and high-risk lesions. The average time between initial referral and colonoscopy was 329 days.

CONCLUSIONS: Our study found that 150 colonoscopy referrals resulted in 52 colonoscopies, for a 35% conversation rate from colonoscopy referral to completed procedure, which is worse than described for uninsured & underinsured Americans. Furthermore, the conversion rate is worse for diagnostic colonoscopy referrals as they accounted for 55% of unique referrals but only 21% of completed procedures. Furthermore, among the 47 patients that received colonoscopies, the time to procedure was nearly 3-fold longer that what has been found in the literature. In our population, the rate of pathologic findings was comparable to the literature. Given these findings, additional research is needed to understand the barriers to care that drive decreased and delayed follow-through with screening & diagnostic colonoscopies.

CHALLENGES IN REFUGEE HEALTH: LESSONS FROM GREECE IN BUILDING TRUST AND COLLABORATION IN THE INTERNATIONAL HUMANITARIAN SETTING

Natalie M. Colaneri¹; Essam Daod²; Hrayr Attarian³; Jess Ghannam⁴; Shannon Galvin⁵

¹Internal Medicine, University of California San Diego, La Jolla, CA; ²Humanity Crew, Haifa, Israel; ³Neurology (Sleep Medicine), Northwestern University Feinberg School of Medicine, Chicago, IL; ⁴Psychiatry and Global Health Sciences, University of California San Francisco, San Francisco, CA; ⁵Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #3876449)

BACKGROUND: Greece is one of many countries facing an ongoing humanitarian health crisis involving displaced people. More than 50,000 asylum seekers and refugees currently reside in Greece, and many suffer from physical as well as mental health concerns. Humanitarian aid workers from around the world are currently working together in an increasingly complex system in Greece, trying to provide support to asylum seekers and refugees from a diverse array of countries. This qualitative study explores ideas to build trust and collaboration in the international humanitarian setting.

METHODS: This qualitative study involved semi-structured interviews with 28 international aid workers who currently or previously worked in Greece. Subjects were recruited through email, word-of-mouth, and utilizing snowballing sampling. Responses to the questions “What can aid workers do to build more trust with refugees?” and “How can aid workers work together to support refugees?” were analyzed using thematic analysis. The study was approved by the Northwestern University Institutional Review Board.

RESULTS: Three major themes emerged regarding ways for aid workers to build more trust with displaced communities: 1. promoting empowerment/agency of asylum seekers and refugees, 2. learning about various aspects of their cultures, and 3. demonstrating certain character traits. Ideas for promoting empowerment/agency of individuals included: asking about needs of communities to guide the services provided, providing individuals with clear information in their language, providing options and choices to individuals, and aid workers viewing their work as "solidarity" rather than “helping” individuals. Many respondents also viewed learning about various aspects of culture as key to building trust, including learning language and exploring traditions and activities. Finally, certain character traits were integral to building trust, including openness, respect, honesty/authenticity, and professionalism. Respondents also suggested ways that aid workers from different backgrounds could work together to support displaced communities, including utilizing specific strengths of each team member, communicating openly, and sharing knowledge with each other.

CONCLUSIONS: This study explores different ways for aid workers to build trust with the communities they serve, including empowering individuals, prioritizing learning about the cultures of different communities, and demonstrating traits including openness and honesty. This research also suggests ideas for collaboration in the humanitarian field, including utilizing strengths of different team members, communicating openly, and sharing knowledge. This study will hopefully lead to further discussion regarding ways to build trust in the international humanitarian setting, and allow aid workers to more effectively work together to improve the health and well-being of asylum seekers and refugees in Greece and around the world.

CHANGES IN DISPARITIES IN OPIOID PRESCRIBING FOR LOW-ACUITY CONDITIONS BEFORE AND AFTER RANDOMIZED CLINICIAN FEEDBACK INTERVENTIONS

Aidan P. Crowley¹; Chuxuan Sun^1,2; Xiaowei Yan⁵; Amol S. Navathe^1,3; Joshua M. Liao^4,3; Mitesh S. Patel⁶; David Pagnotti¹; Zijun Shen⁵; M. K. Delgado^3,7

¹Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²Division of General Internal Medicine, University of Pennsylvania Department of Medicine, Philadelphia, PA; ³Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; ⁴University of Washington Department of Medicine, Seattle, WA; ⁵Center for Health Systems Research, Sutter Health, Sacramento, CA; ⁶Ascension Health, St Louis, MO; ⁷Department of Emergency Medicine and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #3877127)

BACKGROUND: Racial and ethnic minorities historically receive opioid prescriptions at lower rates and dosages than white patients. Stewardship interventions to decrease excessive opioid prescribing may either improve or exacerbate these disparities. However, there is little evidence about these potential differential effects. The objective of our study was to determine how a randomized trial of opioid stewardship clinician feedback interventions that reduced opioid prescribing overall affected patients differently by race and ethnicity.

METHODS: This study used data from a 4-arm cluster randomized clinical trial conducted among 438 clinicians from 21 emergency departments (EDs) and 27 urgent care clinics (UCs) in the western U.S. The clinical trial examined the effects of 3 interventions on opioid prescribing patterns by randomly assigning eligible physicians, physician assistants, and nurse practitioners by ED or UC site to 1 of 4 study arms: usual care, individual audit feedback, peer comparison feedback, or a combination of both forms of feedback. We analyzed data from a 6-month baseline period (Mar-Sep 2019) and a 6-month intervention period (Sep-Mar 2020). The primary outcome was number of pills prescribed (low ≤ 10 pills, medium = 11-19 pills, high ≥ 20 pills). Generalized mixed-effects logistic regression models were used to examine patient characteristics associated with low-pill prescriptions during the baseline period. These model types were also applied to intervention period data to determine whether pills per prescription varied by patient race and ethnicity obtained from the electronic health record (white, Black, Asian, Hispanic, other) between usual care and each of the 3 intervention arms.

RESULTS: Compared with white patients, Black patients were more likely to receive a low-pill prescription during both the baseline (AOR: 1.18, 95% CI: 1.06 to 1.31, p = .002) and intervention (AOR: 1.43, 95% CI: 1.07 to 1.91, p = .015) periods. No other racial or ethnic group was significantly more likely than white patients to receive a low-pill opioid prescription at baseline. While combined feedback led to an overall increase in low-pill prescriptions (AOR: 1.89, 95% CI: 1.28 to 2.78, p = .001), there were no significant differences in any intervention’s treatment effects by patient race and ethnicity as identified by individual interaction terms (Asian AOR: 0.83, p = .30; Black AOR: 0.88, p = .57; Hispanic AOR: 0.86, p = 0.24; Other AOR: 0.80, p = 0.21).

CONCLUSIONS: Combined individual audit and peer comparison feedback reduced the number of opioid pills per prescription equally by patient race and ethnicity. However, this intervention did not significantly ameliorate the baseline disparity we identified in prescribing by race. Future studies should determine whether behavioral interventions can reduce prescription disparities by evaluating standardized dosing strategies or stratified clinician feedback by patient characteristics.

CHASING THE OUNCE OF PREVENTION: THE EFFECT OF THE COVID-19 PANDEMIC ON PREVENTIVE IMAGING

Jenny L. Weon¹; Yin Xi²; Yee Seng Ng²; Lauren N. Cooper³; Marlon I. Diaz⁶; Robert W. Turer⁴; Samuel McDonald⁴; Duwayne L. Willett⁵; Christoph U. Lehmann³; Ling Chu⁵

¹Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX; ²Radiology, The University of Texas Southwestern Medical Center, Dallas, TX; ³Clinical Informatics Center, The University of Texas Southwestern Medical Center, Dallas, TX; ⁴Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, TX;⁵Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; ⁶Texas Tech University Health Sciences Center El Paso Paul L Foster School of Medicine, El Paso, TX. (Control ID #3873220)

BACKGROUND: The COVID-19 pandemic was associated with substantially reduced preventive screening activities. The 2022 AACR Cancer Disparities Progress Report urged researchers to identify how the COVID-19 pandemic affected health disparities in cancer. Our objective was to determine if the pandemic exacerbated health disparities in preventive screening (including cancer screening).

METHODS: We extracted weekly volumes of preventive screening exams (bilateral mammograms and bone density exams) between January 7, 2019 and May 1, 2022 from the radiology data warehouse at an academic medical center in the Southern region. Patients were grouped by race and ethnicity into Hispanic or Latino, non-Hispanic Black, and non-Hispanic White patients. The March 16-May 9, 2020 period was designated as the COVID-19 shutdown. Ratios of post- to pre-shutdown mean weekly volumes were estimated for each subgroup using binomial regression. All analyses were done in SAS 9.4.

RESULTS: For mammograms, post-shutdown volumes were similar to pre-shutdown volumes for all race and ethnicity groups (Hispanic and Latino, ratio of means 1.08, [95% CI 0.90, 1.29], p = 0.99; non-Hispanic Black, ratio of means 1.04, [95% CI 0.87, 1.24], p = 1.00; non-Hispanic White, ratio of means 1.03, [95% CI 0.86, 1.23], p = 1.00). For bone density exams, volumes significantly increased post-shutdown to more than 3-fold for Hispanic patients (ratio of means 3.40, [95% CI 2.77, 4.17], p < 0.0001) and to 2-fold for non- Hispanic Black patients (ratio of means 2.00, [95% CI 1.63, 2.44], p < 0.0001), while volumes significantly decreased post-shutdown to 67% of pre-shutdown volume for non-Hispanic White patients (ratio of means 0.67, [95% CI 0.56, 0.82], p = 0.002).

CONCLUSIONS: In our population there were no significant differences between post- and pre-shutdown volumes in race and ethnicity groups for mammograms and we observed a significant increase in weekly screenings for Hispanic or Latino and non-Hispanic Black patients in contrast to non-Hispanic White patients for bone density exams. The increase of bone density screening for Hispanic or Latino and Black patients over time remains unexplained and requires further examination.

COMMUNICATED BIAS IN THE ELECTRONIC HEALTH RECORD FOR PATIENTS PRESENTING WITH PAIN

Pooja A. Lagisetty^1,2; Adrianne R. Kehne³; Colin macleod¹; Christopher Fung⁴

¹Internal Medicine, University of Michigan, Ann Arbor, MI; ²Veterans Health Administration, Ann Arbor, MI; ³Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI; ⁴University of Michigan Michigan Medicine, Ann Arbor, MI. (Control ID #3876534)

BACKGROUND: There are over 34 million pain-related ED encounters annually. Pain-related stigma and racial discrimination are increasingly recognized as causes of inequity in pain-related care. These biases may be documented in the medical record using stigmatizing language (e.g., “drug seeker,” “real” pain), and may negatively impact downstream general medical care by communicating biases about patients to other providers. Thus we aimed to measure the prevalence of stigmatizing language in notes written upon patients’ initial presentation to the emergency department and evaluate predictors for its presence within these notes.

METHODS: A lexicon of stigmatizing language was determined a priori from the existing literature, expert opinion, and investigator consensus and classified into seven categories: discounting symptoms, commenting on patient behavior, medical stigma, negative patient descriptors, socioeconomic indicators, substance use disorder stigma, and weight-related stigma. We included ED encounters from a large academic center (2017-2021) of patients presenting for the five most common pain complaints: chest pain, abdominal pain, headache, back pain, and injury. We used descriptive statistics to describe the frequency of stigmatizing language and multivariable analysis to determine predictors (demographics, acuity of presentation via the Emergency Severity Index, pain type, and insurance type) of such language.

RESULTS: There were 51,570 pain-related encounters in the sample. The mean triage note length was 48.4 words (SD = 20.5) and 2691 notes (5.2%) contained stigmatizing language. Of the pain conditions examined, chest pain had the highest prevalence of stigmatizing language in encounter notes (6.66% of chest pain encounters). The most common category of stigmatizing language was negative patient descriptors (e.g., “refuse,” “insists”) which comprised 30.4% of stigmatizing language. Language around substance use disorders (e.g., “habit,” “abuse”) was also common (19.7%). In a logistic regression model, notes were significantly more likely to have stigmatizing language when the patient was Black (OR=1.10, p=.04) compared to White patients, male (OR=1.15, p<0.001), a higher acuity score (ESI of 2 vs. 4; OR=2.48, p<0.001), or had Medicaid (OR=1.29, p<.001) or Medicare (OR=1.22, p<0.001) as compared to private insurance.

CONCLUSIONS: Stigmatizing language is present in roughly 1 in 20 ED encounters for pain and is disproportionately prevalent in specific patient populations. Future studies should explore whether this language is copied forward to general medical history and physical note documentation and if this impacts pain-related treatment outcomes such as time to analgesia and type of analgesics delivered.

COMMUNICATION AND ACTIVATION IN PAIN TO ENHANCE RELATIONSHIPS AND TREAT PAIN WITH EQUITY (COOPERATE): A RANDOMIZED CLINICAL TRIAL

Marianne S. Matthias^1,2; Joanne K. Daggy⁵; Matthew J. Bair^3,2; Diana J. Burgess⁴; Johanne Eliacin¹; Kevin L. Rand⁶; Laura J. Myers¹; Michelle Salyers⁶; Adam Hirsh⁶

¹HSR&D, Roudebush VAMC, Indianapolis, IN; ²Medicine, Indiana University School of Medicine, Indianapolis, IN; ³Medicine, Center for Health Information and Communication, Indianapolis, IN; ⁴Medicine, University of Minnesota and Minneapolis Veterans Affairs Health Care System, Minneapolis, MN; ⁵Biostatistics, Indiana University School of Medicine, Indianapolis, IN; ⁶Psychology, Indiana University Purdue University Indianapolis, Indianapolis, IN. (Control ID #3852665)

BACKGROUND: Chronic pain affects tens of millions of Americans and is a leading cause of disability. Racial disparities in pain treatment have been extensively documented, and Black patients exhibit lower levels of patient activation—having the knowledge, confidence, and skills to self-manage—than White patients. Lower patient activation leads to less effective clinical communication (e.g., sharing concerns, shared decision-making), which can adversely affect pain management.

METHODS: COOPERATE is a randomized trial of an intervention to increase patient activation for Black Veterans with chronic pain. It includes 6 individual coaching sessions delivered via phone over 3 months, focusing on two essential skill sets to facilitate patient activation: 1) goal setting/prioritization, 2) clinical communication. 250 Black Veterans were randomized to the intervention or to attention control. The primary outcome was patient activation; secondary outcomes included communication self-efficacy, pain, and psychological functioning. Outcomes were assessed at baseline, 3 (primary endpoint), 6, and 9 months (sustained effects). A linear mixed-model repeated measures approach was used to test change in patient activation compared to the control group at 3 months adjusting for baseline working alliance and number of comorbid conditions. Group differences in mean change from baseline at 6 and 9 months were estimated. Secondary outcomes were analyzed similarly, adjusting for multiple comparisons using the Šídák method.

RESULTS: Patient activation improved significantly relative to the control group from baseline to 3 months (+4.6 vs. +0.13, p=.03). Differences were sustained at 6 (p=.001) and 9 months (p=.03). Communication self- efficacy improved (+3.63 vs. +.92, p=.046) at 3 months. Although improvements persisted, they were not significantly different from the control group at follow-up points after Šídák adjustment. Pain intensity and interference improved more in the intervention group at 3 months (-0.65 vs. -0.04), but differences were not significant after adjustment. Depression and anxiety improved in intervention participants and worsened in in control participants, but group differences were not significant.

CONCLUSIONS: COOPERATE effectively increased patient activation and communication self-efficacy, with differences in patient activation sustained over time. Given its importance for effective self- management, finding ways to increase patient activation is a key path to improved pain management. This is especially important for historically marginalized groups, such as Black patients, who report greater pain severity, worse pain care, and lower quality clinical communication than White patients. Consequently, COOPERATE represents a promising approach to decrease disparities in pain care and may be an important component of efforts to achieve health equity.

COMMUNICATION DISABILITY ACCOMMODATION PROGRAMS IN US HEALTHCARE ORGANIZATIONS

Jennifer Y. Oshita¹; Ashley Couture³; Megan Morris²

¹Medicine, Clinical and Translational Sciences, University of Vermont Larner College of Medicine, Burlington, VT; ²University of Colorado, Denver, CO; ³University of Vermont Medical Center, Burlington, VT. (Control ID #3876379)

BACKGROUND: Adults with communication disabilities in hearing, expression, reception, and cognition (PwCD), make up roughly 14-16% of the US adult population. They experience poorer healthcare outcomes when compared to their peers without communication disabilities. The Americans with Disabilities Act and the Joint Commission mandate equitable access to clear and mutual understanding of healthcare information through reasonable aids and services (Communication Disability Accommodation Programs). Despite these national mandates, few studies have examined how healthcare organizations have operationalized delivery of these aids and services at a systems level. This study aimed to describe the communication aids offered by US organizations and how delivery of accommodations have been implemented into organizational workflows.

METHODS: We recruited participants through purposeful sampling of disability coordinators through the Disability Equity Collaborative LEADERs workgroup, a learning collaborative of disability coordinators representing over 30 large healthcare organizations across the US. We completed semi-structured interviews with 19 disability coordinators representing 15 healthcare organizations from five regions of the US. Interviews were conducted over Zoom and lasted roughly 60 minutes. The transcripts of these interviews were coded and analyzed using qualitative content analysis. Codes were organized and clustered based on their relationships and linkages. Themes were drawn from analyzing these clusters.

RESULTS: Communication Disability Accommodation programs did not typically have dedicated staff or funding. The disability types most often addressed were Deaf, hearing impaired, or visual CDs. Leaders of these programs were most often directors of interpreter services. In two cases, a dedicated disability services program existed. Most organizations relied on providers or patient initiation to flag accommodation needs. In the inpatient setting, workflows were embedded within pre-existing language access practice patterns. In the outpatient setting, workflows were determined by individual clinics. Aids were often provided using a “Toolkit” strategy of a box of basic aids (e.g. a hearing amplifier, communication board, magnifier, white board) readily available at key locations. Delivery of accommodations to patients required coordinated efforts by multiple staff members across departments. Programs did not audit whether patients received accommodations, rather they relied on feedback via patient complaints. Barriers to program implementation included a lack of dedicated staffing and funding, hospital staff turnover, lack of provider awareness of CDs and accommodations, and reduced patient awareness of available accommodations.

CONCLUSIONS: Implementation of communication accommodations in these 15 US Healthcare organizations were limited to a subset of the CD population, typically embedded within language access workflows, and in early stages of development.

COMMUNITY-BASED COVID-19 TESTING AND EDUCATION AMONG FORMERLY INCARCERATED INDIVIDUALS – PRELIMINARY RESULTS FROM THE MOSAIC STUDY Connor S. Holmes¹; Maxwell Ackerman¹; Jordy Rojas-Antigua¹; Lindsey Riback¹; Chenshu Zhang¹; Micaela Linder²; Ronald F. Day²; Aaron Fox¹; Matthew J. Akiyama¹

¹Medicine, Albert Einstein College of Medicine, Bronx, NY; ²Fortune Society, Long Island City, NY. (Control ID #3876617)

BACKGROUND: The largest U.S. single-site COVID-19 outbreaks have occurred in carceral facilities. Many criminal legal system involved (CLSI) individuals live in congregate settings upon reentry and receive limited COVID testing and education. Community based organizations (CBOs) and community health workers (CHWs) provide essential reentry services to CLSI individuals and can contribute to COVID testing and education efforts. Our objective in this randomized controlled trial is to test the effectiveness of a co- located CHW-led COVID testing and education intervention in a reentry CBO. In this preliminary analysis, we aim to examine the vulnerability of the cohort thus far and attitudes towards COVID.

METHODS: We are recruiting 250 CLSI individuals released from jail or prison in the last 90 days. Participants are randomized to onsite Point-of-Care testing and education (O-PoC) or Standard of Care (SoC). Over one year, O-PoC participants receive quarterly testing onsite at the CBO and a CHW provides COVID-related counseling and education. SoC participants are referred for quarterly offsite testing at community sites. Here we report data from baseline assessments, including sociodemographics, comorbidities, prior COVID infection and exposure, and concerns about future infection.

RESULTS: From 4/2022-12/2022 we enrolled 114 participants, mean age is 42, 90% are male, 56% are Black and 35% are Hispanic. Over half (59%) report homelessness and 56% are on probation or parole. Participants report a mean 13 years of lifetime incarceration and 18 months incarceration since March 2020. One-third (36%) report receiving outpatient healthcare in the past 30 days, 61% report active tobacco use, 24% are asthmatic, and 5% are HIV+. One-third (32%) report ever testing positive for COVID (25% while incarcerated) and 60% lived with someone who had COVID while incarcerated. Most (79%) received a COVID vaccine and 47% have at least one booster. On average, participants believed there was a 22% chance they would contract COVID in the next 3 months with only 19% reporting ongoing worry about contracting COVID. On average, more participants worried about family or friends contracting COVID and transmitting COVID to others – 49% and 35%, respectively.

CONCLUSIONS: Preliminary data demonstrate high rates of past COVID exposure and infection while incarcerated with limited concern for future infection. High rates of unstable housing and comorbidities could suggest increased risk of infection and poor outcomes. Elevated COVID-related risk in this CLSI population reflects a need for a tailored CHW-delivered testing and education intervention.

COMMUNITY-BASED ORGANIZATION PERSPECTIVES ON PARTICIPATING IN STATE-WIDE COMMUNITY CANVASSING PROGRAM AIMED TO REDUCE COVID-19 VACCINE DISPARITIES IN CALIFORNIA

Lisa Mansfield²; Nisha Sunku¹; Savanna L. Carson³; Stefanie D. Vassar³; Dale Slaughter⁵; Gloria Kim⁵; Alana G. Troutt⁶; Keith C. Norris⁴; Arleen F. Brown⁴

¹Medicine, UCLA Medical Center Olive View, Sylmar, CA; ²Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles, Los Angeles, CA; ³Division of Internal Medicine & Health Service Research, UCLA, Los Angeles, CA; ⁴Medicine, University of California Los Angeles, Los Angeles, CA; ⁵CERP, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁶Government Operations Agency, State of California, Sacramento, CA. (Control ID #3874862)

BACKGROUND: Get Out the Vaccine (GOTVax), an innovative statewide government-funded COVID-19 vaccine canvassing program in California, aimed to reduce inequities in vaccine accessibility and reliable COVID-related information disproportionately affecting minoritized communities. GOTVax contracted with 34 community-based organizations (CBOs) between April 2021 and December 2021 for vaccine outreach, education, and vaccine registration to reduce structural barriers to vaccination. The academic institution served as the program oversight, contractor, and liaison and provided COVID-19 and vaccine educational training and materials for canvassers. GOTVax was modeled on voter registration and Census door-to-door canvassing approaches and served as an economic stimulation program that hired unemployed and underemployed residents. Communities selected for the program were in zip codes disproportionately impacted by COVID-19, in the lowest quartile of the California Healthy Places Index, and unreached by previous State-led initiatives. The GOTVax CBOs were selected as they already served the state-indicated high-risk zip codes for vaccine registration outreach. We sought to understand the perspectives of CBO leaders participating in GOTVax on the barriers and facilitators to their roles in COVID-19 vaccine outreach. METHODS: We conducted a qualitative community-partnered evaluation of GOTVax. Semi-structured, virtual interviews were conducted with CBO leaders from November 2021 to January 2022. Questions explored the pandemic impact on CBO operations, barriers and facilitators to implementation and management of GOTVax operations, and areas for program improvement. Online demographic surveys described CBO characteristics. Transcripts were analyzed using reflexive thematic analysis.

RESULTS: Thirty-one of 34 CBOs participated (91%). Most CBOs employed less than 25 people (56%), operated for more than 15 years (59%), and reported annual budgets of $1 to $9 million (44%). Identified themes encompassed both facilitators and barriers to program participation. Key facilitators included leveraging trust through recognized entities, promoting empathetic, tailored outreach, and flexibility of milestone-based CBO funding contracts for rapid program implementation. Barriers included navigating community sociopolitical, geographic, and cultural factors, managing canvasser’s safety, desiring performance metrics for self-evaluation of outreach success, mitigating canvassing technology challenges, and concerns of program infrastructure initially limiting outreach to registered voters. CBOs problem solved barriers with the academic and government partners.

CONCLUSIONS: Community-academic-government partnerships should support capacity building for continued COVID-19 outreach and future public health emergencies. Future public health programs should leverage partnerships with community-trusted CBOs and provide flexible funding for tailored outreach in local communities.

COMMUNITY-CENTERED OUTREACH LEADS TO RAPID UPTAKE OF MPOX VACCINES AT COMMERCIAL SEX VENUES IN A LARGE METROPOLITAN AREA OF THE MID-ATLANTIC REGION

Joseph Osmundson^5,6; Katherine Murphy²; Julian Watkins¹; Andrew Wallach^4,2; Adam Baran⁸; Chris Hawke⁷; Ashwin Vasan³; Theodore G. Long²

¹New York City Department of Health and Mental Hygiene, New York, NY; ²Office of Ambulatory Care and Population Health, New York City Health and Hospitals Corporation, New York, NY; ³New York City Department of Health and Mental Hygiene, New York, NY; ⁴NYU Langone Health, New York, NY; ⁵Biology, New York University, New York, NY; ⁶The Rockefeller University, New York, NY; ⁷N/A, N/A, New York, NY; ⁸N/A, N/A, New York, NY. (Control ID #3877336)

BACKGROUND: In May, 2022, the MPOX virus began spreading through global queer sexual networks. Many prior cases in Europe were linked to large queer events with sex on site. While a third-generation smallpox vaccine, JYNNEOS, is maintained in the US Strategic National Stockpile and can prevent MPOX infections, significant shortages remained through the Fall, 2022.

METHODS: We present an on-site vaccination strategy at locations where people meet for sex. All commercial events for queer people with sex on site in a large Mid-Atlantic metropolitan area voluntarily

closed from July 15 through September 3 to help prevent the spread of MPOX. Due to national vaccine shortages, in early September, only first doses of the two-dose JYNNEOS vaccine series were offered in our area. Following the reopening of commercial sex venues, mobile vaccination teams were dispatched to these sites to offer JYNNEOS vaccine on site, including second vaccine doess. Large metropolitan area healthcare officials engaged in bi-directional communication with event hosts and community advocates. Data were collected on doses administered, event size and participant demographics by the event hoses and planners.

RESULTS: From September 3rd through November 12th, mobile uunit healthcare workers administered nearly 400 doses of JYNNEOS vaccines at commercial sex venues. Over this same time period, MPOX cases continued to decrease, even as sexual behaviors returned to baseline. Once second JYNNEOS doses were available at commercial sex venues, vaccine update was high, with 40-60% of event participants receiving an initial dose on site. Mobile units further administered over 2000 doses at public events without sex on site, and over 90% of these were first JYNNEOS does. Mobile units at these event helped increase broad uptake among those who hadn't yet received a dose of MPOX vaccine, while mobile units at commercial sex venues ensured completion of the two-does regimen among those participating in sex with multiple partners. In fct, the mobile units administered nearly 75% of second JYNNEOS doses at commercial sex venues

CONCLUSIONS: We demonstrate the power of tailored community engagement, bringing healthcare to places where people already gather, and show that high uptake of helthcare at commercial sex venues can help decrease the spreaf of sexually transmitted infections, both established and emerging. Our results also emphasize that people attending commercial sex venues could become sexual health hubs that prevent STI transmission throughout entire sexual networks by meeting the needs of their most connected nodes to test for and prevent HIV and bacterial STIs.

COMMUNITY-INFORMED MOBILE OUTREACH AS A STRATEGY TO INCREASE HYPERTENSION AWARENESS AND SCREENING

Priya Sarin Gupta^1,2; Karla Chamorro Garcia³; Miriam Deukmejian³; Anne Fox³; Tavinder Phull³; Elsie Taveras³; Allison S. Bryant²

¹Medicine, Massachusetts General Hospital, Newton, MA; ²Mass General Brigham Inc, Boston, MA; ³Community Health, Mass General Brigham Inc, Boston, MA. (Control ID #3874923)

BACKGROUND: Hypertension is a modifiable risk factor directly related to the development of heart disease. Although hypertension is highly prevalent in historically marginalized communities, awareness and screening remain deficient. There is limited information on mobile health programs as an intervention for hypertension screening modality. This program leveraged a clinic on wheels where the van was co-located using community engagement and data on social vulnerability index. The locales serviced with the mobile clinics have a baseline population of ~40% of individuals born outside of the US, Hispanic ethnicity cited as one of the most common ethnicities and the median household income less than the US average. This approach aimed to evaluate the effectiveness of a mobile-based intervention tasked with increasing blood pressure screenings and awareness in a marginalized population.

METHODS: Partnership with community organizations and data determined where the clinics on wheels held sessions. The vans were typically out in the field for four 4-hour sessions a week. The full menu of services included other primary care services such as vaccination provision. Each van was staffed with a physician medical lead, an NP, MA, CHW and an operations manager. Patients who self-identified as either having an established diagnosis of hypertension or interested in a blood pressure screen in a mobile clinic setting on a walk-in basis were screened. Convenience sampling was used, and urban areas identified as historically marginalized were targeted. Patients found to have abnormal blood pressure readings at clinic were deemed eligible to receive an ambulatory automatic blood pressure monitor and follow-up via phone call. These patients received information pamphlets and verbal delivery of information to foment awareness of the condition. Patients served were asked questions about their demographics and offered a standardized Social Determinants of Health screener.

RESULTS: The population analyzed overall included 857 individual patients who sought walk-in blood pressure screenings from May to November 2022. Individuals were mostly female (64%), median age was 65 years (interquartile range 57-64yrs); ethnicity was 49% Not Hispanic, 44% Hispanic, 7% unavailable. Of the populations analyzed, 47% were white, 28% Other (which includes individuals who cited race as Hispanic/Latino population), 13% Black or African American. About 37% of individuals in this group had an abnormal blood pressure (systolic blood pressure > 140).

CONCLUSIONS: A walk-in low threshold model of blood pressure screening allowed us to reach individuals with elevated blood pressure in historically marginalized communities in the greater boston area. In this setting, women are more likely than men to access blood pressure screening. Mobile-based interventions implemented in partnership with community organizations to provide blood pressure screenings have potential to reach historically underserved communities in large proportion.

COMPARISON OF RACIAL AND ETHNIC DISPARITIES IN COVID-19 MORTALITY BETWEEN NATIONAL VA AND US POPULATIONS.

Evan Shannon^2,1; Taona P. Haderlein^2,3; W. N. Steers²; Michelle S. Wong²; Donna L. Washington^2,1

¹Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA; ²VA Center for the Study of Healthcare Innovation Implementation and Policy, Los Angeles, CA; ³Veterans Emergency Management Center, North Hills, CA. (Control ID #3869274)

BACKGROUND: In the US, racial and ethnic disparities in COVID-19 outcomes have been attributed to structural racism resulting in inadequate healthcare access, more vulnerable social conditions, and more severe underlying comorbidities in minoritized racial and ethnic groups (e.g., Black and Hispanic) compared with non-Hispanic White individuals. The Veterans Health Administration (VA), the nation’s largest single- payer integrated healthcare system, addresses many social determinants of health to eligible patients. Despite this, VA studies have also identified COVID-19-related racial and ethnic disparities. However, it is unclear if the magnitude of disparities in COVID-19 outcomes differ between VA and general US populations. We aimed to determine the extent to which age-adjusted sex-stratified racial and ethnic variations in COVID-19 mortality are comparable between VA and non-VA US populations.

METHODS: We obtained measures of age, sex, and COVID-19 mortality for COVID-19-positive cohorts from VA (23,153 women, 202,077 men) and CDC US population data (5,783,792 women, 5,207,603 men) from 3/1/20–5/7/21. Our analysis included non-Hispanic Black, Hispanic, and non-Hispanic White (White) participants. We tested associations between race and ethnicity and COVID-19 mortality, between data source (VA vs. US) and COVID-19 mortality, and between sex and COVID-19 mortality using clustered logistic regression that controlled for age and included a race and ethnicity-by-data source-by-sex interaction term to test whether the magnitudes of the racial and ethnic disparities differed between VA/US data sources by sex. The racial and ethnic disparities were expressed as Black-White and Hispanic-White differences in

COVID-19 adjusted mortality proportions (AMP), and the differences between disparity estimates were expressed as VA/US Black/White or Hispanic/White difference-in-differences (DID) in AMPs. RESULTS: In the VA, Black/White mortality disparities were present for men (Black Veteran AMP 1.7 percentage points [pp] higher than for White Veterans, 95%CI 1.4,2.0), but not for women. US Black/White

mortality disparities were present for both men (AMP +3.1pp, 95% CI 3.1,3.2) and women (AMP +2.0pp, 95% CI 1.9,2.0). US Black/White disparities exceeded those in the VA for both men (AMP DID +1.5pp, 95% CI 1.2,1.8) and women (AMP DID +2.0pp, 95% CI 1.7,2.3). Hispanic/White mortality disparities were present for men in the VA (AMP +1.7pp, 95% CI 1.2,2.1) and US (AMP +1.5pp, 95% CI 1.5,1.6), but not for women in either population. VA/US Hispanic/White disparities comparisons did not differ for men or women.

CONCLUSIONS: COVID-19 mortality disparities were greater in the US compared with VA for Black men, but similar for Hispanic men. Disparities were present for Black women in the US, but not in the VA, and were not present for Hispanic women in either setting. VA healthcare access and attention to social determinants of health may partially address racial and ethnic COVID-19 mortality disparities.

CONTEXTUALIZING RISK, PATHWAYS, AND SOLUTIONS FOR THE RELATIONSHIP BETWEEN ADVERSE CHILDHOOD EXPERIENCES (ACES) AND TYPE 2 DIABETES: A QUALITATIVE ANALYSIS OF THE LIVED EXPERIENCE OF AFRICAN AMERICAN ADULTS LIVING IN AN INNER-CITY

Jennifer A. Campbell¹; Leonard E. Egede²

¹General Internal Medicine , Medical College of Wisconsin, Milwaukee, WI; ²Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3874535)

BACKGROUND: ACEs confer significant risk for diabetes in adulthood. Within categories of ACEs, evidence shows sexual abuse is related to a 39% increased risk of developing diabetes. The objective of this study was to explore perceptions about risk for sexual abuse, potential pathways leading to diabetes, and solutions based on the lived experience.

METHODS: Three focus groups were conducted with 8-10 participants in each group in the city of Milwaukee, WI. A semi-structured interview guide was used. Focus was placed on sexual abuse based on evidence in the literature demonstrating the relationship with diabetes. Participants were asked to share their perspectives on the prevalence and causes of sexual abuse in their own lives and community and how these experiences relate to adult health, specifically diabetes. Each group ended with a discussion on possible solutions. Grounded theory was used for analysis of qualitative findings. Constant comparisons resulted in emergent themes that were indexed and compared with the rest of the data to establish analytical categories. Analytical categories were further refined as additional data was collected until groups of key themes or categories were identified.

RESULTS: Participants totaled 21 across 3 groups, with approximately 8 – 10 participants in each group. All participants were African American. Average age was 49, average number of years living with diabetes was 13 years. Participants included both men and women. Participants experienced one or more occasions of sexual abuse while growing up. The major themes can be classified as A. Cause, B. Pathway, and C. Treatment/Solution (Figure 1).

CONCLUSIONS: Based on the lived experience, 3 major themes were identified: family instability as a risk for sexual abuse, maladaptive coping as the pathway leading to type 2 diabetes, and social structure as a potential solution to prevent abuse and improve outcomes. Findings from this study provide preliminary data on perspectives of patients who have type 2 diabetes who have experienced sexual abuse. Additionally, these findings emphasize coping as an important factor for mitigating risk of developing diabetes among individuals who have experienced sexual abuse. Future research is needed to examine quantitatively, pathways to inform prevention at the primary, secondary, and tertiary levels of care for both the prevention of sexual abuse, mitigating risk for diabetes, and improving overall health.

COVID-19 TESTING EQUITY IN A LARGE METROPOLITAN AREA OF THE MID-ATLANTIC REGION

Dan H. Rosenfeld¹; Sean Brennan²; Shahrzad Divsalar³; Sarah Joseph Kurien⁴; Chris Keeley⁵; Andrew Wallach^6,4; Theodore G. Long⁴

¹Test & Treat Corps, New York City Health and Hospitals Corporation, New York, NY; ²Mailman School of Public Health, Columbia University, New York, NY; ³Test and Trace, New York City Health and Hospitals Corporation, New York, NY; ⁴Office of Ambulatory Care and Population Health, New York City Health and Hospitals Corporation, New York, NY; ⁵Ambulatory Care, New York City Health and Hospitals Corporation, New York, NY; ⁶NYU Langone Health, New York, NY. (Control ID #3877292)

BACKGROUND: COVID-19 has caused over 43,000 deaths in this large metropolitan area in the Mid- Atlantic, with a disproportional impact on certain communities. As part of the COVID-19 response, this area has directly administered over six million COVID-19 tests (not including millions of indirectly administered tests not covered in this analysis), at no cost to the individual, resulting in nearly half a million poositive results. Given that testing throughout the pandemic has tended to be higher in more affluent areas, these tests were targeted to areas with fewer resources. This study aims to evaluate the impact of this program, specifically, to review its ability to provide equitable testing in economically, geographically, and demographically diverse populations. Of note, in addition to the brick and mortar testing sites evaluated here, this program additionally conducted 2.1 million tests through mobile units, in order to further address testing inequity.

METHODS: Testing data was collected from the in-house Microsoft SQL Server Management Studio Clarity database, representing 6,347,533 total tests, and 449,721 positive tests. These tests were conducted at 48 hospital system locations. Per capita testing rates by zip code tabulation area (ZCTA) and COVID-19 positivity rates by ZCTA were used as dependent variables in separate regressions. Media income, median age, percent English speaking, and percent people of color were used as independent demographic variables, in order to analyze testing patterns across a number of intersecting identities. Negative binomial regressions were run in a Juypter Notebook using Python.

RESULTS: Per capital testing was inversely correlated with median income geographically. The overall pseudo r-squared value when comparing hospital system tests by ZCTA against the selected variables was 0.1101. The number of tests significantly increased as median income fell (SE=1.00000155, p-0.001). Positive tests by ZCTA rose at a significant level alongside the percentage of English-only speakers (SE=0.271, p-0.027).

CONCLUSIONS: This program was able to improve equity through the provision of no-cost testing focused in areas that were disproportionately impacted and had fewer resources. By finding higher numbers of positive tests in resource-poor neighborhoods, the major Mid-Atlantic area was able to deploy additional resources such as contact tracing and isolation/quarantine support including free food delivery and free hotel stays early in the course of hte COVID-19 pandemic. Equitable deployment of testing is feasible and should be considered early on in future epidemics or pandemics.

DELAYS IN CARE AMONG PATIENTS WITH MILD COGNITIVE IMPAIRMENT (MCI) AND MILD COGNITIVE IMPAIRMENT AND DEMENTIA (MCID) DURING THE FIRST WAVE OF THE COVID-19 PANDEMIC

Manying Cui¹; John N. Mafi^1,2; Julia C. Arbanas¹; Mei Leng¹; Chi-Hong Tseng¹; Nina Harawa¹; Catherine Sarkisian¹

¹Medicine – GIM & HSR, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²RAND Corporation, Santa Monica, CA. (Control ID #3876713)

BACKGROUND: The COVID-19 pandemic and associated policies disrupted U.S. ambulatory care. With the growth in the U.S. population with mild cognitive impairment or dementia (MCID), it is important for policymakers to learn about the delays in care Americans with MCID face. We sought to examine delays in care among U.S. Medicare beneficiaries with MCID across Medicare coverage type, ambulatory service type, and racial and ethnic groups during the first wave of the pandemic. We hypothesized that delays in care would be least prevalent among (1) white participants and (2) participants with Medicare Advantage (MA), which allows for greater flexibility in care modalities and more resources for addressing social determinants of health than traditional Medicare (TM).

METHODS: We analyzed survey response data collected during the first 6 months of the pandemic through the Health and Retirement Study, a nationally representative survey of older Americans. To mitigate non-response bias, the participant’s proxy would respond if the participant was unable to do so. We included Medicare beneficiaries aged ≥65 years and used validated cognitive measures to identify participants with MCID. We calculated rates of delays in accessing overall care, medical visits, surgeries, dental care, and prescription drug use, and stratified delays in care across racial and ethnic groups of non-Hispanic Black, Hispanic, and non-Hispanic other participants. We also stratified by MA vs. TM. We accounted for survey clustering and adjusted results by survey weights for national representativeness and response rate.

RESULTS: We identified 1,568 survey respondents, representing an estimated 6,876,434 U.S. Medicare beneficiaries who are 65 and older with MCID; 57.2% were female with the following race/ethnicity: 61.0% white, 20.6% Black, 14.7% Hispanic, and 3.7% other. Approximately 25% of Medicare beneficiaries with MCID reported delays in care during the first wave of the pandemic. There were no statistically significant disparities in delays in overall care (28.7% vs 27.8%, p=0.75), dental care (4.1% vs 4.9%, p=0.52), and surgeries (16.3% vs 13.9%, p=0.31) between racial and ethnic minority and white patients with MCID. There were disparities in prescription drug access between racial and ethnic minority and white patients with MCID (4% vs 2%, p<0.001). We did not find differences in delays in overall care, medical visits, prescriptions, surgeries, or dental visits among patients with MA or TM.

CONCLUSIONS: In this nationally representative survey of older Americans, we found that one-quarter of Medicare beneficiaries with MCID reported delays in care during the first wave of the COVID-19 pandemic. MA coverage was not associated with improved access to care. Racial and ethnic minority patients with MCID reported more delays in prescription drug access than white patients, raising concerns about ensuring equitable access to prescription drugs during the pandemic.

DESIGNING AN IMPLEMENTATION STRATEGY TO INCREASE SOCIAL NEEDS SCREENING IN A RESOURCE LIMITED CLINIC WITH STAKEHOLDER INPUT.

Elena Byhoff¹; Amy LeClair²; Anayelly Medina³; Cara Smith⁴; Tuhin Roy⁵; Mari-Lynn Drainoni^6,7

¹Medicine, University of Massachusetts Chan Medical School, Worcester, MA; ²Department of Medicine, Tufts Medical Center, Boston, MA; ³Tufts University School of Medicine, Boston, MA; ⁴Family Medicine, Duke University Health System, Durham, NC; ⁵Greater Lawrence Family Health Center, Lawrence, MA; ⁶School of Public Health, Boston University, Boston, MA; ⁷Infectious Diseases, Boston Medical Center, Boston, MA. (Control ID #3868719)

BACKGROUND: Collection of social needs screening data in clinical care is increasing exponentially. In practice, broad implementation of data collection is difficult due to contextual factors across clinical practices. This is particularly true for resource-limited settings, such as Federally Qualified Health Centers (FQHCs) that serve predominantly low income populations who often have high prevalence of unmet social needs. We used the Practical Robust Implementation and Sustainability Model (PRISM) to examine internal (patient, staff and provider) and external (clinic and community referral) factors that impact implementation of social needs screening in clinical encounters, and design an implementation strategy to improve screening. METHODS: Between Jan – March 2022, we conducted a rapid ethnographic assessment with opportunistic interviews to understand current patient workflow and real time implementation processes of social needs screening in an FQHC. We then conducted focus groups (n= 5) to understand processes, perspectives, and context for improving social needs screening among clinic staff and patients. A stakeholder panel was convened from members of each group to design an implementation strategy for social needs screening across the clinic.

RESULTS: Our findings suggest three key barriers to implementation. First, the electronic medical record (EMR) design limited accessibility and feasibility of routine social needs screening and documentation within clinic workflow. Second, social needs screening is not prioritized across all clinic staff. Clinic staff were unable to keep up with data collection demands on top of providing health care, thus allowing social needs screening to “fall off” the routine patient intake. Third, clinic staff had limited knowledge of both patient perceptions of social needs screening and opportunities for social services referral to address identified needs. Implementation strategies developed in partnership with clinical and patient stakeholders addressed all three barriers: improved EMR accessibility and reminders, improved workflow for screening with a “no wrong door” approach, and a stakeholder derived peer education campaign to improve knowledge and buy-in for screening.

CONCLUSIONS: Policy change is necessary but not sufficient to facilitate screening for social needs in the clinical context. Resource-limited settings, such as FQHCs, where patients face disproportionate unmet social needs, may benefit from targeted stakeholder engagement to improve screening implementation.

DEVELOPING A PATIENT INFORMED BIAS REPORTING TOOL WITH INPUT FROM VULNERABLE PATIENT POPULATIONS

Delia Shen, Ashley Odai-Afotey, Sonya Davey, Esteban Gershanik. Internal Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #3874265)

BACKGROUND: Data show that vulnerable populations, including racial/ethnic minorities and those with limited English proficiency (LEP), have increased risk of a hospital safety event. However, when reporting systems are stratified by race/language, there are under-reported safety and bias events in vulnerable patients. Changes are needed to incorporate a health equity framework in reporting processes. It is essential to analyze bias incidents in non-punitive, anonymous methods to address implicit and explicit staff bias. We aim to develop an anonymous, voluntary patient-facing Event Reporting Tool within Internal Medicine to collect bias and safety incidents experienced by patients of color and patients with LEP to inform integration into existing hospital-wide reporting structures.

METHODS: This is a qualitative study where patients of color and LEP were surveyed at an academic medical center to: 1) understand experiences of racial and/or language discordance bias 2) elucidate barriers to report incidents and 3) gather feedback to inform tool development. Survey responses were recorded with Likert scales. Open ended questions were coded for themes. The tool was reviewed with the Quality and Safety department and iterative editing meetings with the Patient and Family Advisory Council, consisting of patient volunteers.

A convenience sample of patients admitted to Internal Medicine inpatient units was interviewed. Inclusion criteria were: self-identified non-White and/or non-English speaking patients age>18.

RESULTS: 27 patients were interviewed, with 2 declining to finish. 44% were female with ages 22-81 and mean age 48.5. 63% identified as Black, 33.3% Latino, 7.4% Asian, 7.4% American Indian, and 3.7% Pacific Islander. 22% cited bias incidents due to perceived race, ethnicity or language. The majority (89%) felt the care team explained in a way they could understand. However, 22% disagreed about always receiving enough details about their care. 15% overheard negative conversations about themselves. 11% did not trust their medical team decision making.

77.8% spoke English and 22.2% spoke Spanish as their primary language. Of those who spoke Spanish, they noted that staff only used interpreters 60% of the time. Patients with chronic conditions, including pancreatitis and sickle cell disease, cited bias incidents and perceived “pain-seeking” behavior due to their race. Patients noted care differences when roommates were White or primary English speakers. Patients expressed mixed feelings about their likelihood to report adverse events, citing lack of trust with individuals or the system. Most preferred phone call, internet or paper survey for reporting methods.

CONCLUSIONS: In this qualitative study, vulnerable patients cited bias when asked specifically about unfair incidents related to race or language. This Event Reporting Tool will be used to restructure the reporting system to better capture experiences of bias and to serve as a model for other healthcare institutions.

DEVELOPMENT OF A CONCEPTUAL FRAMEWORK TO EXPLAIN THE RELATIONSHIP BETWEEN ADVERSE CHILDHOOD EXPERIENCES (ACES) AND CLINICAL OUTCOMES IN ADULTS WITH TYPE 2 DIABETES: A MIXED METHODS STUDY

Jennifer A. Campbell¹; Leonard E. Egede²

¹General Internal Medicine , Medical College of Wisconsin, Milwaukee, WI; ²Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3874559)

BACKGROUND: Prior work shows ACEs increase the risk for diabetes, with sexual abuse identified as a major driver of risk amongst ACE categories. Limited data exist on understanding the pathways between sexual abuse, diabetes risk, and diabetes outcomes. This study used mixed methods to identify risk constructs and test the relationships with clinical outcomes in adults with diabetes.

METHODS: Qualitative: Three focus groups were conducted with adults with type 2 diabetes. A semi-

structured interview guide was used to explore risk factors for sexual abuse and pathways leading to diabetes outcomes. Grounded theory was used for analysis of qualitative findings and model development. Major themes were constructed into a conceptual framework with risk constructs based on participant perspectives of how sexual abuse occurs and the factors that influence poor outcomes in diabetes (Figure 1). Quantitative: Wave 1 (1995-1996) and Wave 2 (2004-2006) of the Midlife in the US (MIDUS) study was used and analyzed cross-sectionally. The model was used for variable selection. Logistic and linear regression models were run to assess the relationship between risk constructs, sexual abuse, coping, physical health, and A1C. Separate models were run for each hypothesized relationship.

RESULTS: Qualitative: Focus group participants totaled 21 adults with diabetes, both men and women. Average age was 49. Participants experienced one or more occasions of sexual abuse while growing up. Major themes served as the risk constructs. Quantitative: The final sample included 464 adults with diabetes. In the adjusted models, family instability was significantly associated with increased odds of reporting childhood sexual abuse for foster care (OR=2.65; CI=1.07; 6.54) and having an absent father (OR=0.59; OR=0.35-0.99) but not financial hardship. Maladaptive coping was significantly associated with A1C for comfort eating (b=0.19; CI=0.06;0.31) only. For physical and mental health, fair physical health was significantly associated with HbA1c (b=0.64; CI=0.02; 1.26).

CONCLUSIONS: Certain risk constructs increase risk for odds of sexual abuse, while sexual abuse increases odds of maladaptive coping, and maladaptive coping is associated with worse A1C. Future research is needed to test the direct and indirect pathways and to identify targets for future interventions.

DIFFERENCES IN THE CHARACTERISTICS OF PHYSICIAN NETWORKS THAT TREAT WHITE AND BLACK PATIENTS WITH HEART DISEASE

Ioana Popescu^1,2; Cheryl Damberg²; Luke Matthews²

¹Division of General Internal Medicine, UCLA, Los Angeles, CA; ²RAND Corporation, Santa Monica, CA. (Control ID #3873971)

BACKGROUND: Black-White disparities in high quality hospital use for heart disease treatment may be due to Black and White patients seeing different physicians. The objective of this study was to map physician patient-sharing networks for Medicare patients and assess for Black-White differences in patient-sharing between primary care physicians (PCPs) and cardiologists.

METHODS: We used 100% Medicare Inpatient, Outpatient and Carrier claims for 2016-2017 to identify Black and White fee-for-service Medicare patients with heart disease and the PCPs and cardiologists treating them in hospital referral regions (HRRs) with at least 10 physicians sharing 2 or more Black and White patients (N=226). We used physician claims on shared patients to map separate HRR-level physician networks for Black and White patients focused on PCP to cardiologist patient sharing. We calculated two race-specific network measures: degree (number of cardiologists with whom a PCP shares patients) and transitivity (propensity of physicians to form tightly connected groups). Measures were adjusted for Black- White differences in physician patient panel size and calculated for all settings (hospital and office) and office settings only.

RESULTS: Compared to White patients, Black patients had more cardiology visits, overall (6.9 vs 6.6, p<.001) and with unique cardiologists (3.0 vs. 2.6, p<.001), and were treated less often in office settings (31.7% vs. 40.5%). The Black-White mean differential network degree was 23.4 in all settings and 3.6 in office settings (p<.001 for both), meaning that PCPs shared Black patients with more cardiologists than White patients. The mean differential network transitivity was -0.2 for all settings (p<.001) and near zero for office settings (p=.74), meaning that physicians were less connected in the Black vs. White patient-sharing networks in all but office settings.

CONCLUSIONS: Black-White differences in patient-sharing between PCPs and cardiologists likely reflect differences in referrals, care coordination and ultimately quality of care. Both physician network and patient factors may contribute to these patterns. and/or patients (e.g., regaining community trust).

DIRECT AND INDIRECT RELATIONSHIP BETWEEN HISTORIC REDLINING AND NATIONAL PREVALENCE OF DIABETES: A STRUCTURAL EQUATION MODELING ANALYSIS

Leonard E. Egede²; Rebekah J. Walker¹; Sebastian Linde³; Jennifer A. Campbell⁴

¹Medicine, Medical College of Wisconsin, Milwaukee, WI; ²Medicine, Medical College of Wisconsin, Milwaukee, WI; ³Medicine, Medical College of Wisconsin Department of Medicine, Milwaukee, WI; ⁴General Internal Medicine , Medical College of Wisconsin, Milwaukee, WI. (Control ID #3876093)

BACKGROUND: Structural racism has emerged as an important contributor to poor health outcomes. Historic redlining, the previously legal practice of systematically denying credit access and insurance, resulted from Home Owners’ Loan Corporation (HOLC) residential security maps graded on a color coded scale (A (Green)=Best; B (Blue); C (Yellow); D (Red)=Hazardous), hence the term redlining. The goal of this study was to investigate the direct and indirect relationships between historic redlining and prevalence of diabetes in a national sample.

METHODS: We combined census tract level data across multiple sources: a) diabetes prevalence from CDC PLACES 2019 database, b) HOLC grade from Mapping Inequality project, and c) incarceration risk, poverty, housing, education, employment, job environment, economic mobility, and demographics, from Opportunity Insights database. The assignment of redlining to present-day census tract was done based on overlap with historically HOLC graded areas. The final analytic sample consisted of 9,590 US census tracts. Structural equation modeling was then used to investigate direct and indirect relationships between redlining and diabetes prevalence through possible mediators of health care access, community resources, social capital, and social risk. Stata v16 was used for the analysis and analyses were adjusted for population.

RESULTS: Higher prevalence of diabetes was directly associated with more redlining within a census tract (0.28, p<0.001). All indirect paths were significant with the three strongest indicating diabetes prevalence is indirectly associated with redlining via health care access (0.48, p<0.001); community resources measured via education level (-0.44, p<0.001); and social risk measured via income (-0.23, p<0.001). Figure 1 shows standardized coefficients to allow comparison with higher numbers indicating stronger relationships. CONCLUSIONS: Consistent with our conceptual framework, redlining has significant direct and indirect relationships with diabetes prevalence. Indirect relationships include health care access, community resources including employment and education, social capital, and social risk factors of low income and high incarceration.

DISAGGREGATION OF ASIAN-AMERICAN ETHNICITY CATEGORY REVEALS DISPARITIES IN HOSPITAL LENGTH OF STAY AND DIAGNOSES

Yasuko M. Mano¹; Bianca J. Katnik²; Annie Ro²; Andrew Young¹

¹Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA; ²University of California Irvine, Irvine, CA. (Control ID #3869511)

BACKGROUND: Asian-Americans are the fastest-growing minority in the United States and are comprised of different subgroups. Data for Asian subgroups are often aggregated in research, masking disparities in health and hospital outcomes. Previous studies describe disparities in cardiovascular disease and mortality among Asian subgroups. To our knowledge, no studies have evaluated differences among Asian subgroups in hospitalized patients. We aimed to evaluate differences in average length of stay (ALOS) and illness severity among Asian subgroups for inpatients at a public hospital in Los Angeles, California.

METHODS: We conducted a retrospective analysis of all inpatient encounters at LAC+USC Medical Center in 2019. We combined data from Cerner PowerInsight and Vizient Health System. All data were de-identified to conform to HIPAA requirements. The four Asian subgroups with over 100 encounters were included in the analysis: Chinese, Filipino, Korean, and Vietnamese. Multivariable linear regression was used to assess ALOS, and multivariable logistic regression was used to assess illness severity (reference group: Chinese). Insurance type, primary language, living status, and gender were included in our model to control for confounding. Supplementary regression analyses were performed to assess disparities among the groups in relation to diagnoses. The top five Clinical Classification Software (CCS) diagnostic categories among the cohort were selected as outcomes of interest: septicemia, hypertension, alcohol-related disorders, diabetes, and biliary tract disease. P-values less than 0.05 were deemed significant.

RESULTS: Filipinos were noted to have a significantly lower ALOS compared to Chinese (p-value <0.05). While all patients aggregated had an ALOS of 5.93 days, Chinese had a higher ALOS of 7.74 days. Our data show no significant difference in illness severity among Asian subgroups. Koreans and Filipinos had a larger probability of admission for complications from hypertension compared to Chinese (odds ratio of 2.99 and 5.25, respectively; p-value <0.01). The probability of being admitted for complications from biliary tract disease was larger for Filipinos compared to Chinese (odds ratio of 5.85; p-value <0.05). There were no significant differences in probabilities of being admitted for complications from diabetes, septicemia, or alcohol-related disorders among Asian subgroups.

CONCLUSIONS: Our data show significant differences in ALOS and probabilities of being admitted for complications from hypertension and biliary tract disease among Chinese, Filipinos, Koreans, and Vietnamese. Although limited by small sample sizes, our results show how disparities among Asian subgroups are masked by data aggregation. The Asian-American race category should be disaggregated when analyzing health disparities.

DISPARITIES IN RECEIVING TREATMENTS FOR ALCOHOL USE DISORDER AMONG ALL OF US PARTICIPANTS

Phuc H. Le¹; Jacob Rich^1,2; Eden Y. Bernstein³; Sudie E. Back⁴; Hamlet Gasoyan⁵; Thanh C. Bui⁶; Gina Ayers⁷; Michael B. Rothberg⁸

¹Center for Value-based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH; ²Case Western Reserve University, Cleveland, OH; ³General Internal Medicine, Massachusetts General Hospital, Boston, MA; ⁴Medical University of South Carolina, Charleston, SC; ⁵Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; ⁶College of Medicine, Department of Family and Preventive Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK; ⁷Pharmacy, Cleveland Clinic, Beachwood, OH; ⁸Internal Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #3876051)

BACKGROUND: Alcohol use disorder (AUD) affects approximately 32 million US adults each year. Both medications and behavioral interventions (e.g. psychotherapy) are effective for AUD yet underutilized. Evidence on disparities in treatment utilization is inconsistent and limited. We examined racial/ethnic and socioeconomic disparities in receipt of AUD treatments in US adults.

METHODS: We conducted a retrospective analysis using All of Us Research Program’s nationwide data. We included adults ≥18 years with AUD, defined by ICD codes for alcohol abuse or dependence. Treatment was defined as having any prescription of medications (disulfiram, acamprosate, and naltrexone) or psychotherapy (CPT codes for individual, family or group-based psychotherapy sessions). We compared rates of treatment across racial/ethnic groups, income levels, insurance types, and area deprivation index (ADI) quintiles. In multivariable logistic models, we assessed the association between these factors and receipt of medication or psychotherapy, adjusted for additional sociodemographic characteristics and coexisting substance and other mental health disorders.

RESULTS: We identified 15,315 patients with AUD. Mean age was 55 years; 59% were male. Most patients did not receive any treatment (70%) while 7% received medication only, 18% psychotherapy only, and 5% both medication and psychotherapy. In multivariable models, Black and Hispanic patients, those with Medicare plus Medicaid or Veteran Affairs (VA) plus Medicare, and those living in fourth and fifth ADI quintile areas were less likely to receive medication compared to White patients, those with private insurance and living in the first ADI quintile areas, respectively. In contrast, higher education level and income were associated with larger odds of receiving medication. Black patients (vs. White) were more likely to receive psychotherapy, as were those with VA insurance (vs. private insurance), and higher income. Patients who were homeless, had Medicaid (vs. private insurance), or lived in more economically deprived areas were less likely to have psychotherapy. Finally, patients with other coexisting substance and mental health disorders had larger odds of receiving medication and psychotherapy than those without.

CONCLUSIONS: Disparities in receipt of AUD treatments exist across race/ethnicity and socioeconomic subgroups. Specifically, Blacks and patients with VA insurance were more likely to receive psychotherapy but not medication. Patients living in more economically deprived areas were less likely to receive both medication and psychotherapy. Systematic approaches are required to improve diverse patient access to effective treatments for AUD.

DISPARITIES IN RECOMBINANT ZOSTER VACCINE COVERAGE AMONG ADULTS IN THE UNITED STATES BY RACE AND ETHNICITY AND SOCIAL DETERMINANTS OF HEALTH David Singer¹; Kathryn Evans²; Nikita Stempniewicz¹; Veronique Page³; Samuel Huse²; Ariel Berger²

¹US Health Outcomes and Epidemiology, GSK, Philadelphia, PA; ²Evidera, Bethesda, MD; ³Evidera, Montreal, QC, Canada. (Control ID #3855623)

BACKGROUND: Recombinant zoster vaccine (RZV) has been recommended for prevention of herpes zoster (HZ) in adults aged ≥50 years in the United States (US) since 2018. Despite this, RZV coverage remains suboptimal and previous studies have found disparities in HZ vaccine coverage by race/ethnicity. This study aimed to describe disparities in RZV coverage by race/ethnicity and by social determinants of health (SDOH).

METHODS: The study used data from the 2020 National Health Interview Survey (NHIS), a cross-sectional survey of noninstitutionalized civilian households in the US conducted by the National Center for Health Statistics at the Centers for Disease Control and Prevention. NHIS uses a geographically clustered sampling design and includes survey weights for projecting findings to the noninstitutionalized US population. The survey includes questions on respondent clinical characteristics, SDOHs, race/ethnicity (self-reported) and receipt of vaccines, e.g., RZV (at least one dose). We report RZV coverage for all adults in the US aged ≥50 years, as well as by SDOHs and race/ethnicity. Survey weights were applied to project findings from each analysis to the US population. To assess for differences in vaccine coverage across groups, Rao-Scott Chi- square tests were used. Two-sided CIs were calculated using the Clopper-Pearson method adapted for complex surveys by Korn and Graubard.

RESULTS: Of the 31,568 individuals surveyed in the 2020 NHIS, 18,384 were aged ≥50 years. RZV coverage in the US population aged ≥50 years was estimated to be 14.1% (95% confidence interval [CI]: 13.4-14.8%), with an estimated 15,791,839 adults in the US aged ≥50 years having received at least one dose as of the time of the survey. Significant differences were observed by race/ethnicity, an estimated 16.6% (95%CI: 15.8-17.5%), 13.7% (95%CI: 10.1-18.0%), 6.9% (95%CI: 5.4-8.6%), and 6.3% (95%CI: 5.1-7.7%) of non-Hispanic white, non-Hispanic Asian, non-Hispanic Black, and Hispanic adults were covered, respectively (Rao-Scott Chi-square p<0.0001). Among adults reporting household income ≥$100,000, RZV coverage was 18.8% (95%CI: 17.4-20.3%) versus 12.8% (95%CI: 11.4-14.4%) and 8.8% (95%CI: 7.9-9.7%) among those with self-reported household incomes of $35,000-$49,999 and <$35,000, respectively. Adults with high food security had RZV coverage of 15.2% (95%CI: 14.4-16.1%) while those with marginal, low, or very low food security had lower coverage (range: 5.2-7.3%).

CONCLUSIONS: RZV coverage in the overall US adult population aged ≥50 years is suboptimal and significant disparities exist in coverage by social determinants of health and by race/ethnicity. These findings demonstrate the need to improve vaccination against HZ in older adults and show that it will be important to ensure this recommended preventive care service is provided in a more equitable manner.

DISPARITIES IN VIDEO CARE USE AMONG VETERANS WITH CARDIOVASCULAR DISEASE Rebecca L. Tisdale^1,3; Claudia Der-Martirosian²; Caroline Yoo⁴; Karen Chu²; Donna Zulman^5,1; Lucinda B. Leung^6,2

¹Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA; ²Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles (GLA), US Department of Veterans Affairs, Washington, DC; ³Department of Health Policy, Stanford University School of Medicine, Stanford, CA; ⁴Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ⁵Medicine, Stanford University, Stanford, CA; ⁶Division of General Internal Medicine, UCLA David Geffen School of Medicine & West LA VA Medical Center, Los Angeles, CA. (Control ID #3860899)

BACKGROUND: Video care expanded rapidly in the Veterans Health Administration (VA) at the onset of the COVID-19 pandemic and remains a significant proportion of all VA care. Prevalence of cardiovascular disease (CVD) in Veterans is high, and ensuring access to care for CVD will likely require continued virtual care use. However, there remains a lack of evidence regarding which patients with these CVD conditions are more likely to receive video care. We sought to characterize use of video care for Veterans with two common cardiovascular diseases, heart failure and hypertension.

METHODS: This retrospective cohort study included Veterans established in VA primary care with diagnoses of heart failure and/or hypertension between 3/11/2019 and 3/10/2022, i.e., in the calendar year prior to the novel Coronavirus (COVID-19) pandemic and for the first two pandemic years. We identified individual-level predictors of one or more video-based visits, accounting for patient- and site-level clustering with a two-level mixed-effects logistic regression model adjusted for sociodemographic and clinical covariates and time.

RESULTS: Our analytic cohort comprised 3,807,820 Veterans with diagnoses of heart failure, hypertension, or both with 52 million visits. 456,901Veterans had both heart failure and hypertension, 50,753 had heart failure only, and 3,300,166 had hypertension only. Veterans with heart failure and hypertension had an average baseline age of 71.6 years and mean Charlson Comorbidity Index of 3.0. 2.9% were female at birth, and 34.8% lived in a rural or highly rural setting.

In our multi-level logistic regression model, odds of using video care were highest during the first year of the pandemic, then declined in the second (AOR 15.3, 95% CI 15.1-15.4 and 11.5, 95% CI 11.3-11.6, respectively, compared to the pre-pandemic year). Male patients had lower odds of ever using video care than female patients (adjusted odds ratio [AOR] 0.73, 95% confidence interval [CI] 0.72-0.74). Age showed a gradient: patients 75 years or older had an AOR of 0.38 compared to those aged 18-44 years (95% CI 0.38-0.39). Rural-dwelling Veterans had lower odds of using video care than urban-dwellers (AOR 0.71, 95% CI 0.70-0.71). Veterans with heart failure had slightly higher odds of video care use than those with hypertension only (AOR 1.06, 95% CI 1.05-1.07).

CONCLUSIONS: Veterans with CVD had a 15-fold increase in odds of use of video-based care in the first year of the COVID-19 pandemic. Male, older, and rural-dwelling Veterans had lower odds of using video care than their respective reference groups. Video care remains an important proportion of care delivered to Veterans with cardiovascular disease. Given lower odds of video care among certain veteran groups, continued expansion of video care could make CVD services increasingly inequitable. As VA expands virtual care for CVD, these insights can inform equitable and effective triage of patients to virtual versus in-person care.

DISPARITY IN AGE OF PRESENTATION OF ALCOHOL-RELATED CIRRHOSIS AND ALCOHOL-RELATED HEPATITIS DUE TO THE COVID-19 PANDEMIC IN A TERTIARY U.S. CENTER

Corinne P. Camp¹; Elizabeth Esselman¹; Angela Keniston²; Lauren McBeth³; Susan Calcaterra⁴; Reem M. Hanna⁵

¹Internal Medicine, University of Colorado, Denver, CO; ²Division of Hospital Medicine, University of Colorado, Aurora, CO; ³Medicine/Hospital Medicine, University of Colorado, Aurora, CO;⁴Medicine, University of Colorado - Anschutz Medical Campus, Aurora, CO; ⁵Department of Medicine, University of Colorado, Denver, CO. (Control ID #3876794)

BACKGROUND: The average age of patients hospitalized for chronic liver disease (CLD) in the US is 57 years old. However, data suggests that alcohol-related cirrhosis (ARC) presents at a younger age compared to other causes of CLD, with one study demonstrating that 11% of Caucasian and 16% of Hispanic patients diagnosed with ARC were younger than 40 years old. Additionally, data has shown increased hospitalizations for alcohol related liver disease since the start of the COVID-19 pandemic with a possible cause being increased alcohol consumption in the US since 2019. Our study aimed to evaluate if the COVID-19 pandemic contributed to an earlier age of presentation of ARC and/or alcohol-related hepatitis (ARH) in hospitalized patients, specifically among Hispanic and Black populations compared to non-Hispanic white populations.

METHODS: This was a retrospective observational analysis of all hospitalized patients, aged 18 years and older, with an ICD 9/10 code for ARC or ARH to a university hospital in Colorado from January 2018 to December 2019 and January 2021 to April 2022. We limited encounters to the patient’s first hospitalization (index encounter) during each time period and evaluated for temporal trends across time periods using chi- square tests.

RESULTS: A total of 2,366 patients were included. An unadjusted chi-square test was used to evaluate whether the proportion of patients younger than 40 years who were hospitalized with ARC and/or ARH increased relative to those >40 years after the start of the COVID pandemic. We observed a significant increase in the proportion of patients younger than 40 in the time periods after the start of COVID (18.2%) compared to before (12.5%, p= 0.0001). While the comparison limited to Hispanic patients was trending towards significant, there was insufficient data to corroborate this.

CONCLUSIONS: Our preliminary data shows there was a significant increase in the proportion of younger patients hospitalized with ARC and ARH between the two study time periods. Our study includes hospitalizations that occurred before and during the COVID-19 pandemic. Future work should explore temporal trends of ARC and AHR related hospitalizations by race and ethnicity to inform culturally appropriate interventions to address risks related to alcohol use among various populations.

DISTANCE TO CARE BARRIERS FOR FORMERLY HOMELESS INDIVIDUALS IN A LARGE NATIONAL SURVEY

Stefan Kertesz^2,8; Aerin deRussy¹; Sally K. Holmes²; Ann E. Montgomery^2,3; Kevin Riggs^2,8; April Hoge¹; Audrey L. Jones^4,9; Lillian Gelberg^5,6; Joshua S. Richman^2,8; Erika L. Austin⁷; Adam J. Gordon^4,9.

¹Research , Birmingham VA Medical Center, Birmingham, AL; ²Birmingham VAMC, U.S. Department of Veterans Affairs, Birmingham, AL; ³Health Behavior, The University of Alabama at Birmingham School of Public Health, Birmingham, AL; ⁴VA Salt Lake City Health Care System, Salt Lake City, UT; ⁵Family Medicine, University of California Los Angeles, Los Angeles, CA; ⁶VA of Greater Los Angeles, Los Angeles, CA; ⁷Biostatistics, The University of Alabama at Birmingham School of Public Health, Birmingham, AL; ⁸The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL; ⁹University of Utah Health, Salt Lake City, UT. (Control ID #3873911)

BACKGROUND: The impact of distance on access to care for formerly homeless (FH) individuals –who are often accommodated in areas remote from city centers– has not been studied. Using a national survey of FH Veterans, we hypothesized that (a) actual distance would be associated with reported barriers to care, and (b) reported barriers would predict lower primary care (PC) utilization.

METHODS: In 2018, we surveyed 4654 FH Veterans who got PC at 26 VA Medical Centers (VAMCs). Dependent variables: Reported distance barrier, based on “does the distance you…travel make it difficult to get care at [VAMC]?” Distance was “as the crow flies” from mailing address to VAMC. PC utilization was 12-month visit count. Covariates:

Predisposing: gender, race/ethnicity, age

Enabling/impeding: difficulty paying for needs, employment, social support, recent criminal justice experience

Need: emotional distress, chronic pain, self-reported health, drug or alcohol problem, chronic homelessness, 24 Elixhauser comorbidities

Analysis: We used multivariable logistic regression to model reported distance barrier in relation to geographic distance and all covariates, with a site random effect. A generalized linear mixed regression modeled PC visit counts in relation to a reported distance barrier, the listed covariates (sans geographic distance) and Elixhauser comorbidities.

RESULTS: Among FH respondents, 40% resided <5 miles, 29% >5 to <10 miles, 19% >10 to <20 miles and 12% >20 miles from their VAMC. Reporting a distance barrier (28% overall) rose with distance (14%, 27%, 39% & 57% across 4 categories, Mantel-Haenszel Χ² p<0.001). Multivariable-adjusted predicted probabilities rose similarly(Fig). Most covariates were significant, with odds ratios of 1-2. In multivariable regression, respondents reporting distance barriers had fewer PC visits (adjusted mean 2.9, 95% CI 2.7-3.2) compared to those not reporting (mean 3.5, 95% CI 3.4-3.7), adjusted for all covariates.

CONCLUSIONS: Reporting a distance barrier to care is common among FH Veterans, and is associated with fewer PC visits, even for those 5 or more miles from clinic, which applied to 60% of respondents. Health systems serving formerly homeless individuals should address these challenges, with transportation (e.g. rideshares), mobile services or telehealth.

DIVERSITY, BIAS, AND DISCRIMINATION IN PRIMARY CARE: FACULTY SELF- ASSESSMENT OF ATTITUDES, OPINIONS, AND EXPERIENCES IN AN ACADEMIC HEALTH SYSTEM

Erica Chan²; Regina Wang³; Megha Shankar¹; Nancy Binkin⁴; Akbar Rahman³

¹Medicine, University of California San Diego, La Jolla, CA; ²School of Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ³Family Medicine, University of California San Diego, La Jolla, CA;⁴Public Health, University of California San Diego, La Jolla, CA. (Control ID #3876215)

BACKGROUND: Academic medical centers are looking to advance diversity, equity, and inclusion (DEI) efforts through major structural changes. Efforts include promoting faculty and student diversity, monitoring patient outcomes, and integration of DEI principles into clinical training. While increasing diversity of trainees is crucial, downstream efforts to improve diversity, equity, and inclusion in clinical practice are more challenging. Understanding faculty members’ experiences, opinions, and perceptions around DEI issues and discrimination, is essential to dismantling structural racism, and diversifying the physician workforce. This pilot study of primary care clinical faculty was undertaken to fill this research gap, and guide internal efforts.

METHODS: From 2021-2022, we distributed an online survey to faculty in the Departments of Internal Medicine (IM) and Family Medicine (FM) at an academic medical center in the California-Hawaii Region (N=132, response rate 55%). The survey used a 5-item Likert scale to assess personal observations and actions related to DEI, and perceptions of colleagues’ DEI knowledge and practices; it also collected data on demographic characteristics, personal and family background information, and personal experiences of discrimination. Likert scale items were dichotomized, and then summed to create a composite score. Items were then compared between demographic groups and those who did and did not experience discrimination, using t-test and chi-squared testing.

RESULTS: Our sample included 72 respondents (30 IM, 42 FM), of whom 67% were female, 56% were White, and 31% were Asian/Pacific Islander. A quarter (25%) were born outside of the U.S; mean year of medical school graduation was 2000 (SD=11). Most reported past experiences of discrimination (83%). A total of 83% had witnessed patients experiencing bias or stereotyping and 56% had witnessed such behaviors toward colleagues. Compared to faculty of color, white faculty were significantly more likely to perceive their colleagues favorably around issues of bias, diversity, and equity (p=0.007). Those who experienced discrimination were more likely to witness instances of patients experiencing bias or stereotyping (p=0.043), and to intervene in such instances (p=0.044), than those who had not experienced discrimination.

CONCLUSIONS: Our results show that personal experiences of discrimination, as well as witnessed episodes of bias and stereotyping against patients and colleagues, are common among clinical faculty. They also provide quantitative evidence of the difference in perception of DEI climate, between white faculty and faculty of color. These results also suggest the possibility of creating a virtuous cycle, whereby recruitment of faculty from marginalized backgrounds can improve the experience of patients who currently experience bias and stereotyping, since these faculty are more likely to intervene and potentially change institutional culture.

DOES DISABILITY IDENTITY INFLUENCE PATIENTS’ PERCEPTIONS OF TRUST, RESPECT, AND FAIRNESS?

Maggie R. Salinger¹; Brian Feltz²; Stephanie H. Chan^4,3; Anna Gosline^4,3; Carine Davila⁸; Suzanne Mitchelle⁵; Lisa I. Iezzoni^6,7

¹General Internal Medicine, Massachusetts General Hospital, Boston, MA; ²3D Research Partners LLC, Boston, MA; ³Blue Cross Blue Shield of Massachusetts, Boston, MA;⁴Massachusetts Coalition for Serious Illness Care, Boston, MA; ⁵University of Massachusetts Chan Medical School, Worcester, MA; ⁶Health Policy Research Center, Massachusetts General Hospital, Boston, MA; ⁷Harvard Medical School, Boston, MA; ⁸Internal Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #3858850)

BACKGROUND: People with functional impairments do not necessarily self-identify as disabled. However, most studies of disabled populations use impaired functioning alone to specify these individuals. With this functional status-based definition, studies have shown disparate care quality for people with disability. We examined whether disability identity itself was associated with differing perceptions of healthcare encounters.

METHODS: We analyzed findings from a nationally representative survey of 1854 US adults conducted in Spring 2021. The survey asked seven impairment questions [six on functional status, adopted from the American Community Survey (ACS-6) and one on health decline]; it also asked, “do you have a disability?” We grouped the 816 participants with impairments by disability identity: Yes-DI=“yes” to disability; No-DI=“no” to disability but “yes” to ≥ 1 impairment question. We also dichotomized Likert scale measures of trust, communication, respect, and fairness in healthcare encounters (henceforth “procedural justice”). Across groups, we compared sociodemographic indicators and rates of dichotomized procedural justice responses (X², ANOVA). We performed multivariable logistic regressions adjusting for baseline characteristics to estimate effects of disability identity (Yes-DI vs. No-DI) on perceptions of procedural justice. All analyses applied survey weights to reflect the US Census.

RESULTS: In Yes-DI (disability identity, n= 340), 39% (n=131) indicated no impairment in response to the ACS-6 questions and thus would have been missed by this measure of function alone. In No-DI (n=476), all participants reported impairments but no disability identity. Most functional impairment subtypes were more prevalent in Yes-DI than in No-DI; Yes-DI had more total impairments [Yes-DI vs. No-DI mean(SD): 1.7(1.3) vs. 1.4(0.8), p<0.001] whereas No-DI had a higher prevalence of reported health decline [No-DI: 329/476 (69%) vs. Yes-DI:178/340 (52%)].

Yes-DI was also older and had higher proportions of participants who were Black, single, not-working, publicly-insured, in low income brackets, and/or who had less than a college degree. Compared to No-DI, Yes-DI rated clinician effort and understanding of health goals more favorably but had worse ratings of fairness and respectful communication. In multivariable models, disability identity was independently associated with higher odds of reporting unfair treatment but also of being unafraid to disagree or ask questions.

CONCLUSIONS: Disability is an integral dimension of diversity and identity that is distinct from impairment status. We showed that perceptions of fairness, communication, and respect differ between people with impairments who do vs. do not self-identify as having disability. In addition to functional status, health systems should capture disability identity to better assess and mitigate disparities in care quality and outcomes for people with impairments.

DO SOCIAL NEEDS INTERVENTIONS ADVANCE RACIAL HEALTH EQUITY? FINDINGS FROM A RAPID REVIEW OF SCOPING REVIEW

Crystal W. Cene¹; Meera Viswanathan⁶; Caroline Fichtenberg²; Sara M. Kennedy⁶; Nila A. Sathe⁶; Laura M. Gottlieb³; Yuri N. Cartier⁴; Monica E. Peek⁵

¹Medicine, University of California San Diego, La Jolla, CA;²Center for Health and Community, UCSF, San Francisco, CA; ³Family and Community Medicine, UCSF, San Francisco, CA; ⁴Social Interventions Research and Evaluation Network, University of California, San Francisco, San Francisco, CA; ⁵Medicine, The University of Chicagoa, Chicago, IL; ⁶RTI International, Research Triangle Park, NC. (Control ID #3874636)

BACKGROUND: Social needs interventions aim to improve health outcomes and mitigate inequities by addressing health-related social needs, such as lack of transportation or food insecurity. However, it is unclear whether these interventions are reducing racial or ethnic inequities. We sought to examine whether studies of social needs interventions explain how race and ethnicity were conceptualized and used in analyses of intervention effectiveness.

METHODS: We conducted a rapid review of studies in multiracial or multiethnic populations included in the Patient-Centered Outcomes Research Institute’s (PCORI’s) recent scoping review and evidence map of social needs interventions in health care settings to explore how these studies conceptualized race or ethnicity and analyzed differential intervention effects outcomes by race or ethnicity.

We developed a framework to assess whether studies were “conceptually thoughtful” for understanding root causes of racial health inequities (i.e., noted that race or ethnicity are markers of exposure to racism) and whether analyses were “analytically informative” for advancing racial health equity research (i.e., examined differential intervention impacts by race or ethnicity).

RESULTS: Of the 152 studies conducted in multiracial or multiethnic populations, 44 studies included race or ethnicity in their analyses, but only 4 of those studies (9%) were conceptually thoughtful about what race or ethnicity means. Among the 152 studies, only 21 (14%) were analytically informative.

CONCLUSIONS: Studies of social needs interventions in multiracial or multiethnic populations were rarely conceptually thoughtful for understanding root causes of racial health inequities and infrequently conducted analytically informative analyses on intervention effectiveness by race or ethnicity. Racism at multiple levels (e.g. interpersonal, structural) impacts minoritized groups’ access to and experience of social needs interventions. Studies of social needs interventions need to be conceptually thoughtful and analytically informative to advance racial equity.

DO VOICE ASSISTANTS PROVIDE EQUALLY APPROPRIATE ADVICE REGARDING COLORECTAL CANCER SCREENING IN DIFFERENT LANGUAGES?

Atul Sinha¹; RAJMOHAN RAMMOHAN²; Tulika Saggar¹; Melvin Joy¹; Paul Mustacchia¹

¹Internal Medicine, Nassau University Medical Center, East Meadow, NY; ²INTERNAL MEDICINE, NASSA UNIVERSITY MEDICAL CENTER, East Meadow, NY. (Control ID #3877022)

BACKGROUND: A voice assistant (VA) is a voice enabled artificial intelligence that allows users to communicate with a device to perform a task or seek information. From the year 2000 to 2019 there was a 56.8% and 10.0% increase in Spanish and French spoken at home in the United States, respectively. With the increase in the percent of non-English languages spoken, we were curious if non-English speakers were receiving appropriate medical advice when asking their VAs questions. We did this study to determine if VAs provide the same quality of advice regarding colorectal cancer in English as compared to in other languages.

METHODS: Four voice assistants: Apple Siri, Amazon Alexa, Google Assistant, and Microsoft Cortana were tested. Voice recordings were done for 5 commonly asked questions regarding colorectal cancer screening in 4 different languages. The authors decided if each of the four VAs provided clinically appropriate advice in each of the languages.

RESULTS: We found that clinically appropriate advice was provided 100% by Apple Siri, 60% by Amazon Alexa, 100% by Google Assistant, and 40% of the time by Microsoft Cortana in English (Image 1). Clinically appropriate advice was provided 80% by Apple Siri, 60% by Amazon Alexa, 80% by Google Assistant, and 40% of the time by Microsoft Cortana in Spanish (Image 1). Clinically appropriate advice was provided 40% by Apple Siri, 0% by Amazon Alexa, 60% by Google Assistant, and 100% of the time by Microsoft Cortana in French (Image 1). Clinically appropriate advice was provided 100% by Apple Siri, 60% by Google Assistant, and 0% of the time by Microsoft Cortana in Mandarin (Image 1).

CONCLUSIONS: Overall, the virtual assistants provided clinically appropriate advice regarding colon cancer in English better than in the other 3 languages. Overall, Apple Siri was the best performing virtual assistant at proving clinically appropriate advice regarding colon cancer. None of the VAs instructed users to speak to a healthcare provider, which we believe is a vital aspect to any medically related search result. Most of the VAs performed well in our study but we believe there is a need for improvement, especially with how technology is becoming more ingrained in our everyday lives how much non-English spoken language has grown in the United States.

DYNAMICS OF THE DIGITAL DIVIDE: TELEMEDICINE USE AMONG MEDICAID BENEFICIARIES IN WASHINGTON

Anna M. Morenz^1,4; Lingmei Zhou^2,4; Edwin S. Wong^3,4; Ashok Reddy⁵; Joy S. Lee^1,4; Judy Zerzan- Thul^1,6; Chistopher P. Chen^1,6; Joshua M. Liao^1,4

¹Department of Medicine, University of Washington, Seattle, WA; ²General Internal Medicine , University of Washington, Seattle, WA; ³University of Washington Department of Health Services and Population Health, Seattle, WA; ⁴Value and Systems Science Lab, University of Washington, Seattle, WA; ⁵Medicine, University of Washington System, Seattle, WA; ⁶Washington State Health Care Authority, Olympia, WA. (Control ID #3872559)

BACKGROUND: COVID-19 necessitated expansion of telemedicine as alternatives to in-person care. However, this expansion has been accompanied by concerns about a “digital divide” – a chasm in access and use among older, non-English-speaking, and minoritized patients. Insight about patterns and equity of telemedicine utilization can inform coverage and payment policies that promote equity.

METHODS: In Washington State (WA), Medicaid changed telemedicine policy in response to COVID-19.

We conducted a retrospective analysis of telemedicine use between March and December 2020 among adults in WA enrolled in Medicaid managed care for at least 6 months in 2019 – 2020. Outcomes were (a) any telemedicine use and (b) intensity of use based on per-person counts of telemedicine visits. Telemedicine included audio-only (phone) and audio-video for new or return visits.

Multivariable generalized linear models were used to assess the association between beneficiary characteristics (age, gender, race, ethnicity, primary language, federal poverty level, clinical complexity) and outcomes. We also assessed the association between residence in a high Social Vulnerability Index (SVI) area (defined by overall and four SVI sub-categories) and outcomes.

RESULTS: Among 355,443 Medicaid beneficiaries, 57,342 used audio-only (16.1%) and 62,804 used audio- video (17.7%) telemedicine. Mean age was 37.8 years, with 57.5% female, 8.5% Black, and 16.4% Hispanic. Overall, 7.1% were homeless, 92.8% identified English as their primary spoken language, and 70.1% resided in areas of high social vulnerability.

Individuals of Black race (aOR 1.11, 1.07-1.14), with primary spoken language of English (1.10, 1.04-1.18), or residing in area with greater household type and transportation vulnerability (1.14, 1.12-1.17) were more likely to have any use of telemedicine. Individuals experiencing homelessness (0.90, 0.87-0.93), of Hispanic ethnicity (0.97, 0.95-0.99), or residing in areas with greater household composition and disability vulnerability (0.977, 0.959-0.995) were less likely to use any telemedicine.

Older age, English as primary spoken language, or residence in areas with greater household type and transportation vulnerability were associated with greater intensity of telemedicine use. Lower intensity of use was associated with Black race (aIRR 0.90, 0.89-0.91) or Hispanic ethnicity.

CONCLUSIONS: Amid COVID-19, there were varied patterns of telemedicine use among different groups of Medicaid beneficiaries in WA. Some patterns – such as greater use of any telemedicine coupled with lower intensity use, as observed among Black individuals – may suggest limited acceptability of telemedicine, or barriers to repeated use, rather than outright access barriers. To bridge the digital divide and promote equity through telemedicine, future policy may need to account for these dynamics and emphasize not just access, but also acceptability of and engagement with telemedicine among historically marginalized populations.

EARLY IMPACT OF A BIDIRECTIONAL CLINIC TO COMMUNITY ELECTRONIC REFERRAL SYSTEM ON ADDRESSING HEALTH-RELATED SOCIAL NEEDS AND HEALTH OUTCOMES Shari Bolen^1,2; Jonathan Lever²; Chris Mundorf²; Alvonta Jenkins²; Samantha Smith³; Matthew Finley⁴; Joseph Daprano⁵; Eva Johnson⁶; Marie Masotya⁶; Anandhi Gunder⁶; Melissa E. Lohr⁷; David Bar-Shain⁷; David Kaelber⁸; Tatyana Khaled³; Dieter W. Sumerauer⁶

¹Medicine, MetroHealth/Case Western Reserve University, Cleveland, OH; ²Better Health Partnership, Cleveland, OH; ³Epidemiology, Surveillance, & Informatics, Cuyahoga County Board of Health, Parma, OH; ⁴United Way of Greater Cleveland, Cleveland, OH; ⁵Internal Medicine/Pediatrics, MetroHealth Medical Center, Willoughby Hills, OH; ⁶Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH; ⁷Pediatrics, The MetroHealth System, Cleveland, OH; ⁸Internal Medicine, Pediatrics, and Informatics, The MetroHealth System/CWRU, Cleveland, OH. (Control ID #3874734)

BACKGROUND: Addressing social needs of safety-net patients could have a large impact on health, yet effective models to address these needs are limited. We describe the impacts of an electronic health record (EHR) facilitated, clinic-to-community linkage program addressing social drivers of health (SDoH) on health outcomes.

METHODS: We report on an ongoing prospective longitudinal cohort study with enrollment of 5 safety net clinics at 3 health systems between 2018-2022. Patients were eligible if they were: 1) adults with hypertension and uncontrolled blood pressure (BP≥140/90 mmHg) at 1 clinic; or 2) children 2-17 years old with overweight/obesity (i.e., body mass index (BMI) percentile ≥85^th) or with asthma at the 4 remaining clinics. Primary care teams referred consenting eligible patients (or whose parent/legal guardian consented) to United Way 2-1-1 (UW 211) via a point-of-care EHR referral. UW 211, a non-profit organization covering 2.5 million Ohioans, called the patients to assess and refer them to any of over 20,000 community resources from their database. UW 211 provided feedback to clinics (e.g., resources provided) via standardized electronic health information exchange in the EHR. First, we describe SDoH referrals. Next, using a case- control study with 4:1 matching on age, race/ethnicity, neighborhood income, sex, insurance type and comorbidity, we compare selected health outcomes (BMI percentile and asthma exacerbations for kids, and BP for adults) in the 1-year post vs. the 1-year pre-referral between the intervention groups (IG) and control groups (CG).

RESULTS: From the 5 clinics, 1,192 eligible patients were referred (referral ranges by clinic: 6% to 40%). Of the 1,192 patients, 450 (38%) were reached by a UW 211 navigation specialist. All 450 had at least one need identified, and 88% (n=395) had at least one need resolved or a resolution in progress. Reached patients reported an average of 2.9 (SD 1.3) SDoH needs per patient, and were referred to an average of 10.1 community resources (SD 6.1). Patients had the following top 5 needs: food (75%); recreation (68%); health care (32%); housing (32%); and utility assistance (30%). In the matched case-control study, no statistically significant differences were identified in BMI, asthma exacerbation, or BP health outcomes between groups. In children, the BMI percentile increased by 3 kg/m2 in the IG (n=243) and 4 kg/m2 in the CG (n=1,000), and asthma exacerbations did not change in the IG (n=6) and increased by 1% in the CG (n=17). In adults, BP control (<140/90 mmHg) increased 7% in the IG (n=210) and 6% in the CG (n=900)

CONCLUSIONS: A seamless EHR-facilitated closed-loop community resource referral and feedback process is feasible in busy primary care practices to address patients’ SDoH. Early changes in health outcomes were not identified. However, impacts on health outcomes in the outpatient setting from addressing SDoH will take years and should not be the sole criteria used to determine continued program funding.

EFFECT OF PATIENT-PHYSICIAN RACIAL CONCORDANCE ON OUTCOMES OF PATIENTS TREATED BY HOSPITALISTS

Evan Shannon, Mariah B. Blegen, Ruixin LI, Yusuke Tsugawa

Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA. (Control ID #3877324)

BACKGROUND: Literature suggests that patient-physician racial concordance may improve care quality and patient satisfaction for Black patients. This could be due to shared cultural values, improved communication and attenuated implicit bias between concordant pairs. However, evidence that such concordance contributes to improved patient outcomes is mixed. The aim of this study is to determine if patient-physician racial concordance is associated with outcomes for patients treated by hospitalists

METHODS: We linked 2016-2019 data on Traditional Medicare beneficiaries from the 100% Medicare inpatient file with Medical Board of California data, which contains physician self-reported race and ethnicity for 24.7% of hospitalists. Physicians were considered hospitalists if their specialty was general medicine, >=90% of their E&M claims were in the inpatient setting and at least 20 claims were filed during the study period. We included all medical primary admission diagnoses and restricted the sample to Black and White patients aged 65-99 years. We then coded patient-physician dyads as racially concordant if patients and their physicians shared the same race. For the primary analysis, we calculated if racial concordance was associated with improved 30-day mortality and 30-day readmission compared to non-concordance using generalized linear models adjusted for patient age, gender, zip code median income, Medicaid status, comorbidities, month/year of admission, weekend admission and physician age, gender and patient volume, with robust standard error estimates.

RESULTS: Among the 8957 patients (7.5% Black patients) treated by 320 hospitalists (11.6% Black hospitalists) in our sample, 114 (16.9%) Black and 7687 (92.6%) White patients were treated by racially- concordant hospitalists. Although the differences were not statistically significant, after adjustment, we found a trend toward lower mortality when Black patients were treated by racially-concordance hospitalists. The risk-adjusted mortality rates were 6.9% (95%CI 2.4% to 11.3%) for Black patients treated by Black hospitalists, 9.1% (95% CI 6.6% to 11.5%) for Black patients treated by White hospitalists, 8.3% (95%CI 7.7% to 8.9%) for White patients treated by White hospitalists, and 8.2% (95% CI 6.0% to 10.3%) for White patients treated by Black hospitalists (p-for-interaction=0.69).

CONCLUSIONS: In a sample of Medicare beneficiaries treated by hospitalists with California medical licenses, we did not find evidence that patient-physician racial concordance was associated with clinical outcomes for Black patients; however, we found a trend toward lower mortality for Black patients treated by racially-concordant hospitalists. Our study was limited by the relatively small number of patients linked to physicians with self-identified race. Further studies with a larger sample size are warranted to determine whether racial concordance leads to better patient outcomes among patients hospitalized for medical conditions.

EQUITABLE PATIENT ENGAGEMENT IN A REMOTE PATIENT MONITORING PROGRAM FOR HYPERTENSION

Nadia Liyanage-Don^3,4; Harry West¹; Kelsey B. Bryant²; Jessica R. Singer⁴; Luis Blanco³; Adina Fraser⁵; Rakhi Kalra⁵; Nadine Dandan⁶; Ian Kronish^3,4

¹IEME, Columbia University, New York, NY; ²Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY; ³Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, NY; ⁴Department of Medicine, Columbia University Irving Medical Center, New York, NY; ⁵IT, NewYork-Presbyterian Healthcare System Inc, New York, NY; ⁶Pharmacy, NewYork-Presbyterian Healthcare System Inc, New York, NY. (Control ID #3871924)

BACKGROUND: Home blood pressure (BP) monitoring using wireless BP devices that transmit data to the electronic health record, also known as remote patient monitoring (RPM), is recommended by national guidelines as an evidence-based approach to improve hypertension (HTN) control. However, there are disparities in patient access to and engagement with such technology, particularly among the elderly, minorities, or those with low health literacy. Barriers to equitable access and uptake must be considered in the design and implementation of RPM and other telemedicine modalities.

METHODS: We used principles of human-centered design to develop a HTN RPM program and implementation strategy. This involved careful mapping of the user experience based on input from key stakeholders and iterative testing in real-world settings. The final program provided patients with a wireless BP cuff, two-way tablet, and virtual nursing support free of charge. Other features aimed at reducing disparities included bilingual program materials, use of interpreter services, option for in-person device installation, and no technology requirements (e.g. Wifi). We retrospectively reviewed medical records of patients referred to the program to assess sociodemographic differences in program engagement. We quantified the proportion of referred patients who subsequently enrolled in the program and the frequency of home BP readings during the first 6 months of enrollment. Regression analysis was used to identify patient characteristics associated with program enrollment and BP measurement.

RESULTS: From June 2019 to August 2021, 443 patients were referred to the HTN RPM program (mean age 67±13 years, 68% female, 24% Black, 62% Hispanic, 60% non-English). Of these, 74% actively enrolled and took at least one home BP measurement. The mean number of home BP measurements was 19±9 in the first month, declining to 11±8 by the sixth month. There were no differences in program enrollment or number of mean monthly BP readings based on patient age, sex, race, ethnicity, or language (Table)

CONCLUSIONS: There were no significant sociodemographic differences in patient enrollment or engagement with our HTN RPM program over six months. Although the mean number of home BP measurements declined from the first month to the sixth month, this occurred irrespective of age, sex, race, ethnicity, or language. These findings suggest that our approach to program design and implementation was equitable, highlighting the importance of equity considerations when developing telehealth solutions for diverse populations.

EVALUATING RACIAL/ ETHNIC EQUITY IN THE PREVENTIVE HEALTH INVENTORY DELIVERY AND OUTCOMES AMONG VETERANS WITH DIABETES AND HYPERTENSION Leah Marcotte¹; Chelle Wheat²; Mayuree Rao³; Edwin S. Wong⁴; Paul Hebert⁴; Karin Nelson¹; Jorge Rojas Jr.⁵; Eric Gunnink⁶; Ashok Reddy⁷

¹Medicine, University of Washington, Seattle, WA; ²Primary Care Analytics Team, Veterans Health Administration, Seattle, WA; ³Veterans Health Administration, Seattle, WA; ⁴Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System Seattle Division, Seattle, WA; ⁵HSR&D, Veterans Health Administration Operations, Washington, DC; ⁶HSR&D Puget Sound, US Department of Veterans Affairs, Washington, DC; ⁷Medicine, University of Washington System, Seattle, WA. (Control ID #3870749)

BACKGROUND: The Preventive Health Inventory (PHI) is a virtual care intervention implemented in March 2021 across the Veterans Health Administration (VA), a national system of over 900 primary care clinics, to address pandemic-related disruptions in primary care. PHI consists of a national quality metrics dashboard and template for individualized outreach by nurses to Veterans via video or telephone to address preventive- and chronic-care gaps. This study evaluated whether PHI was delivered equitably among racial/ethnic groups and if disparities in diabetes and hypertension outcomes changed after PHI receipt.

METHODS: This is a retrospective study among 1,805,658 Veterans with diabetes and/or hypertension and eligible for PHI from 2/28/2021 to 3/31/2022. Two measures - Hemoglobin A1c >9% and blood pressure

<140/90 mmHg - were used to evaluate diabetes and hypertension outcomes. Race/ethnicity was determined using standard groups and a validated algorithm. We defined disparities as worse group outcomes compared to non-Hispanic white (NHW) Veterans. We used logistic regression to evaluate PHI receipt by racial/ethnic group, compared to NHW Veterans. Next, we used logistic regression to separately estimate disparities in outcome probability at the pre-intervention (2/28/2021) and post-intervention (3/31/2022) time points. We then calculated a difference-in-difference (DID) estimate of the change in disparity over time.

RESULTS: Of eligible Veterans, 5.7% NHW (N=68,744), 5.6% non-Hispanic Black (NHB) (N=22,580), 10.2% Hispanic (N=13,313), 6.2% Asian/Pacific Islander/Native Hawaiian (N=1,868), 5.1% American Indian/Native Alaskan (N=744), and 5.6% multiple races or other race (N=1,647) Veterans received PHI. We found no significant population-level or within clinic disparities in PHI receipt. Prior to PHI, NHB (42.2%) and Hispanic (39.5%) Veterans were less likely to have controlled hypertension vs. NHW Veterans (47.5%; p <0.001 and p = 0.048, respectively); NHB Veterans (32.9%) were more likely to have uncontrolled diabetes vs. NHW Veterans (25.1%; p <0.001). Hypertension and diabetes measures improved in all groups post- intervention. There were no new or worsened disparities after PHI, and in DID analysis, among NHB Veterans, the disparity in uncontrolled diabetes improved by 1.9 percentage points (95% confidence interval 0.2, 3.6).

CONCLUSIONS: Organizations should routinely evaluate equity in novel interventions. Our findings support continued use of the PHI as an equitably deployed intervention. Outcomes in all groups improved but most racial/ethnic disparities did not after PHI implementation; findings highlight additional need for tailored interventions to achieve equity in health outcomes.

EXAMINING WITHIN-GROUP HETEROGENEITY IN COVID-19 ASSOCIATED FOOD INSECURITY AND MENTAL HEALTH IMPACTS AMONG LATINO ADULTS IN THE UNITED STATES

Maissa Trabilsy²; Kasim Ortiz³; Marlene Camacho-Rivera¹

¹Community Health Sciences, SUNY Downstate Health Sciences University, New York City, NY; ²SUNY Downstate Health Sciences University College of Medicine, New York, NY; ³Drexel University Dornsife School of Public Health, Philadelphia, PA. (Control ID #3876709)

BACKGROUND: The COVID-19 pandemic has disproportionately burdened the Latino community, exacerbating the negative impacts on mental health and food insecurity. Latinos are more likely than Whites to experience occupational and residential segregation that puts them at a higher risk for COVID-19 infection and mortality. However, the differential impacts of social and material hardships related to COVID-19 within the Latino community, by ethnicity, generational status, and chronic disease history, remains an unexplored area of research.

METHODS: We used publicly available data from the nationally representative Understanding

America Study, administered from April 1, 2020 through July 20, 2021. Our primary outcome of food insecurity was based on the following three questions: “In the past seven days, were you worried you would run out of food because of a lack of money or other resources?”; “Did you eat less than you thought you should because of a lack of money or other resources?”; and “Did you go without eating for a whole day because of a lack of money or other resources?”. Participants were categorized as reporting food insecurity if they responded “Yes” for any of the three questions. Mental health symptoms were assessed using the PHQ9 and GAD7. Covariates included gender identity, age, immigration status, education, insurance status, and smoking status. We conducted generalized linear models, weighted for the complex survey design, stratified by gender to examine associations between food insecurity, demographic characteristics, and mental health symptoms.

RESULTS: In fully adjusted models, Puerto Rican and Mexican men were more than twice as likely and 1.3 times as likely to report food insecurity compared to non-Hispanic white men (aPR 2.16, 95% CI 1.50-3.12 and aPR 1.30, 95% CI 1.08-1.57). Conversely, men of other Latinx background were 50% less likely to report being food insecure compared to non-Hispanic white men (aPR 0.43, 95% CI 0.28-0.66). Mexican and Puerto Rican women were 1.2 times as likely and 3 times as likely to report being food insecure compared to non-Hispanic White women (aPR 1.21, 95% CI 1.12-1.39 and aPR 3.01, 95% CI 2.42-3.75). Examining mental health symptoms, statistically significant interactions between food insecurity and asthma status were observed where asthmatics that were food insecure were more than 4 times as likely to report mental distress compared to asthmatics without food insecurity (aPR 4.43, 95% CI 3.10-6.33).

CONCLUSIONS: Among Latinos, significant heterogeneity in the burden of food insecurity among Latino subgroups emerged, which was masked when examining Latinos as one overall ethnic group. As COVID-19 disparities have disproportionately impacted both Latinos and individuals living with chronic health conditions such as asthma, health professionals must continue to screen for and intervene on social determinants of health, including food insecurity, to improve engagement in care and chronic disease self-management.

EXPERIENCES OF VIOLENCE AMONG PEOPLE EXPERIENCING HOMELESSNESS (PEH) IN CALIFORNIA

Anita S. Hargrave^1,2; Kim H. Nguyen^3,4; Kara Ponder^4,3; Jennafer Birkmeyer^4,3; Margot Kushel^3,4

¹Internal Medicine, University of California San Francisco, San Francisco, CA; ²Internal Medicine, San Francisco VA Health Care System, San Francisco, CA; ³Department of Medicine, ZSFG, UCSF Center for Vulnerable Populations, San Francisco, CA; ⁴UCSF Benioff Homelessness and Housing Initiative, San Francisco, CA. (Control ID #3872336)

BACKGROUND: Sexual and physical assault are critical determinants of health and healthcare costs. In a representative sample of PEH in CA, we assessed the prevalence of violence and who perpetrated it.

METHODS: Using a sampling frame to recruit a representative sample of all adults experiencing homelessness, we recruited adults (18+yrs) in 8 CA counties from 10/2021-12/2022 with venue-based sampling. The questionnaire inquired about types, duration and perpetrators of violence. We performed bivariate analyses with stratification by gender identity, adjusted for survey weight to generate representative statewide estimates, and using tests of significance (chi-square, anova).

RESULTS: Among 3014 PEH, 71% male (cis), 79% female (cis), and 92% of all other genders reported a lifetime experience of violence. While homeless, a third reported physical assault; 8% males, 18% females and 28% of all other genders reported sexual assault. Other-gendered participants reported greater exposure to childhood, emotional and financial abuse as well as police violence. The most common perpetrators of physical, sexual, and financial abuse differed by participants’ gender.

CONCLUSIONS: Violence is highly prevalent among PEH and may impact risk of becoming homeless or ability to exit homelessness.

EXPLAINING REDUCED BLACK-WHITE DISPARITIES IN VIDEO-BASED PRIMARY CARE VISITS IN THE VETERANS HEALTH ADMINISTRATION: A DECOMPOSITION ANALYSIS OF GEOGRAPHIC ACCESS AND PATIENT FACTORS

Lucinda B. Leung¹; Karen Chu²; Nicholas J. Jackson¹; Maia Carter⁴; Leonie Heyworth³; Donna L. Washington¹; Claudia Der-Martirosian⁵

¹Division of General Internal Medicine, UCLA David Geffen School of Medicine & West LA VA Medical Center, Los Angeles, CA; ²Pharmaceutical Economics and Policy, University of Southern California, Los Angeles, CA; ³General Medicine, VA San Diego Healthcare System, La Jolla, CA; ⁴Office of Primary Care/Patient Care Services, Veterans Affairs, Washington, DC; ⁵Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles (GLA), US Department of Veterans Affairs, Washington, DC. (Control ID #3875582)

BACKGROUND: While telehealth is increasingly used as a tool to reduce health care access barriers, Black patients have been found to have fewer video visits than White patients. Differences in geographic access (e.g., rurality) and patient factors (e.g., age) affect this disparity, but their relative contributions are unknown. The Veterans Health Administration (VA) rapidly expanded telehealth use for patients during the COVID-19 pandemic (e.g., distributed tablets for video visits; provided digital health education). We aimed to examine Black-White differences in video visits for VA primary care services over time and then to quantify the influence of various factors on differences.

METHODS: This retrospective study examined 0.9M self-reported Black and 3.6M Non-Hispanic White patients who received primary care services from 138 VA healthcare systems nationally. We determined if each patient ever had a video-based primary care visit in the year before (3/16/2019-3/15/2020) and year after pandemic onset (3/16/2020-3/15/2021). We fit linear probability regression models, adjusting for geographic access (rurality, VA healthcare system, broadband/high-speed internet available in census block [≥25/3Mbps per FCC]) and for patient factors (age, gender, comorbidity, received VA tablet, census-based socioeconomic data [Area Deprivation Index]). We used decomposition methods to quantify the proportion of Black-White differences explained by differences in study covariates, and that which was left unexplained (e.g., discrimination), before and after pandemic onset.

RESULTS: Initially, 1.8% of Black and 2.6% of White patients ever used video visits, compared to 24.4% of Black and 17.8% of White patients after pandemic onset. Geographic access and patient factors accounted for the majority of Black-White differences in video use (60.9% pre and 82.6% post; p’s<.001). Pre-pandemic, racial differences were almost entirely due to geographic access. Of the 0.8 percentage-point (pp) difference between Black and White patients, rurality and VA healthcare system each made up 0.4pp (p’s<.001), both favoring White patients. Post-pandemic onset, differences were not as much from geographical access. Of the 5.6pp difference, contributions from VA healthcare system made up 1.6pp (p<.001; rural, p=.13), newly favoring Black patients. Among patient factors, age was the greatest contributor to Black-White differences (2.4pp, p<.001), while others (e.g., VA tablet) made up <1pp.

CONCLUSIONS: Black-White differences in ever using video-based primary care visits were initially due to geographic access barriers, but largely reversed to favor Black patients with pandemic-related VA telehealth expansion. Only a minority of Black-White differences were due to unmeasured variables (e.g., discrimination). VA telehealth implementation helped reduce health system and contextual reasons for disparities, but outreach to older Veterans is still needed to achieve digital health equity.

EXPLORING RACIAL AND ETHNIC DISPARITIES AND RISK FACTORS FOR NONALCOHOLIC FATTY LIVER DISEASE (NAFLD)

Janet N. Chu¹; Mindy Hebert-Derouen³; Alison Canchola³; Aly Cortella³; Yihe Daida²; Scarlett L. Gomez³; Pushkar P. Inamdar³; Hashem El-Serag⁴; Salma Shariff-marco³

¹Internal Medicine, University of California San Francisco, San Francisco, CA; ²Center for Integrated Health Care Research, Hawaii Permanente Medical Group, Honolulu, HI; ³Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA; ⁴Medicine-Gastroenterology, Baylor College of Medicine, Houston, TX. (Control ID #3876998)

BACKGROUND: While 25% of U.S. adults has NAFLD, few studies have examined NAFLD risk factors in racially and ethnically diverse populations. Minoritized racial and ethnic groups are at higher risk for diabetes and obesity, which are associated with NAFLD.

METHODS: This electronic medical record (EMR)-based cohort study included adults (18+ years) at a large, integrated healthcare system in Hawaii during 2000-2017. We extracted sociodemographic data (age, sex, race/ethnicity) as well as prospective data on behaviors (tobacco use and care utilization), International Classification of Diseases (ICD)-9 and -10 codes, prescriptions, vital signs, and lab results. NAFLD was defined using ICD codes (571.8, 571.8, K75.81, K76.0, K75.8). Descriptive statistics were used to describe the cohort and those with NAFLD. Univariable logistic regression with an outcome of NAFLD was used to estimate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS: Of 637,436 patients, 10,590 (1.7%) had a diagnosis of NAFLD. There were significant differences between those diagnosed with NAFLD vs. those who were not, based on sociodemographic characteristics and medical comorbidities. Compared to non-Hispanic (NH) White patients, minoritized racial and ethnic groups had higher odds of NAFLD (Table 1). Patients in specific racial and ethnic groups (including American Indian/Alaska Native, Native Hawaiian, Pacific Islander, Chinese, Japanese, Korean, and Hispanic) had higher frequency of obese BMI, limited English proficiency, ever smoked, hypertension, dyslipidemia, and diabetes, than NH White patients, which may contribute to these disparities

CONCLUSIONS: In this EMR-based cohort, only 1.7% had a NAFLD diagnosis, consistent with prior studies that NAFLD is underdiagnosed in the general population. This is one of the first studies to report disparities in NAFLD diagnosis based on detailed race and ethnicity data. Next steps include determining which risk factors are independently associated with NAFLD across detailed racial and ethnic groups.

EXPLORING THE IMPACT OF SOCIOECONOMIC HEALTH DISPARITIES IN THE US HOSPITALS ON PREGNANT PATIENTS ADMITTED WITH SEPSIS

Andrea J. Zapata¹; Falah I. Abu Hassan³; James ". Walker²

¹school of medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; ²Internal Medicine, Texas Tech, Amarillo, TX;³Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX. (Control ID #3874319)

BACKGROUND: In pregnant women literature shows a large stratification in the rate of complications and negative outcomes between socioeconomic classes, regardless of resource availability. Similarly, mortality due to sepsis has been attributed to socioeconomic variables, but the impacts of socioeconomic status (SES) on sepsis outcomes in pregnant patients specifically is poorly understood. It is in this population that we sought to explore the impact of health disparities by examining rates of spontaneous abortion (SA) and hospital length of stay (LOS) in the United States.

METHODS: The national inpatient sample (NIS) was searched for pregnant women between the years 2016 to 2019 who were admitted with a sepsis diagnosis using the appropriate ICD-10 codes. The median household income (MHI) of the patients’ ZIP Code of residence was used to place patients into MHI determined quartiles. Disparity between patients residing in areas within the lower 25th percentile of MHI was compared to all other patients with higher MHI. Additionally, self-pay patients' outcomes were assessed against patients with insurance. Univariate logistic regression was performed to compare the outcomes of the two groups in terms of the occurrence of SA and LOS. The results were reported as an odds ratio with a 95% confidence interval. Significant results had a p value < 0.05.

RESULTS: The NIS resulted 7,346 patients meeting the selected criteria. Cases with missing ZIP codes or insurance data were excluded. The mean age of patients residing in the lowest 25th percentile of MHI was 27 years compared to 28 years in other patients. Pregnant patients with sepsis from the lower 25th percentile had an odds ratio (OR) of 1.409 (CI 1.152 - 1.723, p = 0.001) of developing spontaneous abortions. Similarly, OR of developing the same complication in uninsured patients was 1.920 (CI 1.334 - 2.763, p < 0.001). OR for the length of stay in the hospital for patients of the lower 25th percentile MHI was 5.259 (CI 5.026 - 5.492, p < 0.001), and 5.495 (CI 5.304 - 5.685, p < 0.001) for uninsured patients.

CONCLUSIONS: Our findings suggest that there persists in the United States a significant impact of social and economic factors on health outcomes. In septic pregnant women fetal mortality was significantly higher in patients who were uninsured and patients from low-income zip codes. LOS was also prolonged for these two populations, however prolonged LOS for low SES patients is not a new phenomenon, as these patients tend to require more resources. Consequently supplementary compensation has been proposed for hospitals that disproportionately serve these populations. Our findings would therefore support a need in the US for greater resources devoted to supporting these patients, and the hospitals that serve them.

FACTORS ASSOCIATED WITH ACUTE HEALTHCARE USE IN A REPRESENTATIVE SAMPLE OF ADULTS EXPERIENCING HOMELESSNESS IN CALIFORNIA

Jessica D. Fields^1,2; Kim H. Nguyen^2,3; Tiana Moore^2,3; Jennafer Birkmeyer^2,3; Eve Perry^2,3; Margot Kushel^2,3

¹University of California Berkeley University of California San Francisco Joint Medical Program, Berkeley, CA; ²University of California San Francisco Benioff Homelessness and Housing Initiative, San Francisco, CA; ³University of California San Francisco Center for Vulnerable Populations, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA. (Control ID #3874593)

BACKGROUND: Poor health increases risk for homelessness, and homelessness is detrimental to health. Due to high prevalence of comorbidities and poor access to longitudinal care, people experiencing homelessness (PEH) are at high risk of emergency department (ED) use and hospitalization. In a representative sample of adult PEH in California (CA), we assessed prevalence of and factors associated with acute healthcare use.

METHODS: We recruited a representative sample of adult PEH across 8 counties in CA between Oct. 2021 and Nov. 2022. Our dependent variables were any past 6-month use of ED and physical health hospitalization. Using the Gelberg-Anderson Behavioral Model for Vulnerable Populations, our covariates included predisposing factors (sociodemographics, homeless histories), enabling factors (healthcare access), and need factors (physical and mental health, substance use). We weighted data to generate state-wide estimates and assessed bivariate relationships with chi-square and t-tests. Multivariable regression models were informed by collinearity diagnostics and prior hypotheses.

RESULTS: Among 3065 participants, the weighted median age was 47 (IQR 37-57), 69% male, 36% Latinx/Hispanic, 23% Non-Hispanic (NH) White, 24% NH Black. Three-quarters (73%) met time criteria for chronic homelessness; 74% were unsheltered. In the prior 6 months, 38.4% visited the ED and 22.2% were hospitalized. We present unadjusted bivariate rates and multivariable odds ratios of acute care use (Table 1). A sensitivity analysis removing insurance and regular source of care, out of concern for effect-cause, was similar.

CONCLUSIONS: Adult PEH have rates of ED use and hospitalization higher than previous reports and dramatically higher than housed populations. Need factors, which increase the risk of and are exacerbated by homelessness, are associated with acute care use. While insufficient to prevent acute care, insurance and primary care may facilitate access to needed care. Preventing and ending homelessness may decrease acute care use.

FACTORS ASSOCIATED WITH HIV TESTING AMONG ASIAN-AMERICANS: AN ANALYSIS OF THE NATIONAL HEALTH INTERVIEW SURVEY

Armaan Jamal¹; Malathi Srinivasan²; Andrew Nevins³; Gloria S. Kim⁴; Sanah Vohra²

¹Department of Medicine, Johns Hopkins University, Baltimore, MD; ²Medicine, Stanford University School of Medicine, Palo Alto, CA; ³Stanford University School of Medicine, Stanford, CA; ⁴Medicine, Stanford University, Stanford, CA. (Control ID #3873403)

BACKGROUND: Asian Americans are the fastest growing ethnic group in the United States. Despite universal HIV screening recommendations, Asian Americans have the highest rate of undiagnosed HIV, often due to cultural factors inhibiting HIV screening, prevention, and treatment. Limited research exists about factors associated with HIV testing among Asian Americans.

METHODS: We examined the National Health Interview Survey (NHIS) from 2006-2018 to determine factors associated with self-reported HIV screening (ever tested) in non-Hispanic white (NHW), Chinese, Asian Indian, Filipino, and Other Asian adults. Our sample included 200,349 individuals (NHW [n=185,357], Chinese [n=3,111], Asian Indian [n=3,033], Filipino [n=3,435] and Other Asian [n=5,413]). We used logistic regression to calculate the odds ratios (OR) and 95% confidence intervals (CI) to identify demographic (age, sex, race, marital status, region of residence [Western/Eastern/Southern/Midwestern US], nativity [US born], US citizenship), socioeconomic (education, income, occupation) and health-related (insurance coverage [Medicare/Medicaid/Private/Other], self-reported health status [HRQOL], and number of doctor visits in the past 12 months) factors associated with HIV testing.

RESULTS: In our sample, 36% of NHWs, 34% of Chinese, 36% of Asian Indians, 39% of Filipinos and 35% of Other Asians reported lifetime HIV testing. All Asian subgroups reported lower odds of HIV testing compared to NHWs (Chinese: OR [95% CI] = 0.63 [0.58-0.69]; Asian Indian: 0.60 [0.55-0.65], Filipino: 0.84 [0.77-0.91] and Other Asian: 0.68 [0.63-0.72]). Within aggregate Asians, female gender (vs. male), 27-64 age group (vs. 18-26), higher education level, higher income, health insurance coverage and higher number of doctor visits were positively associated with HIV testing (OR range: 1.16-1.94). On the other hand, the 65+ age group (vs. 18-26), and foreign-born status decreased the odds of HIV testing (OR range: 0.62-0.91). Across the four Asian American subgroups, 27-64 age group, any health insurance coverage and higher number of doctor visits increased odds of HIV testing (OR range: 1.91-2.41). Within Chinese, Filipinos and Other Asians, higher income increased odds of HIV testing (OR range: 1.16-1.34). Additionally, within Asian Indians and Filipinos, foreign-born status decreased odds of HIV testing (OR range: 0.52-0.80)

CONCLUSIONS: Asian Americans report being screened for HIV less often as non-Hispanic whites, after adjusting for sociodemographic features. Creating culturally appropriate interventions to increase HIV screening rates may improve HIV outcomes amongst Asian Americans.

FACTORS ASSOCIATED WITH HIV-TESTING IN THE US POPULATION OVERALL AND BY RACE/ETHNICITY: AN ANALYSIS OF THE 2006-2018 NATIONAL HEALTH INTERVIEW SURVEY

Armaan Jamal³; Malathi Srinivasan¹; Andrew Nevins²; Gloria S. Kim¹; Sanah Vohra⁴

¹Medicine, Stanford University School of Medicine, Palo Alto, CA; ²Stanford University School of Medicine, Stanford, CA; ³Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; ⁴University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #3869894)

BACKGROUND: The Center for Disease Control and Prevention recommends that individuals between 13 and 64 obtain HIV screening at least once, as part of routine preventive health care. While universal HIV screening for adults has been recommended since 2006, screening has been uneven across racial/ethnic groups. In this study, we examined national HIV screening prevalence among racial/ethnic groups in the US, and the sociodemographic factors associated with testing.

METHODS: Using National Health Interview Survey (NHIS) (2006-2018), we analyzed participant HIV testing status (self-reported, ever tested), analyzed by self-identified race and demographics. Our sample included 282,433 individuals (non-Hispanic white (NHW) [n=183,323], Hispanic [n=45,271], non-Hispanic Black (NHB) [39,104] and Asian [14,753]). Using logistic regression, we calculated odds ratios (OR) and 95% confidence intervals (CI) to identify demographic (age, sex, race, marital status, region of residence [Western/Eastern/Southern/Midwestern US], nativity [US born], US citizenship), socio-economic (education, income, occupation) and health-related (insurance coverage [Medicare/Medicaid/Private/Other], self-reported health status [HRQOL], and doctor visits in the past 12 months) factors associated with HIV testing.

RESULTS: We found that 36% of NHWs, 46% of NHBs, 60% of Hispanics and 36% of Asians reported having an HIV test. Hispanics (OR [95% CI]: 1.30 [1.27-1.34]) and NHBs (2.46 [2.40-2.42]) had higher odds of HIV testing, whereas Asians (0.74 [0.71-0.77]) had lower odds of HIV testing compared to NHWs.

Factors that were positively associated with HIV testing included female gender, 27-64 age group (vs. 18-26), higher education level, higher income, working in service and professional specialties (vs. managerial/administrative), any health insurance coverage, higher number of doctor visits, US citizenship, foreign born status and residing in western and southern US (vs. northeastern) (OR range: 1.04-2.23). Factors that were negatively associated with ever being tested for HIV included age 65+, production/manufacturing jobs, married, better self-reported health status (vs. fair/poor), and living in the midwestern US (OR range: 0.62-0.91). Factors associated with HIV testing varied when stratified by race/ethnicity.

CONCLUSIONS: Race/ethnicity is significantly associated with self-reported HIV testing. We found that non-Hispanic blacks reported testing twice as often, Hispanics a third more often, and Asians three-quarters less often, as non-Hispanic whites, after adjusting for key covariates. Tailoring HIV screening outreach to specific racial/ethnic and sociodemographic groups may reduce health disparities in HIV detection and treatment, improving public health across the nation.

GETTING GRANULAR: DIABETES AND HYPERTENSION DISPARITIES AMONG CHINESE AND SPANISH SPEAKERS IN A LARGE HEALTH SYSTEM

Chai Arnold^1,2; Leonor Fernandez³

¹Diversity, Equity and Inclusion, Beth Israel Lahey Health, Cambridge, MA; ²Harvard Medical School, Boston, MA; ³Medicine, Beth Israel Deaconess Medical Center, Waban, MA. (Control ID #3874436)

BACKGROUND: Patients with Limited English proficiency (LEP) experience many health disparities. As part of a larger effort to reduce racial and ethnic disparities in diabetes and hypertension in a large health system, our analysis aims to provide a preliminary perspective on the relationship between LEP and disparities in chronic disease.

METHODS: This QI study is a cross sectional analysis of data collected from January to July 2022 in a large health system in New England. We used Arcadia software to identify patients with at least one billed diagnosis of hypertension and/or diabetes in the preceding 12 months. Preferred language (PL) was obtained from EMR patient registration data. Our analysis focused on Medicaid and Medicare subgroups. Primary measures included the most recent HbA1c for patients with diabetes and the most recent documented blood pressure for patients with hypertension. Sample T-tests were used to compare LEP and English-speaking subgroups.

RESULTS: Chinese-speaking patients in the Medicare subgroup had comparable mean HbA1c to English speakers (7.25 (N=132) vs. 7.27 (N=5977)), but significantly higher mean blood pressures (140.07 (N=160) vs. 129.58 (N=8337), p-value <0.001) compared to English-speaking patients. In contrast, Spanish speakers in the Medicare subgroup had significantly higher mean HbA1c compared to English speakers (7.68 (N=133) vs. 7.25 (N=5977), p-value 0.0012), with no significant differences in mean blood pressure. Similar findings were present within the Medicaid subgroups though with less variation among PL groups.

CONCLUSIONS: While limited English proficiency is often associated with disparities in both diabetes and hypertension, Chinese and Spanish LEP groups exhibit markedly different patterns in this study, with less glycemic control among Spanish speakers, and less hypertension control among Chinese speakers. This heterogeneity in chronic disease subgroup outcomes is relevant when setting meaningful goals for improving equity. Among many, education, literacy, diet, physical activity, cost of specific medications, and cultural factors specific to each chronic condition may each play important roles in shaping intersectional or compound inequities. Exploring and understanding these granular patterns should guide health system equity strategies and population health interventions.

HEALTH AND CARE NEEDS OF TRANSITION AGE YOUTH EXITING LOS ANGELES JAILS AND SUCCESSFUL ENGAGEMENT DURING REENTRY

Joyce Lee¹; Jessica Jara^2,6; Stefanie D. Vassar³; Laura Abrams⁴; Christine Grella⁵; Mitchell D. Wong⁶; Elizabeth Barnert⁷

¹School of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Los Angeles County Department of Health Services, Los Angeles, CA; ³Division of Internal Medicine & Health Service Research, UCLA, Los Angeles, CA; ⁴University of California Los Angeles Meyer and Renee Luskin School of Public Affairs, Los Angeles, CA; ⁵Psychiatry and Biobehavioral Sciences, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁶Medicine, David Geffen School of Medicine at UCLA, Mitchell Wong, CA; ⁷Pediatrics, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #3869432)

BACKGROUND: Reentry from jail to the community is a difficult juncture for transition age youth (TAY; ages 18-24), who simultaneously face the challenges of emerging adulthood. Health-related needs during reentry for TAY may be substantial. However, few empiric data exist to describe the healthcare and social service needs of TAY during reentry. Further, poor engagement with reentry interventions for TAY limitstheir impact, and factors affecting engagement are not well understood. We sought to describe: 1) the healthcare and social service needs of, and 2) factors associated with, TAY engaging with a reentry intervention post-release.

METHODS: We partnered with a community health worker-based intervention that connects adults returning home from jails to health and social services. We examined county electronic health and sheriff’s department data to describe participants’ criminal justice involvement, health diagnoses, reentry service needs, and reentry services utilization from May 2017 to December 2021. Post-release engagement was defined as connection to post-release services. We performed chi-squared tests and t-tests to compare needs and characteristics of TAY who did versus did not engage in post-release services. We then used logistic regressions to identify factors associated with engagement.

RESULTS: Our analytic sample included 2,525 TAY clients in the community program. Most participants were male (72.6%), Hispanic or Black (80.2%), and had a history of being unhoused (60.9%). Among all TAY clients, diagnoses of mental disorders were most common (57.2%), followed by substance use disorders (45.8%), physical health conditions (39.9%), and chronic pain (38.1%). Overall, most participants had good physical health with mean Charlson Comorbidity Index (CCI) score 0.53. Most common reentry service needs by domains were social needs (40.7%) and substance use treatment (21.8%), and by sub-domains were primary care access (19.6%) and housing (14.4%). Older age and history of being unhoused were independently associated with post-release engagement (age: odds ratio [OR]=1.06, 95% CI 1.02 to 1.11; ever unhoused: OR=1.18, 95% CI 1.00 to 1.40).

CONCLUSIONS: TAY exiting jail have high-stakes behavioral health and social needs, with housing a key basic need for linkage. Interventions tailored to TAY, particularly younger TAY, may improve linkages to care during reentry, and can ultimately serve as a lever to address health inequities and address cycles of incarceration at a crucial life stage.

HEALTHCARE ACCESS AND COVID-19 VACCINATION IN THE US: A NATIONAL STUDY Lily Gage¹; Jaclyn Perreault¹; Chloe A. Thomas¹; Charles De Guzman¹; Dier Hu¹; Lynn Wiwanto¹; Jose Henriquez-Rivera¹; Emily Harris¹; Danny McCormick^2,1; Adam Gaffney^2,1

¹Internal Medicine, Cambridge Health Alliance, Cambridge, MA; ²Medicine, Harvard Medical School, Boston, MA. (Control ID #3873460)

BACKGROUND: Healthcare access affects use of many preventive medical services. Although federal legislation made COVID-19 vaccines free, access to medical care may affect vaccine uptake through, for example, facilitating recommendations for vaccination from trusted primary providers. We sought to assess whether medical care access was associated with uptake and timeliness of COVID-19 vaccination in the US.

METHODS: We used a cross-sectional design to examine exposure to four metrics of healthcare access among sample adults in the 2021 National Health Interview Survey (NHIS): health insurance, having an established place for medical care, having a provider visit within the past year, and medical care affordability. We examined two outcomes: receipt of one or more COVID-19 vaccines, and (among those vaccinated) receipt of a first vaccine within 6 months of vaccine availability. We examined the association between each healthcare access metric and each outcome using logistic regression, unadjusted and adjusted for demographic, geographic, and socioeconomic covariates. We also constructed an “access score” with one point assigned for having access to each of these measures (score range 0-4) and then examined the association between each access score and receipt of COVID-19 vaccine using logistic regression.

RESULTS: Our sample included n=21,532 adults. Overall, participants with better access to care were older and had higher socioeconomic status. In unadjusted analyses, each metric of healthcare access was associated with uptake of COVID-19 vaccination, and (among those vaccinated) early vaccination. In adjusted analyses, having health coverage (adjusted odds ratio [AOR] 1.51; 95% CI 1.31, 1.74), a usual place of care (AOR 1.59; 95% CI 1.42, 1.76), and a provider visit within the past year (AOR 1.42, 95% CI 1.27, 1.58) remained associated with COVID-19 vaccination. Only having a usual place of care was associated with early vaccine uptake in adjusted analyses. In adjusted analyses, relative to those with an access score of 0, the odds of vaccination were 1.08-fold higher among those with a score of 1 (95% CI 0.68, 1.71), 1.30-fold higher among those with a score of 2 (95% CI 0.87, 1.94), 1.54-fold higher with a score of 3 (95%CI 1.05, 2.26), and 1.98-fold higher with a score of 4 (95% CI 1.35, 2.90).

CONCLUSIONS: Several individual metrics of healthcare access, as well as higher access scores based on these metrics, are independently associated with uptake of COVID-19 vaccines. Policies that achieve universal coverage, and facilitate long-term relationships with trusted providers, may be an important component of a pandemic response.

HEAT STRESS AND KIDNEY FUNCTION AMONG CONSTRUCTION WORKERS IN TEXAS Yosha Singh¹; Bethany Boggess Alcauter²; George Delclos³; Snehal Patel⁴

¹Dell Medical School, The University of Texas at Austin, Austin, TX; ²National Center for Farmworker Health, Buda, TX; ³The University of Texas Health Science Center at Houston, Houston, TX; ⁴Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #3872309)

BACKGROUND: Construction workers comprise 6% of the U.S. workforce but 36% of workplace heat- related deaths. Yet, there is a lack of peer-reviewed research documenting heat stress and strain among U.S. construction workers. Our study had two aims: quantitatively assess heat strain among construction workers in Texas and measure kidney function changes during a work shift.

METHODS: Twenty construction workers were recruited to assess heat stress, strain, and kidney function during working hours over two weeks. Workers were eligible if they were currently employed in construction; between 18 and 54 years old; and of male sex. Participants were excluded if they reported Type 1 diabetes.

Heat stress was assessed through temperature and humidity data from an iButton sensor on the participant. Core body temperature was also estimated through heart rate recordings from a BioHarness device. Dehydration levels were assessed through urine specific gravity measured pre- and post-shift each day. Participants completed a daily survey to report signs of heat-related illnesses, fluid intake, and use of non- steroidal anti-inflammatory drugs or alcohol, derived from the Second Central American Survey of Working Conditions and Health.

Kidney function changes were assessed through pre- and post-shift urine specimens, done twice a week for two weeks. Urine protein and pH were tested through dipstick analysis. A point-of-care device was used to analyze urine creatinine, albumin, and hemoglobin levels.

RESULTS: 75% of participants endorsed one or more symptoms of heat illness, per the survey. 56% reported fatigue, 12% reported headaches, and other symptoms included dizziness, cramps, blurred vision, and dark urine. BioHarness data was inconclusive.

100% of participants had at least one post-work urine specific gravity > 1.030, reflecting severe dehydration.

12% of participants’ urine revealed proteinuria, and 44% revealed hematuria without RBCs

CONCLUSIONS: Construction workers are a high-risk group to experience heat stress and strain, which affects kidney function.

Three-quarters of workers endorsed one or more symptoms of heat illness, and every worker exhibited severe dehydration at least once throughout the study. The BioHarness was unable to accurately record temperature in half of participants. We thus rely on survey data to reflect heat stress but will consider other methods in further studies.

Nearly half of participants had urine with hematuria without RBCs, concerning for myoglobinuria. Although the sample size and study duration were limited, this study reveals that Texan construction workers may be at risk for rhabdomyolysis.

Further study of heat strain and kidney function in construction workers is needed through serum creatinine and creatinine kinase to assess for rhabdomyolysis and kidney injury. Policy to prevent dehydration among construction workers should be improved. After the study ended, researchers held a workshop to recommend hydration tactics, short breaks, and urine tracking to workers.

HEMOGLOBIN A1C AND BODY MASS INDEX CHANGES FOLLOWING A HEALTHCARE SYSTEM-BASED FOOD INSECURITY INTERVENTION: PRELIMINARY DATA

Alexandra Cardy¹; Colleen Ereditario²; Elizabeth Cuevas¹; Bruce Ling²

¹Internal Medicine, Allegheny Health Network, Pittsburgh, PA; ²Allegheny Health Network, Pittsburgh, PA. (Control ID #3877217)

BACKGROUND: The Healthy Food Center (HFC) in Pittsburgh, Pennsylvania is a unique social determinants of health concept-driven referral-based intervention for patients experiencing food insecurity. The HFC is embedded within Allegheny Health Network, a large healthcare system in Pittsburgh, Pennsylvania, and offers comprehensive services addressing social determinants of health related to food insecurity. Patients are referred by providers based on screening positive for food insecurity, and receive fresh produce and cooking utensils, transportation to the HFC, produce coupons, dietitian counseling, and budgeted produce shopping education. Here we examine preliminary data related to changes in hemoglobin A1c (HgbA1c) and body mass index (BMI) following participation in this food insecurity intervention

METHODS: HgbA1c and BMI data were abstracted from HFC participants using the electronic medical record. BMI data were examined for the year 2021 and HgbA1c data for the years 2018-2021.These two variables were evaluated for change across two time points: prior to the initial HFC encounter and at six months post-initial HFC encounter. Participants were categorized into various baseline levels of BMI and HgbA1c with the data presented as frequencies. This data was compared statistically for changes at six months after baseline in BMI and HgbA1c respectively using Chi-Square test.

RESULTS: BMI data was available for 255 participants (mean baseline BMI 33.4) and HgbA1c data was available for 174 participants (mean baseline HgbA1c 7.9) at both time points. There was a higher frequency of decrease at six months in BMI (45.1%) than those who stayed the same (20.8%) or increased (34.1%). While not statistically significant (p=0.14), there was a trend for a higher percentage of those categorized as obese at baseline (BMI > 30, n=162) (49.4%) to show a decrease in BMI at six months compared to those not obese (BMI < 29.9, n=93) (37.6%).

For HgbA1c at six months, there was a higher frequency of decrease in HgbA1c (32.8%) than increase (25.3%). This finding was most notable (p<.00001) in the highest HgbA1c group (HgbA1c > 9, n=64) where 60.9% had a decrease at six months compared to those with a baseline HgbA1c of 7-8.9 (n=57) (26.3%) or < 7 (n=53) (5.7%).

CONCLUSIONS: Those with higher hemoglobin A1c and higher BMI at baseline had a higher propensity to show reductions at six months, suggesting that the intervention may be more beneficial for patients with poorly controlled chronic conditions. This preliminary data suggests that addressing social determinants of health with a healthcare system-based food insecurity intervention can facilitate chronic disease management at the population level, especially for those with more severe disease.

HISTORIC STRUCTURAL RACISM AND PRESENT-DAY DIABETES PREVALENCE: AN EXAMINATION OF STATE SPECIFIC ASSOCIATIONS

Sebastian Linde¹; Rebekah J. Walker³; Jennifer A. Campbell⁴; Laura Hawks⁵; Leonard E. Egede²

¹Medicine, Medical College of Wisconsin Department of Medicine, Milwaukee, WI; ²Medicine, Medical College of Wisconsin, Milwaukee, WI; ³Medicine, Medical College of Wisconsin, Milwaukee, WI; ⁴General Internal Medicine , Medical College of Wisconsin, Milwaukee, WI; ⁵General Internal Medicine, Medical College of Wisconsin, Wauwautosa, WI. (Control ID #3874548)

BACKGROUND: Recent work has shown that structural racism, as captured by historic residential redlining practices under the Home Owners’ Loan Corporation (HOLC), is associated with present-day diabetes (and all cause) mortality and years of life lost rates, and that these associations have remained consistently strong across decades (Linde, Walker, Campbell and Egede 2022). However, it remains unknown whether associations between historic structural racism and present-day diabetes prevalence exist and whether these associations vary across different US states. To this end, the objective of our study was to examine whether structural racism (proxied using historic residential redlining practices) is associated with present-day diabetes prevalence, and whether these associations vary across US states.

METHODS: In constructing our analytic sample of 11,457 census tracts, we combined census tract level data across multiple sources. First, diabetes prevalence was sourced from the CDC Places database. Second, historic neighborhood redlining grades were constructed using historic HOLC maps from the Mapping Inequality project (Nelson et al. 2022). Third, census tract data on socioeconomic demographics and population counts were sourced from the Opportunity Insights database. For our estimation approach we utilized linear regression models with stepwise additions of covariates; and we also adjusted for state fixed effects to remove bias due to unobserved state-level confounders.

RESULTS: Diabetes prevalence was 8.9% within areas with a historic HOLC grading of A (best); 10.3% within areas graded as B (still desirable); 11.9% within areas graded as C (declining); and 13.1% within areas graded as D (hazardous). Preliminary state fixed effect regression estimates indicate that a unit increase of an area’s historic HOLC grading (e.g., an increase from a grade of B=”still desirable” to C=”declining”) is associated with a 1.47% (95%CI=; p<0.001) increase in diabetes prevalence. Additional estimation results indicate considerable heterogeneity (across different US states) within the association between historic residential redlining and present-day diabetes prevalence. Regression estimates from models with stepwise additions of covariates further suggest that historic redlining is primarily mediated by factors related to poverty, incarceration and education.

CONCLUSIONS: Structural racism, as proxied by historic residential redlining, is found to be associated with present-day diabetes prevalence. These associations are found to be both statistically and clinically meaningful, and they are found to vary across states with the strongest associations noted within southern US states. Policy programs targeted at addressing community level disparities in poverty, incarceration and education may help ameliorate the persistent influence of historic structural racist policies upon present-day population health.

HOW HOUSING STATUS AT BASELINE IMPACTED HOSPITALIZATION IN COMPLEX PATIENTS ENROLLED IN THE SUMMIT A-ICU RANDOMIZED CONTROLLED TRIAL AT A HEALTHCARE FOR HOMELESS CLINIC

Anna Geduldig¹; Meg Devoe¹; Priya Srikanth²; Eileen Vinton³; Richard Bruno³; Samuel T. Edwards^4,1; Brian Chan¹

¹Medicine, Oregon Health & Science University, Portland, OR; ²School of Public Health, Oregon Health & Science University, Portland, OR; ³Central City Concern, Portland, OR; ⁴Portland VA Medical Center, Portland, OR. (Control ID #3876844)

BACKGROUND: People experiencing homelessness are at risk for poor health outcomes and early death. “Ambulatory Intensive Care Units” (A-ICUs) have multi-disciplinary team members and flexibility to tailor care for medically and socially complex patients at risk for high-utilization. It is unclear which patients most benefit from these high-resource interventions. We assessed how housing instability at baseline impacted outcomes of patients enrolled in SUMMIT, a recently completed randomized controlled trial of an A-ICU at an urban healthcare for the homeless federally qualified health center.

METHODS: The SUMMIT A-ICU is made up of physician, nurse, care coordinators, social workers, pharmacist, and team manager with reduced panel size and flexible scheduling. Patients could be referred if they had 1+ hospitalizations in the prior 6-months and had 2 or more chronic medical, substance use disorder, or mental health diagnoses. We collected baseline surveys including unstable housing status (e.g., sleeping outside, place not meant for habitation, shelter) and assessed changes in 6-month rates of hospitalization (primary outcome) and patient reported health related quality of life scores (HRQoL) using the SF-12 survey. To assess whether housing status modified the impact SUMMIT had on outcomes, we fit a linear mixed effects model and tested for the three-way interaction between randomization arm, time point, and housing status, using P-value < .20 as the cutoff for significance. We report mean within-group (WG) change and standard error (SE) from the model.

RESULTS: The trial enrolled 159 patients. Patients with unstable housing (UH) at baseline were younger (UH 53.4 [SD 10.4] vs stably housed 57.0[SD 8.4], P-value=0.02) and had higher rates of cognitive impairment (49.3% vs 31.2%, P-value=0.02). We found evidence that housing status at baseline modified the effect of SUMMIT on hospitalization rates (P-value for interaction=0.19). SUMMIT patients with unstable housing at baseline had increased hospitalizations at 6-months (WG change in hospitalization = 0.40 [SE 0.66]) compared to those who were stably housed at baseline (-1.12 [SE 0.34]). We found similar evidence of interaction for HRQoL domains of physical health composite (interaction P-value = 0.15, UH WG change = 0.06 [SE 1.67] vs stably housed WG change = 4.91 [SE 2.21]) and physical functioning domain (interaction P-value = 0.05, UH WG change = -2.42 [SE 1.93] vs stably housed WG change = 4.18 [SE 2.12]).

CONCLUSIONS: Compared to patients who lacked housing immediately prior to enrolling in SUMMIT, patients who were stably housed experienced decreases in 6-month hospitalization rates and improved physical health and functioning. Having secure housing may promote ability to engage with the SUMMIT team. Stabilizing housing status for medically complex patients at risk of homelessness should be prioritized for these patients in parallel with intensive primary care interventions to improve outcomes.

HOW IMMIGRATION-RELATED FACTORS DIFFER BY LEVELS OF ACCULTURATION AND SOCIOECONOMIC STATUS: RESULTS FROM THE HISPANIC COMMUNITY HEALTH STUDY/STUDY OF LATINOS (HCHS/SOL) SOCIOCULTURAL ANCILLARY STUDY

Chelsea Truong¹; Amanda S. Hinerman¹; Erik Rodriquez¹; Aimee Afable²; Eliseo J. Perez-Stable¹

¹Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, MD; ²SUNY Downstate Health Sciences University School of Public Health, New York, NY. (Control ID #3872419)

BACKGROUND: Although it is generally believed that greater acculturation adversely impacts the health of Hispanics/Latinos and that acculturation level and socioeconomic status (SES) are closely related, segmented assimilation theory would suggest that years lived in the U.S. and age at immigration differ between immigrants who have higher vs. lower acculturation and SES levels. Using data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), we tested this hypothesis.

METHODS: The study used data from Visit 1 (2008-2011) and the Sociocultural Ancillary Study of HCHS/SOL, a prospective cohort study in Bronx, Chicago, Miami, and San Diego. Binary and ordinal logistic regressions models were used to evaluate the cross-sectional differences between (1) years lived in the U.S. (0-5; 6-10; 11-15; 16-20; and 21+) and perceived SES (low; moderate; high), (2) years lived in the U.S. and acculturation level (low; high), and (3) age at immigration (<12; 12-18; 19+) and education (<9^th; 9^th to <12^th; high school; >high school).

RESULTS: Adults (n=4,287) who identified as Central American, Cuban, Dominican, Mexican, and Puerto Rican were included. Overall, 52% were female, the mean age was 41, the mean years lived in the U.S. was 21, and 60% had a high school education or less. Individuals who have lived in the U.S. for 11-15 years were more likely to have a higher perceived SES compared to individuals who have lived 0-5 years in the U.S. (OR=1.7, 95% CI=1.2, 2.3). Those who have lived in the U.S. for 0-5 years were more likely to be less acculturated compared to those who have lived 21+ years in the U.S. (OR=11.9, 95% CI=8.1, 17.4). Respondents who immigrated at age <12 were more likely to have higher education compared to individuals who immigrated at age >19 (OR=1.6, 95% CI=1.2, 2.1).

CONCLUSIONS: Different levels of acculturation are associated with diverging paths of SES, leading to unique immigrant experiences. Our results highlight the heterogeneity of Hispanics/Latinos and may provide a link to observed differing health patterns.

IDENTIFYING INDIVIDUALS WITH HIGHEST SOCIAL RISK IN ADULTS WITH TYPE 2

DIABETES: TWO PARAMETER ITEM RESPONSE THEORY METHODOLOGY

Leonard E. Egede²; Rebekah J. Walker¹; Sebastian Linde³; Joni S. Williams⁴

¹Medicine, Medical College of Wisconsin, Milwaukee, WI; ²Medicine, Medical College of Wisconsin, Milwaukee, WI; ³Medicine, Medical College of Wisconsin Department of Medicine, Milwaukee, WI; ⁴Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3876216)

BACKGROUND: Social determinants of health are widely recognized as a contributor to health outcomes for adults type 2 diabetes. Though multiple social risk factors are identified, their impact on outcomes is not equal. In addition, prior research suggests simply adding the number of social risk factors present does not identify high social risk. The aim of this analysis was to use item response theory to discriminate across social risk factors in adults with type 2 diabetes and identify social risk indicators that reliably distinguish between high social risk and low social risk subgroups.

METHODS: Cross-sectional data of 615 adults with diabetes recruited from two primary care clinics were used. Participants completed assessments including validated scales on economic instability (financial hardship), the neighborhood and built environment (crime, violence, and neighborhood rating), education (highest education and health literacy), food environment (food insecurity and healthy food access), social and community context (social isolation), and psychological risk factors (perceived stress, depression, serious psychological distress, and diabetes distress). Item response theory (IRT) models were used to understand the association between a participant’s underlying level of a particular social risk factor and the probability of that response. A two-parameter logistic IRT model was used with each of the 12 social determinant factors being added as a separate parameter in the model. Higher values in item discrimination indicate better ability of a specific social risk factor in differentiating participants from each other.

RESULTS: The mean age was 61.3 with mean years having been diagnosed with diabetes 12.3. Sixty four percent of the sample was Non-Hispanic Black, 38.4% were women, and 48.8% received care at a VAMC. Rate of crime reported in a neighborhood (discrimination 3.13, SE 0.50; item difficulty -0.68, SE 0.07) and neighborhood rating (discrimination 4.02, SE 0.87; item difficulty -1.04, SE 0.08) had the highest discrimination (see Figure 1 for comparison between factors).

CONCLUSIONS: Based on these findings, crime and neighborhood rating discriminate best between individuals with type 2 diabetes who have high social risk and those with low social risk. These two questions can be used as a parsimonious social risk screening tool for research and clinical purposes.

IF MY MOOD IS LOW, I CAN’T HELP THE PATIENT: A QUALITATIVE STUDY TO UNDERSTAND THE MENTAL HEALTH CHALLENGES OF HOME HEALTH AIDES

Melissa Yanez¹; Elizabeth Kuo¹; Ann Lee²; Aida E. Ramos¹; Joanna B. Ringel¹; Elissa Kozlov³; Susan J. Andreae⁴; Monika M. Safford¹; Ariel Avgar⁵; Megan Shen⁷; Daniel Shalev¹; Catherine Riffin⁶; Faith Wiggins²; Madeline R. Sterling¹

¹Medicine, Weill Cornell Medicine, New York, NY; ²Training and Employment Fund, 1199SEIU United Health Care Workers East, New York, NY; ³School of Public Health, Rutgers The State University of New Jersey, New Brunswick, NJ; ⁴Kinesiology, University of Wisconsin- Madison, Madison, WI; ⁵School of Industrial and Labor Relations, Cornell University, Ithaca, NY;⁶Medicine, Weill Cornell Medicine, New York, NY; ⁷Fred Hutchinson Cancer Research Center, Seattle, WA. (Control ID #3872556)

BACKGROUND: Home Health Aides (HHAs) provide personal and medical care in the home to older adults and individuals with chronic conditions. Despite this, HHAs, themselves, are a vulnerable workforce that experiences high levels of stress and social isolation; these outcomes have worsened since the COVID-19 pandemic. In the present study, we aimed to understand the perspectives of HHAs towards their mental health challenges including how their job impacts their mood and potential interventions that can meet their needs.

METHODS: We conducted focus groups from August to December 2022 in partnership with the 1199SEIU Training and Employment Fund (TEF), a benefit fund of the 1199SEIU United Healthcare Workers East, the largest health care union in the U.S. TEF provides training and benefits to 55,000 agency-employed HHAs in New York, NY. We included English or Spanish speaking HHAs with ≥ 1 risk factor for poor mental health, defined as: 1) depressive symptoms (Personal Health Questionnaire 8-item [PHQ8] scale ≥ 5 points), 2) stress (Cohen’s Perceived Stress 4-item scale [PSS4] ≥5), and 3) loneliness (≥6 on the 3-item UCLA Loneliness scale). Focus groups were audio recorded, professionally transcribed, and analyzed thematically. The topic guide and analysis were informed by the Pender’s Health Promotion Model and the National Institute for Occupational Safety and Health’s Total Worker Health Model.

RESULTS: In total, 19 HHAs employed by 11 unique home care agencies participated. They had a mean age of 54 years (SD: 11.7), 18 (95%) were female, and 11 (56%) were Black; they had a median of 21 years (IQR: 10.0, 25.0) of job experience. Five main themes emerged: (1) HHAs personal lives outside of work, including family caregiving responsibilities, influences their mental health; (2) the day-to-day work associated with being a HHA, and their relationships with patients, impacts their mental health; (3) the COVID-19 pandemic worsened HHAs mood and stress levels; (4) HHAs use a variety of strategies (e.g. breathing exercises, religion, etc.,) to cope; (5) HHAs are eager for interventions that can improve their mental health, particularly peer support programs which can bring them closer to other HHAs and foster a sense of community.

CONCLUSIONS: For many HHAs, mental health is currently a challenge that is influenced by occupational and personal factors. Interventions with peer support features may be warranted for this workforce.

IMPACT OF MEDICALLY-TAILORED MEALS ON CLINICAL OUTCOMES AMONG LOW- INCOME ADULTS WITH DIABETES: A PILOT RANDOMIZED TRIAL

Jeanne M. Clark¹; May Thu Thu Maw¹; Kathy Pettway²; Geetanjali Chander³; Susan Elias⁴; Sam J. Zisow- McClean⁴; Nisa Maruthur¹; Raquel C. Greer¹. ¹Medicine/General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; ²Priority Partners, Johns Hopkins Medicine, Baltimore, MD; ³University of Washington School of Medicine, Seattle, WA; ⁴Moveable Feast, Baltimore, MD. (Control ID #3875122)

BACKGROUND: Low-income adults with diabetes experience significant barriers to healthful eating, including limited knowledge and skills around diet, and limited access to healthy foods. We conducted a pilot randomized controlled trial to examine the impact of medically-tailored meals (MTM) with Medical Nutrition Therapy (MNT) on clinical outcomes among low-income adults with type 2 diabetes.

METHODS: We recruited English-speaking adults with type 2 diabetes (DM) and A1c >8% from Maryland Medicaid plans using mailed brochures or provider referral and follow-up phone calls. We excluded anyone unable to safely consume the MTM. Eligible individuals were randomized to usual care or an intervention involving home delivery of 12 medically tailored, frozen meals and a fresh produce bag weekly for 3 months, and individual phone calls with a Registered Dietitian monthly for 6 months. Our outcomes were change from baseline to 6 months in A1c (primary), body mass index (BMI), blood pressure and diabetes-related quality of life, knowledge and self-efficacy (secondary).

RESULTS: Of 1537 adults assessed for eligibility from January 2020 to March 2022, we randomized 73 into the study, of whom 57 (78%) had complete data on the outcomes of interest. Their mean age was 48 years, 40% were male, 77% Black, 47% had < college education, and 49% had household income < $30,000. The mean A1c was 10.3%, mean BMI was 37.9 kg/m², and 54% had ≥3 medical conditions at baseline. Eighty- six percent of meals were delivered, and the mean number of nutrition visits completed was 4.8. Overall, at 6 months both the intervention and control groups had improvements in A1c (-0.7 vs. -0.6%), with no significant difference between groups. In exploratory analyses, more favorable changes in diabetes medications in the control group likely explained some of the lack of difference in improvement in A1c between groups. There was a trend towards greater improvement in A1c among those who reported eating ≥9 meals weekly compared to less (-1.8 vs. -0.4%, p=0.1), but no difference by number of nutrition visits. Similar to A1c, changes in systolic blood pressure (-6.3 vs. -3.7 mmHg) and BMI (-0.02 vs. -0.20 kg/m²) at 6 months did not differ between groups. Food security improved significantly from baseline to 3 months in the intervention group (47 to 83%) compared to control (52 to 56%; p<0.01), but this was not sustained at 6 months, when meal deliveries had stopped. Diabetes related quality of life, knowledge and self-efficacy improved modestly, but not differently by group.

CONCLUSIONS: Even during COVID, recruitment and retention of an at-risk group of adults with DM was feasible. MTM intervention uptake was good but did not improve A1c or other outcomes. MTM interventions that are more specifically diabetes directed and clinically integrated are likely needed to achieve significant clinical benefits.

IMPLEMENTATION COMMUNITYRX-CARDIOVASCULAR DISASE, AN E-INTEGRATED COMMUNITY RESOURCE REFERRAL SYSTEM IN RURAL NC FEDERALLY QUALIFIED HEALTHCARE CLINICS

Maura Drewry²; Amelia DeFosset²; Christopher Shea²; Emily Abramsohn³; Leah Frerichs²; Donald Cavellini¹; Gaurav Dave²; Giselle Corbie²; Stacy T. Lindau³

¹Project GRACE, Rocky Mount, NC; ²The University of North Carolina at Chapel Hill, Chapel Hill, NC; ³The University of Chicago Medicine, Chicago, IL. (Control ID #3875957)

BACKGROUND: African Americans in the rural Southeast experience disproportionate cardiovascular disease (CVD) burden due to structural inequalities resulting in unmet disease self-management and social care needs. The COVID-19 pandemic has exacerbated these gaps in self- and social care needs, especially in rural minoritized communities. Federally Qualified Health Centers (FQHC) in rural settings, and the communities they serve, have unique strengths and challenges around implementing clinic-community care models. Understanding and working within this rural FQHC context is key to ensuring successful implementation processes and outcomes. CommunityRx-CVD is an evidence-based intervention that integrates an electronic health record (EHR)-based referral system with clinical workflows to link African American patients with local community resources to address self- and social care needs and support cardiometabolic health. Using Implementation Science frameworks, researchers partnered with clinic-based implementation teams to build, test, and refine custom workflows supported by mixed methods data collection activities. This study describes outcomes of that process.

METHODS: This study triangulates data from 3 sources conducted at 2 clinics within the same FQHC system: 1) an 8-item survey based on the Organizational Readiness for Implementing Change (ORIC) measure (item range: 1-5, 5 indicating complete readiness), self-administered to clinic staff pre- and post- testing cycles, 2) a structured reporting form to capture clinic staff experiences with the implementation workflow during testing cycles, and 3) semi-structured focus groups conducted with Medical Assistants (MAs) and Care Coordinators to further refine the workflow post testing cycles.

RESULTS: Thirty-four staff and providers across the 2 intervention clinics completed ORIC surveys (56.7% response rate). Preliminary data shows that physicians and leadership (n=8) have high change commitment scores and moderate change efficacy scores (mean=4.45 and 3.85). Clinic support staff (e.g., MAs, front desk staff) show high scores for change commitment and change efficacy (mean=4.35 and 4.23)

CONCLUSIONS: Clinical Staff readiness for changes related to the intervention is high as they enter the testing phase of implementation, but physicians and leadership may need additional support to feel ready.

This presentation will describe how changes in ORIC scores over the testing period are interpreted in tandem with data from the structured reporting form and qualitative focus groups, and used to drive implementation planning, such as changes to the implementation workflow or staff training, or provision of targeted supports to clinic leadership. Physician leaders can build off of the results and processes described in this presentation to explore implementing e-integrated community-resource referral systems in rural health clinics, allowing them to apply innovative approaches to address emerging and complex patient care challenges.

IMPLEMENTATION OF A UNIVERSAL FOOD INSECURITY SCREENING TOOL AT AN ACADEMIC FAMILY MEDICINE CLINIC

Katherine E. Barnes²; Chioma Onuoha¹; Kira Furie¹; Kevin Reyes¹; Aria Sikaroudi¹; Hasan Abdulbaki¹; Shwesha Govil²; Sarah GaleWyrick²

¹School of Medicine, University of California San Francisco School of Medicine, San Francisco, CA; ²School of Medicine, University of California San Francisco, San Francisco, CA. (Control ID #3858566)

BACKGROUND: Only a minority of hospitals and physician practices in the United States report regular screening for basic needs, including food insecurity. These low screening levels indicate that most practices lack a systematic screening procedure. This study assesses the feasibility and utility of a universal food insecurity screening tool at an academic family medicine clinic.

METHODS: In this observational study, we distributed a food insecurity screening tool to all patients at our clinic for three months. Our screening tool consisted of the validated 2-item Hunger Vital Sign™ screening

tool and two additional questions that assessed interest in food resources. The screening tool was distributed by front desk staff and abstracted by medical assistants. Patients could request information about local food resources regardless of whether they screened positive or negative. Physicians discussed these resources with patients and included them in the after-visit summary. Demographic information and screening results were summarized descriptively.

RESULTS: 1,005 patients were screened in three months. 122 patients (12.1%) screened positive for food insecurity. Distribution by race/ethnicity is shown in Table 1. Food insecurity was highest among patients residing in zip codes 94165 (66.7%), 94103 (55.6%), 94134 (22.9%), and 94124 (21.1%). It was lowest in zip codes 94080 (6.4%) and 94131 (7.7%). Data on interest in food resources was missing for 128 patients; of the remaining 734 patients, 78 (10.6%) requested resources. 48 of these patients (48.7%) did not report food insecurity.

CONCLUSIONS: Rates of food insecurity are highest in Black/African American, Latinx, and American Indian/Alaska Native populations, and the zip codes with the highest rates of food insecurity all had median incomes below the county average. This distribution mirrors that seen in social determinants of health nationwide, suggesting validity of our data. Our data also suggest that food resources should be offered regardless of whether a patient indicates food insecurity, as many patients who screened negative requested information about resources. Overall, implementation of a short universal food insecurity screening tool is feasible and reveals a substantial need for screening.

IMPLEMENTING LOW BARRIER COVID-19 WALK-UP TESTING CLINICS FOR VULNERABLE POPULATIONS TO INCREASE TESTING ACCESS.

Gloria Sclar²; David Ngandu²; Sumayo Awale²; Ambia Ahmed¹; Kathleen Fairfield^2,1; Swapnika Mallipeddi²; Hina Hashmi²; Grace Price²; Andrew Volkers³; Caroline Fernandes³; Marie Louise Mudasigana⁴; Leslie Nicoll⁵; Elizabeth A. Vinton²; Daisy E. Parker²; Elizabeth Jacobs⁶

¹Medicine, Maine Medical Center, Portland, ME; ²Institute for Research, MaineHealth, Portland, ME; ³Preble Street, Portland, ME; ⁴Greater Portland Health, Portland, ME; ⁵Portland Community Free Clinic, Portland, ME; ⁶Academic Affairs, MaineHealth, Portland, ME. (Control ID #3874470)

BACKGROUND: COVID-19 disproportionately affects people from vulnerable communities, who are also less likely to receive antiviral treatment. To reduce spread of COVID-19 and advance equitable access to antivirals, we must improve accessibility and availability of COVID-19 testing and treatment. Effective public health strategies for delivering care include community input and partnerships.

METHODS: With national RADx-UP initiative funding, we created a partnership between an academic medical center and three community partners to offer low-barrier COVID-19 walk-up testing clinics for vulnerable populations in Portland, Maine. We aimed to serve people who are unhoused, low-income and/or uninsured, and immigrant groups. The clinics were run collaboratively by the study team and community partners: one community-based organization (serving people who are unhoused), the City of Portland’s public health center (serving low-income/uninsured, as well as providing a syringe exchange program and a sexually transmitted disease treatment clinic), and a Federally Qualified Health Center (FQHC; serving a large and diverse immigrant community). We offered COVID-19 rapid antigen tests. Patients completed their own anterior nasal swab while clinic staff processed the test. Language interpretation was provided, as needed, and individuals were asked to complete a brief survey while awaiting results. For positive cases, we reported the case to the Maine CDC and ensured patients were connected to antiviral treatment (Paxlovid) within 24 hours, if desired and eligible.

RESULTS: Between 1/14/2022 and 11/28/2022, we tested 217 people across the three sites, 17 of whom were positive for COVID-19 (8%). Among positive patients, 4 received Paxlovid while the remaining declined treatment. People sought testing for a variety of reasons, including symptoms (n = 128; 59%), close contact exposure (n = 66; 30%), and/or need for a negative test result to access services (i.e. healthcare, shelter) or an activity (i.e. work, travel) (n = 59; 27%). Among patients who completed the survey questions, 38% were unhoused (38/101), 26% uninsured (25/97), 37% made less than $15,000 before taxes in 2019 (33/89), and 49% were non-White (70/143). Only 9% were unvaccinated for COVID-19 (8/88). Lastly, almost half of all patients tested previously had COVID (n = 104, 48%). The collaboration with community partners helped build trust; identify unique COVID support needs for different groups; and co-locate testing with other desired services such as clothing and other medical care.

CONCLUSIONS: Providing low-barrier testing clinics is instrumental to reducing the spread of COVID-19 and reducing disparities in antiviral treatment access. Partnering with trusted community organizations is an approach that may make vulnerable populations more comfortable accessing testing. With the availability of effective antiviral therapy, these partnerships provide a way to reduce COVID-19 treatment disparities.

INEQUALITIES IN COVID-19 VACCINE COVERAGE AMONG U.S. 5-11-YEAR-OLDS VS 12-17- YEAR-OLDS

Israel Agaku¹; Theodore G. Long²

¹NYC Test and Trace Corps, New York City Health and Hospitals Corporation, New York, NY; ²Ambulatory Care, NYC Health + Hospitals, New York, NY. (Control ID #3865771)

BACKGROUND: The Pfizer-BioNTech COVID-19 vaccine has been approved for use among U.S. children aged 5-17 years, but CDC vaccination data shows less vaccine coverage among children aged 5-11 years vs adolescents 12-17 years. This study quantified the disparity in COVID-19 vaccine coverage among U.S. children aged 5-11 vs 12-17 years using population-level data and explored underlying contributing factors.

METHODS: Data were from the Household Pulse Survey conducted during December 1, 2021—February 7, 2022. Target population was parents/guardians of vaccine-age children 5-17 years who reported living with their children in the household (n=52,345). Descriptive and multivariable analyses were performed.

RESULTS: Of all U.S. parents/guardians of children aged 5-17 years, 55.6% reported that at least one child in their household had received a COVID-19 vaccine, ranging from 35.8% in Mississippi to 72.4% in Massachusetts. For each given number of children in U.S. households during December 1, 2021—February 7, 2022, having ≥one child vaccinated was less prevalent among parents/guardians of 5–11-year-olds than those of 12–17-year-olds. For example, of single-child households, 72.5% of parents/guardians of 12-17- year-olds reported that the adolescent had received a COVID-19 vaccine, vs 41.6% of parents/guardians with a 5-11-year-old child. Compared to parents/guardians of unvaccinated 12-17-year-olds, parents/guardians of unvaccinated 5-11-year-olds were more likely to report that their pediatrician had not offered a COVID-19 vaccine to them; they also had higher prevalence of various safety-related concerns.

CONCLUSIONS: Intensified efforts are needed to educate parents/guardians about the safety of COVID-19 vaccines, and to offer the vaccines to those eligible.

Key words: COVID-19, children, vaccine, hesitancy, disparities.

INFLUENCE OF NEIGHBORHOOD SOCIO-ECONOMIC DEPRIVATION ON EFFECTIVENESS OF AN INTENSIVE LIFESTYLE INTERVENTION

Mamadou Sy¹; Scott J. Pilla¹; Kesha Baptiste-Roberts²; Tiffany L. Gary-Webb³; Jessica Yeh¹; Dhanajay Vaidya¹; Jeanne M. Clark¹

¹General Internal Medicine, Johns Hopkins University, Baltimore, MD; ²Department of Behavioral Health Science, Morgan State University, Baltimore, MD; ³Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA. (Control ID #3875163)

BACKGROUND: Lifestyle interventions, including behavior modification, nutrition, and physical activity, are recommended in diabetes management. While neighborhood socioeconomic status has been shown to be associated with glycemic control, whether it impacts the effectiveness of lifestyle interventions remains unclear. Therefore, we conducted an ancillary study to the Look AHEAD (Action for Health in Diabetes) trial to examine if neighborhood socio-economic deprivation, a composite measure of SDOH (education, income, and occupation), influenced the effectiveness of an intensive lifestyle intervention (ILI). We hypothesized that higher neighborhood deprivation would be associated with less improvement in clinical outcomes from an ILI. METHODS: Look AHEAD randomized patients with overweight/obesity and type 2 diabetes to an ILI aimed at weight loss, or a comparison group, Diabetes Support and Education (DSE). We linked individual- level data of participants from 4 study sites to environmental and community data from the 2000 United States (U.S) Census used to generate a summary score estimating neighborhood socio-economic deprivation. We analyzed the effect of tertile of neighborhood deprivation on weight and A1c changes from baseline across the first 4 years of follow-up using a mixed effects linear model with random intercept and an interaction term between neighborhood, study year, and study arm.

RESULTS: Among 1,213 participants, the mean age was 60 years, 41% were male, and 65%, 26%, and 4% had self-reported race/ethnicity of white, Black, and Hispanic, respectively. 84% had a college degree or greater, and 75% reported an annual income over $40,000. At baseline, the mean A1c was 7.3% and mean BMI 36.1 kg/m², mean deprivation score was -5.33 in the 1^st tertile (min: -12.04; max: -2.61) and 5.68 in the 3^rd tertile (min: 2.01; max:18.69). The intervention effectiveness on weight at year 1 did not differ by tertile of neighborhood deprivation in the ILI group (1^st vs 3^rd tertile: -8.99% vs -9.32%, p=0.6); or the DSE group (1^st vs 3^rd tertile: -0.19% vs -0.62%, p=0.5). There we also no differences at year 1 in effect on A1c in the ILI group (1^st vs 3^rd tertile: -0.71% vs -0.59%, p=0.27) or the DSE group (1^st vs 3^rd tertile: -0.13% vs -0.12%, p=0.96). Finally, there were no statistically significant differences between weight and A1c changes across the tertiles over the 4 years.

CONCLUSIONS: In this clinical trial population, the intensive lifestyle intervention was equally effective across levels of neighborhood socio-economic deprivation. However, these findings may not extend to individuals with the lowest income and educational attainment who are not typically represented in clinical trials and for whom more research is needed.

INSIGHTS INTO PATIENT PERCEPTIONS OF SOCIAL DETERMINANTS OF HEALTH (SDOH) AND THE USE OF CONDITIONAL CASH TRANSFERS (CCTS) TO ADDRESS THEM IN A PRIMARY CARE CLINIC

Marguerite Balasta¹; Kerry Meltzer¹; Anna U. Morgan²; Corinne M. Rhodes³

¹Department of General Internal Medicine, University of Pennsylvania, Philadelphia, PA; ²Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ³Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #3873490)

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) has highlighted the importance of social determinants of health (SDOH) and mandated healthcare organizations conduct social needs assessments. Health systems struggle with effective ways to manage SDOH, often referring to community programs and government resources which are helpful but may not provide a solution to unique patient problems. There is little known about patient perception of SDOH and their impact on health. There is an opportunity to learn about how patients experience the health impacts of SDOH and tools for providers to effectively address them. Conditional cash transfers (CCTs) are a well-established intervention in behavioral economics and policy research to address SDOH but have not been studied in primary care.

METHODS: We conducted a randomized controlled trial to explore patient understanding of how SDOH influence health and the impact of CCTs. Thirty patients were recruited from 2 primary care clinics in Philadelphia November 2021 to February 2022. Eligible adults resided in zip codes with annual household income <$50k, had Medicare or Medicaid, and at least 1 chronic medical condition. All screened positive for at least 1 of 3 SDOH factors: financial strain, transportation needs, or food insecurity. We conducted semi- structured interviews at enrollment and 15 participants were randomized to receive $500. Patients were re- interviewed at 6 months.

RESULTS: Participants were 70% female, 90% black, and 54% had Medicare. 83% completed the study. Key themes related to patients’ reflections on the effect of SDOH on health, the role of primary care providers (PCPs) in addressing social needs, and views on CCTs were revealed through rapid qualitative analyses. While patients understood their social needs, they did not readily connect SDOH to health. Most felt PCPs had no role in addressing social needs and instead referenced SDOH as a personal responsibility. All were appreciative of CCTs and a few used it towards specific health-related uses like transportation to appointments, but most addessed a pressing financial need.

CONCLUSIONS: Patients recognize they have social needs, but do not clearly link SDOH to health and do not see addressing social needs as a responsibility of their primary care clinician.

INSURANCE STATUS AND PRIOR KNOWN DIAGNOSIS OF DIABETES AMONG PATIENTS HOSPITALIZED WITH COVID

Anisha Ganguly^2,1; Michael Harms²; Kavita Bhavan^2,1

¹Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; ²Parkland Health, Dallas, TX. (Control ID #3877128)

BACKGROUND: Underdiagnosis of diabetes has been associated with lack of insurance. Texas is a Medicaid non-expansion state and has the largest uninsured population in the country, resulting in decreased access to preventive care. During the pandemic, uninsured patients presented to health systems for the first time due to COVID hospitalization.

METHODS: Using EMR data from our safety-net hospital in Dallas, TX, we conducted a cross-sectional analysis of patients with diabetes hospitalized with COVID infection from June 2020 to December 2021 to examine the relationship of insurance and prior known diagnosis of diabetes. Diagnosis of diabetes was defined by an A1c of ≥6.5 and/or by diagnosis code. Insurance cohorts were uninsured, charity coverage, Medicare, and Medicaid. The primary outcome was known diagnosis of diabetes in the past year. Logistic regression was used to evaluate the association between prior known diagnosis of diabetes and insurance status.

RESULTS: Among patients with diabetes hospitalized with COVID (n=1,254), there were 22.1% uninsured, 20.9% charity coverage, 40.6% Medicare, and 16.4% Medicaid (Table 1). The majority of the population was male, >45, and Hispanic. After adjusting for age and race/ethnicity, the uninsured were less likely to have known diabetes prior to their COVID hospitalization compared to those with Medicaid (OR 0.56 [95% CI 0.39-0.82], p <0.01).

CONCLUSIONS: Uninsured patients with diabetes admitted with COVID were less likely to have a known diagnosis of diabetes before their COVID hospitalization. These findings reflect decreased primary care access and screening for diabetes among the uninsured in Texas. These findings may support universal testing for diabetes in acute settings to screen patients without primary care access and inform future policy efforts to expand healthcare coverage.

INVESTIGATING NAVIGATION TO HELP ADVANCE LUNG EQUITY (INHALE): A PRAGMATIC TRIAL OF PATIENT NAVIGATION FOR LUNG CANCER SCREENING AT A HEALTH CARE FOR THE HOMELESS PROGRAM

Travis P. Baggett^1,2; Nora Sporn¹; Joana Barbosa Teixeira³; Elijah C. Rodriguez⁴; Nillani Anandakugan⁵; Natalia Critchley¹; Evangeline Kennedy¹; Katherine Hart¹; Andrea Joyce⁵; Yuchiao Chang¹; Sanja Percac- Lima¹; Elyse Park⁵; Nancy A. Rigotti¹

¹Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA; ²Boston Health Care for the Homeless Program, Boston, MA; ³Ragon Institute, Charlestown, MA; ⁴New York University Grossman School of Medicine, New York, NY; ⁵Massachusetts General Hospital, Boston, MA. (Control ID #3874258)

BACKGROUND: People experiencing homelessness die of lung cancer at over 2-fold higher rates than people in the general population. Lung cancer screening (LCS) with low dose computed tomography (LDCT) reduces lung cancer mortality among those at increased risk, but the circumstances of homelessness create multiple barriers to LCS LDCT completion. Patient navigation is a promising but untested strategy for overcoming these barriers in a homeless-experienced patient population.

METHODS: In 2020-2022, we conducted a pragmatic trial of LCS patient navigation at a large urban Health Care for the Homeless (HCH) program. To be eligible, participants were required to have a history of homelessness, have a primary care provider (PCP) at the HCH program, be proficient in English, and meet the 2015-2022 Medicare LCS coverage criteria: 55-77 years old, 30 pack-year smoking history, and smoking within the past 15 years. Enrolled participants completed a baseline survey and were randomized 2:1 to usual care with or without LCS navigation. Following a theory-based, patient-centered protocol, the navigator provided lung cancer education, facilitated LCS shared decision-making visits with PCPs, assisted in making and attending LCS LDCT appointments, arranged follow-up when needed, and offered tobacco cessation support for current smokers. The primary outcome was receipt of LCS LDCT at 6 months, ascertained by medical records review and compared between study arms with the Chi square test. Using a sequential explanatory mixed methods approach, qualitative interviews assessed participants’ perceptions of the navigation intervention.

RESULTS: Two hundred sixty participants were randomized to usual care with (n=173) or without (n=87) LCS navigation. The mean age was 60.5 years, 70.8% were male, 36.9% were Black, 36.9% were white, and

14.6% were Hispanic. One-third of participants (32.3%) were currently homeless, and 67.7% were formerly homeless (23.5% precariously housed, 43.1% stably housed). Half (50.8%) reported fair or poor health, and 85.0% currently smoked. Serious mental illness (28.8%), at-risk drug use (27.7%), and at-risk alcohol use (23.5%) were common. At 6 months, 43.4% of navigation arm participants and 9.2% of usual care arm participants had completed LCS LDCT (p<0.001). The intervention effect did not differ by housing status (p=0.68); however, across both study arms, housed individuals had higher LCS completion rates than currently homeless individuals in unadjusted (37.5% vs. 20.2%) and multivariable adjusted (aOR 3.52, 95% CI 1.57, 7.88) analyses. In qualitative interviews, participants identified multiple types of social support provided by the navigator, including informational, emotional, instrumental, and affirmational support

CONCLUSIONS: Patient navigation produced a nearly 5-fold increase in LCS completion at a large HCH organization. Even with individualized navigation support, housing status remained a major determinant of study outcomes.

INVESTIGATION OF WHETHER PERCEIVED ACCESS MEDIATES RACIAL AND ETHNIC DISPARITIES IN CHRONIC DISEASE CONTROL IN THE VETERANS HEALTH ADMINISTRATION: AN OBSERVATIONAL STUDY

Evan Shannon^2,1; W. N. Steers²; Donna L. Washington^2,1

¹Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA; ²VA Center for the Study of Healthcare Innovation Implementation and Policy, Los Angeles, CA. (Control ID #3876060)

BACKGROUND: Literature suggests that minoritized racial and ethnic (e.g., Black and Hispanic) groups report lower perceived access to healthcare compared to non-Hispanic White patients. Prior research has also demonstrated lower rates of hypertension (HTN) and diabetes mellitus (DM) control among minoritized racial and ethnic groups compared to White individuals in the Veterans Health Administration (VA). However, it remains unclear if patient perceived access mediates the association between race or ethnicity and chronic disease control, such that minoritized groups perceive lower levels of access which, in turn, leads to worse disease control.

METHODS: We performed a cross-sectional analysis of linked data from the VA Patient Centered Medical Home (PCMH)-Survey of Healthcare Experience of Patients (SHEP) and the VA External Peer Review Program, a set of standardized clinical performance measures, for fiscal years 2016-2019. The primary outcomes of interest were HTN (<140/90 mmHg) and DM (HgbA1c<9%) control among patients with known disease. Our primary predictor, self-identified race and ethnicity, was categorized as American Indian/Alaska Native (AIAN), Asian, Black, Hispanic, Multi-Race, Native Hawaiian and Other Pacific Islander (NHOPI) and non-Hispanic White (White). The hypothesized mediator was patient perception of access to their PCMH, scored on a scale of 0-100 percentage points. We then tested for disparities between non-White and White patients, and tested whether any observed disparities were attributable to less perceived access among minoritized groups using the Tchetgen Tchetgen inverse odds weighting approach, and adjusting for age, sex, rural/urban status, socioeconomic status, education, self-rated physical and mental health and Gagne comorbidity score.

RESULTS: Our analytic HTN sample had 53,515 patients and our analytic DM sample had 34,004 patients. The race and ethnicity distributions for each sample were comparable, with the distribution for the HTN sample presented here: 0.7% AIAN, 0.6% Asian, 11.6% Black, 4.1% Hispanic, 0.8% Multi-Race, 0.8% NHOPI, 3.9% unknown, 77.4% White. After adjustment for covariates, Black patients had significantly lower rates of HTN control than White patients (75.7% v 79.6%, p<0.001). Both Black (83.7%) and Hispanic (83.1%) patients had significantly lower rates of DM control than White patients (86.9%, p<0.001 for both differences). After adjustment for covariates, there was no evidence that perceived access scores mediated the associations between Black race, Hispanic ethnicity and HTN or DM control.

CONCLUSIONS: We observed disparities in HTN and DM control among minoritized patients in our sample, but did not find evidence that patient’s perception of access to their PCMH mediated the association between race and ethnicity and HTN or DM control for these patients. Reducing racial and ethnic disparities within VA in HTN and DM control requires interventions beyond those focused on improving patient access.

IS SUPPORTIVE HOUSING SUPPORTIVE ENOUGH? QUALITATIVE RESULTS FROM THE PATIENT CENTERED HOUSING OPTIONS, OUTCOMES, SERVICES, AND ENVIRONMENT (PCHOOSE) STUDY

Maria Y. Patanwala^1,4; Roya Ijadi-Maghsoodi^2,3; Bikki Tran Smith⁵; Howard Padwa⁶; Melissa Chinchilla¹; Taylor Harris¹; Lillian Gelberg⁷

¹VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²Division of Population Behavioral Health, University of California Los Angeles Health System, Los Angeles, CA; ³HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ⁴Department of General Internal Medicine, University of California Los Angeles Health System, Los Angeles, CA; ⁵Department of Biomedical & Health Sciences, University of Vermont, Burlington, VT; ⁶Integrated Substance Abuse Programs, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁷Family Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #3876260)

BACKGROUND: The US has over half a million people experiencing homelessness (PEH) who, as a population, exhibit high rates of morbidity and mortality. Social support and housing are key determinants of health, and permanent supportive housing (PSH), by providing both, has the potential to improve health for PEH. Place-based PSH (PB-PSH) are buildings designated for PEH with onsite case managers, and scattered- site PSH (SS-PSH) are apartments throughout the community with mobile case managers. This qualitative study examines how recently housed adults describe their social supports in PSH and how social supports differ across PSH housing models. We aim to report perspectives and experiences of newly housed adults to inform PSH best practices in providing social supports in housing interventions.

METHODS: PCHOOSE is a comparative effectiveness study of different PSH models that recruited over 500 adults who entered PSH between January 2021 and June 2022. We invited a purposive sub-sample to complete 3 semi-structured interviews: at baseline (within the first month of housing) and at 3 and 6-months post-housing. This analysis focuses on baseline interviews (N=27), which explored housing history, health status, social supports, and current housing experience. Multiple researchers iteratively coded interview transcripts and performed thematic analyses related to social relationships and supports. We compared experiences by PB-PSH (N=11) versus SS-PSH (N=16) and interviewee characteristics.

RESULTS: Among the 27 baseline interviewees, the average age was 45 years-old, median time spent homeless was 7 years, 44% were men, 52% reported fair/poor physical health, and 42% reported fair/poor mental health. We identified four themes related to social supports in baseline interviews: 1) housing brought hope for improved relationships – “Now they’re all happy that I have a place, and they’re starting to talk to me again,” 2) housing changed physical or geographic conditions of relationships – “Now, so that I have a place—I have my kids over to visit…” 3) changes in social networks were sometimes desired – “…it’s what I needed, to be away from, one, away from people that I knew,” and 4) participants relied on formal supports like former and current case managers and informal supports like family for different needs or if the other support failed. At baseline, we identified no thematic differences by PSH unit type.

CONCLUSIONS: Our findings elucidate how newly housed adults perceive and navigate formal and informal sources of social support upon moving into PSH. Findings can be used to enhance assessments and services in PSH such as social health screenings that guide placement and connections to community- partnered organizations to fill support gaps. As cities respond to growing rates of homelessness with more PSH development, it is imperative that we also develop best practices within PSH that prioritize the social needs of homeless-experienced individuals to promote their health and retention in housing.

LATINO-WHITE DISPARITIES IN SCREENING FOR UNHEALTHY ALCOHOL USE IN THE OCHIN NETWORK OF COMMUNITY HEALTH CENTERS

Brian Chan^1,2; David Ezekiel-Herrera³; Jennifer A. Lucas³; Miguel Marino³; Steffani Bailey³; Sophia Giebultowicz²; Zoe Larson²; John Heintzman³

¹Medicine, Oregon Health & Science University, Portland, OR; ²Oregon Community Health Information Network, Portland, OR; ³Family Medicine, Oregon Health & Science University, Portland, OR. (Control ID #3876641)

BACKGROUND: Unhealthy alcohol use and the sequelae of alcohol-related diseases continue to be an important health concern; there is evidence that the COVID-19 pandemic was associated with increased alcohol use and related mortality. In 2018, the US Preventative Services Task Force (USPSTF) updated its recommendation to screen for unhealthy alcohol use in primary care settings in adults. It is known that Latino drinking patterns differ from non-Hispanic White (NHW) and other racial groups; while less likely to drink than NHW, Latinos who do drink may consume higher volumes and are at risk for health complications of chronic alcohol use. Given existing cardiovascular health disparities in Latino populations compared to NHW, equitable screening for unhealthy alcohol use and alcohol use disorders is important in community health settings that serve a high proportion of Latino patients.

METHODS: We evaluated the odds of unhealthy alcohol screening in adults by ethnicity and language preference. This was an observational cohort study using OCHIN data, a multi-state electronic health record (EHR) network of community health centers (CHCs). The population was adults seen in primary care between 2012-2020. We used logistic regression via generalized estimating equations to estimate the covariate-adjusted relative odds of receipt of alcohol screening, noted by EHR completion of Screening Brief Intervention and Referral to Treatment (SBIRT). Our predictor of interest was ethnic-language preference groups (NHW, Latino-Spanish language preferred, Latino-English language preferred). For regression analysis, NHW were considered the referent group and robust standard errors were estimated to allow for clustering at the clinic level.

RESULTS: There were 1,781,206 patients in the sample across 26 states with average age of 41.5 years (SD=15.3). Over half were female (57%); 22% were never insured, while 51% reported some public insurance. There were 57% NHW, 27% Latino-Spanish language preferred, and 16% Latino-English language preferred patients. Of the study sample, 41% had received SBIRT screening during this period. Latinos who preferred Spanish had 52% increased odds of alcohol screening compared to NHW (aOR=1.52, 95% CI: 1.26, 1.84). Compared to NHW, Latinos who preferred English had similar odds of alcohol screening completion (aOR=1.04, 95% CI 0.90, 1.22).

CONCLUSIONS: In a multi-state cohort of CHC patients seen in primary care, we found less than half of the patients received USPSTF recommended screening for unhealthy alcohol use, and that Latinos who speak Spanish had 52% higher odds of having been screened compared to non-Hispanic whites. Further investigation on how CHCs implement culturally relevant screening in diverse populations may aid in efforts to address screening and health equity gaps in other health settings.

MEDICAL STUDENTS WITH DISABILITIES: THE CRITICAL IMPORTANCE OF PROGRAM ACCESS TO EFFECTIVE LEARNING ENVIRONMENTS

Christopher Moreland¹; Melissa Plegue³; Karina Pereira-Lima³; Zoie Sheets⁴; Neera Jain⁵; Erene Stergiopoulous⁶; Benjamin Case⁷; Amy Addams⁸; Lisa Meeks²

¹Internal Medicine, Dell Medical School at UT Austin, Austin, TX; ²Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI;³University of Michigan, Ann Arbor, MI; ⁴University of Illinois Chicago, Chicago, IL; ⁵The University of British Columbia Faculty of Medicine, Vancouver, BC, Canada; ⁶University of Toronto, Toronto, ON, Canada; ⁷University of Wisconsin-Madison, Madison, WI; ⁸Association of American Medical Colleges, Washington, DC. (Control ID #3877317)

BACKGROUND: Disability is underrepresented in the workforce with student-to-physician attrition. Program access facilitates wellbeing for students with disabilities (SWD); learning climates contribute to attrition for many marginalized in medicine. We hypothesized that SWD perceive learning climates as suboptimal (vs nondisabled students) & that program access narrows this gap.

METHODS: The AAMC surveys 2nd-year medical students on agreement with learning environment statements & perceptions of:

1) Schools fostering students’ personal/professional development;

2) Environment via shortened version of validated Medical School Learning Environment Scale (MSLES) inventory;

3) 3 MSLES sub-scales corresponding to emotional climate, student-faculty interactions, student-student interactions.

In two cohorts (2019/2020) totaling 23898 students, we compared 3 groups (students reporting no disabilities, SWD reporting program access, SWD without program access) on learning environment measures (chi-square & ANOVA).

RESULTS: 2438 (10.2%) reported disability. 84% of SWD (n= 2039) reported having program access (i.e. appropriate accommodations or not needing accommodations). 16% (n=399) reported lack of program access (i.e. accommodations denied, under review, or not requested for some reason other than not needing them).

Fostering Development: Students without disabilities reported higher agreement that schools fostered development as a person (72%) & a physician (93%), compared with SWD, both with & without program access (p<0.001). SWD without program access reported lower agreement than SWD with program access (p<0.001). 66% & 86% (respectively) of SWD with program access endorsed development as a person & as a physician, compared to SWD without program access (44% & 79%, respectively).

Medical school environment: 9 statements address multiple domains (e.g., how performance is evaluated, isolation feelings, shared values). For 8 statements, nondisabled students reported higher agreement than SWD, both with & without program access (p<0.001); SWD with program access had higher agreement than those without (p<0.001).

Learning environment scales: address perceptions of student-student interactions (e.g. getting to know one another), student-faculty interactions (e.g. faculty guidance quality), emotional climate (e.g. if educational experience leads to sense of achievement). All groups differed on all scales (all p <0.001). Nondisabled students reported higher agreement than SWD both with & without program access (all p <0.01); SWD with program access reported higher agreement than those without program access (all p <0.001)

CONCLUSIONS: Our study is the first to explore SWD learning environment perceptions & program access. SWD report less favorable learning climates & program access mitigates differences, confirming accessible education’s importance. Medical schools should review structural accommodation barriers & enhance program access pathways.

MEDICATION MANAGEMENT SUPPORT FOR INDIVIDUALS WITH LIMITED ENGLISH PROFICIENCY: AN ONLINE REVIEW OF PATIENT LANGUAGE RESOURCES AND SURVEY OF PHARMACIES

Claire Arnold¹; Nancy Nguyen³; Joseph Herges³; Tyler Benning³; Rozalina G. McCoy². ¹Internal Medicine, Mayo Clinic Department of Internal Medicine, Rochester, MN; ²Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Foundation for Medical Education and Research, Rochester, MN; ³Mayo Clinic Minnesota, Rochester, MN. (Control ID #3876098)

BACKGROUND: Nearly 25 million Americans have limited English proficiency (LEP). Language services are needed in all sectors of the healthcare system, not only in direct clinical care settings. We therefore systematically examined the availability, accessibility, and breadth of language services available in pharmacies in a Midwest city with a high prevalence of LEP.

METHODS: Pharmacies in Rochester, Minnesota, were identified from institutional resources and augmented for completeness using an internet search. Pharmacies were characterized as chain, hospital/clinic-affiliated, and locally owned. We then systematically reviewed language resources offered by each pharmacy as publicized on their public-facing websites to assess what is available and accessible to individuals with LEP, documenting the specific language services offered, quality of patient instructions to access these services, and the number and types of supported languages. Results were cataloged and descriptively analyzed. To complement the information available to consumers online, we then created a RedCap structured interview guide with both closed- and open-ended questions for a telephone survey of pharmacy staff. Questions probed for specific language services available for each of the languages and staff satisfaction with currently available language services.

RESULTS: We identified 29 retail pharmacies, including 15 chain pharmacies, 10 hospital/clinic-affiliated, and four locally owned pharmacies. Ten of the 15 chain pharmacies offered interpreter services, and only one specifically listed the languages supported by interpreter services; others quantified the number of languages offered but did not specify which ones. Ten of the chain pharmacies indicated that they provide information in languages other than English, with 6 specifying what information is provided. Two of the chain pharmacies had a complex multistep process for setting up language services; these steps were outlined only in English with no non-English language support available on the website. Four chain pharmacies offered talking prescription labels that can be translated into other languages to accompany dual-language prescription labels. Locally owned pharmacies did not have any available information about language services but instead publicized different medication packaging options or offered medication consultations. Hospital/clinic- affiliated pharmacies only mentioned that interpreter services and/or medication consultations were available, but did not specify what services were available, the languages supported, or how to access them. Only one chain and one locally owned pharmacy offered the ability to translate their websites into Spanish; remaining pharmacies’ websites did not have a direct method of translating the contents of their websites

CONCLUSIONS: Structured interviews of all pharmacies are ongoing to better understand what may be available to consumers directly.

MENTAL HEALTH OUTCOMES AND HEALTHCARE SYSTEM ENGAGEMENT: AN ANALYSIS OF FORMERLY INCARCERATED TRANSGENDER INDIVIDUALS

Rachel Engelberg^1,2; Maria R. Khan¹

¹Population Health, NYU Langone Health, New York, NY; ²Internal Medicine, NYU Langone Health, New York, NY. (Control ID #3855439)

BACKGROUND: Transgender individuals face distinct challenges compared to cisgender counterparts, particularly in terms of mental health outcomes and healthcare access. Despite an increased risk for transgender individuals to experience incarceration, less is understood about healthcare disparities specific to transgender populations that have intersected with the criminal legal system. We sought to determine if formerly incarcerated transgender individuals experienced mental health disparities and differences in healthcare engagement compared to formerly incarcerated cisgender groups.

METHODS: In a secondary data analysis using the U.S. Transgender Population Health Survey (TransPop), we performed multivariate logistic regression to estimate the relationships between transgender identity and the following outcomes: attempted suicide, psychological distress, self-harming acts, having a doctor, and having health insurance. All analyses were conducted with respondents who had indicated a lifetime history of incarceration. Models were adjusted for key covariates of age, race/ethnicity, and education level.

RESULTS: Of respondents in the analytic sample (N=214), 24.3% identified as transgender. Among people with a history of incarceration, transgender participants (versus cisgender, the referent) were more likely to report attempted suicide (adjusted odds ratio (AOR): 6.3, 95% confidence interval (CI): 2.2-18.5), high psychological distress (AOR: 4.9, CI: 1.8-13.5), and self-harming behaviors (AOR: 3.8, CI: 1.1-12.4). There were no statistically significant differences between transgender status and having a doctor (AOR: 1.2, CI: 0.4-3.5) and having health insurance (AOR: 1.4, CI: 0.3-5.7).

CONCLUSIONS: Despite no differences in healthcare system engagement, formerly incarcerated transgender individuals experience significant mental health disparities when compared to criminal legal- involved cisgender peers. Formerly incarcerated transgender groups represent an at-risk population in need of improved access to mental health treatment.

MINORITIES, ADULTS 45-49, AND THOSE WITH LIMITED ENGLISH PROFICIENCY WERE LESS LIKELY TO REPORT RECEIVING COLORECTAL CANCER SCREENING IN 2019. Jennifer Bayly¹; Mara A. Schonberg²

¹General Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Medicine, Beth Israel Deaconess Medical Center, Brookline, MA. (Control ID #3873683)

BACKGROUND: Colorectal cancer (CRC) incidence has risen in adults younger than 50 years old, particularly within minority populations. Therefore, in 2018, the American Cancer Society (ACS) updated its CRC screening guidelines to lower the recommended age to begin CRC screening to age 45. ACS also recommend multiple modalities for screening. We aimed to examine receipt of CRC screening in US adults 45-75 after publication of these guidelines, especially among minorities and those with limited English proficiency (LEP).

METHODS: We analyzed cross-sectional data from the 2019 National Health Interview Survey among adults 45-75 years old without a history of CRC (weighted n=96,709,386). Adults were considered up to date with CRC screening (UTD) if they reported a screening colonoscopy within 10 years, FIT/DNA within 3 years, or any stool test within 1 year. Adults reporting sigmoidoscopy or CT colonography within 5 years were excluded (n=452) since the reason these tests were done was not assessed. Adults not UTD with screening were asked if a doctor had recommended CRC screening, and if so which test. We used multivariable logistic regression to examine receipt of UTD screening by age, race/ethnicity, limited English proficiency (defined by language of interview other than English only), race and other sociodemographic variables.

RESULTS: Participant mean age was 59 years (+/-0.09), 17% were aged 45-49 years, 11% were Black, 14% were Hispanic, and 7% had LEP. Overall, 53% of adults reported being UTD with CRC screening; 10% of adults aged 45-49 compared to 74% of adults 65-75. Adults with LEP were significantly less likely to be UTD with CRC screening than those without LEP (28% vs. 55%, (adjusted odds ratios [aOR] = 0.65; 95% confidence interval [CI] = 0.48 – 0.90) and Hispanic adults were less likely to be screened than non-Hispanic whites (36% vs. 58%, aOR=0.77). Among adults who were not UTD (47%, weighted n = 44,232,365), only 16% reported that their doctor recommended CRC screening (11% of those with LEP); Hispanics were less likely to report receiving a recommendation than non-Hispanic whites (aOR = 0.69 (0.48-0.96). Among

adults who reported being recommended screening, 73% were recommended a colonoscopy and 22% were recommended stool-based tests.

CONCLUSIONS: Despite new ACS guidelines, only 10% of adults 45-49 were UTD with CRC screening in 2019. Regardless of age, CRC screening was especially low in Hispanics and in adults with LEP. Concerningly these adults were also less likely to report a clinician recommendation for CRC screening. Despite guidelines recommending multiple screening modalities, clinicians continue to recommend colonoscopies more often than stool cards which may be easier for patients to obtain. Multi-level interventions are needed to increase CRC screening especially for adults 45-49, minority populations and those with LEP.

MORTALITY TRENDS AMONG HOMELESS-EXPERIENCED ADULTS IN BOSTON, MASSACHUSETTS OVER 16 YEARS

Danielle R. Fine^1,2; Kirsten Dickins³; Logan Adams^1,2; Nora Horick⁴; Jessie Gaeta^5,6; Elizabeth Lewis^5,7; Sarah Looby^8,2; Travis P. Baggett^9,2

¹Division of General Internal Medicine, Massachusetts General Hospital, Brookline, MA; ²Harvard Medical School, Boston, MA; ³Rush University Medical Center, Chicago, IL; ⁴Biostatistics, Massachusetts General Hospital, Boston, MA; ⁵Boston Health Care for the Homeless Program, Boston, MA; ⁶Boston Medical Center, Boston, MA; ⁷Boston University School of Public Health, Boston, MA; ⁸Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA; ⁹General Medicine Division, Massachusetts General Hospital, Boston, MA. (Control ID #3847701)

BACKGROUND: Mortality rates among people experiencing homelessness (PEH) are high, but few studies have examined temporal mortality trends in this population. A comprehensive, temporal assessment of mortality among PEH can inform important equity-focused policy decisions. The objective of this study was to assess patterns in all-cause and cause-specific mortality in a large cohort of PEH.

METHODS: We linked a cohort of 60,092 adults seen at Boston Health Care for the Homeless Program (BHCHP) from 2003-2017 to Massachusetts death occurrence files spanning 2003-2018. Using the US urban Northeast population as the reference population, we used indirect standardization to calculate annual age- and sex-standardized all-cause mortality rates in the BHCHP cohort. We used Poisson regression models to compare temporal trends in the standardized BHCHP rates to the rates in the reference population. We used the cohort-by-year interaction term to determine whether the rates of change differed significantly between the BHCHP cohort and reference population. We repeated this process for the six leading causes of death observed in the BHCHP cohort. We also examined age-, sex-, and race/ethnicity-stratified all-cause and cause-specific mortality rates aggregated across time, in comparison to the reference population.

RESULTS: A total of 7,130 deaths occurred during 520,430 person-years of follow-up. From 2003-2018, the standardized all-cause mortality rate in the BHCHP cohort did not significantly change (0.16% annual growth; 95% CI: -0.36%, 0.68%; P=0.54), whereas the all-cause mortality rate in the urban Northeast population decreased 1.21% annually (95% CI: -1.25%, -1.17%; P<0.0001), contributing to a significant widening in the mortality disparity between these populations (P interaction<0.0001). Drug overdose was the leading cause of death (23.7%), with the standardized drug overdose mortality rate increasing on average 9.35% annually (95% CI: 7.90%, 10.79%; P<0.0001), compared to an average annual increase of 7.57% (95% CI: 7.34%, 7.80%; P<0.0001) in the urban Northeast (P_interaction=0.018). Cardiovascular disease, cancer, and liver disease were other leading causes of death in the BHCHP cohort, with rates that declined significantly over the study period. Suicide was a leading cause of death among BHCHP cohort men and women ages 18-34 years; homicide was a leading cause of death among Black and Latinx men <50 years; and HIV was a leading cause of death among Black and Latinx men and women ages 35-64 years.

CONCLUSIONS: In this large cohort of PEH, the mortality gap with the general population widened over a period of 16 years, driven partly by drug overdose deaths. Several demographic subgroups were differentially affected by certain causes of death and frequently demonstrated higher mortality rates compared to the general population. Policies addressing housing access and interventions tailored to meet the distinct needs of PEH are essential to reducing mortality disparities in this population.

NAVIGATING A CLIMATE OF BURDEN: THE EXPERIENCES OF UNDOCUMENTED IMMIGRANTS IN APPLYING FOR COVID-19 DISASTER RELIEF ASSISTANCE FOR IMMIGRANTS (DRAI) IN CALIFORNIA

Irving Ling¹; Hye Young Choi^3,2; May Sudhinaraset²

¹Internal Medicine, Kaiser Permanente Northern California, Oakland, CA; ²Community Health Science, University of California Los Angeles, Los Angeles, CA; ³Yale School of Medicine, New Haven, CT. (Control ID #3859954)

BACKGROUND: Undocumented immigrants experienced some of the highest levels of economic insecurity during the pandemic while being excluded from COVID-19 relief and unemployment benefits. In April 2020, California became the first state to offer financial aid to undocumented immigrants through the Disaster Relief Assistance for Immigrants (DRAI) program in collaboration with community-based organizations (CBOs). However, the application process was marked by many implementation challenges. This study represents one of the first to call attention to the personal experiences of undocumented immigrants in applying for DRAI and examines how administrative burden interacts with structural and personal factors to affect the decision to apply for aid. This study aims to generate recommendations to improve public policy interventions that address the social determinants of health of undocumented immigrants.

METHODS: Twenty participants were recruited through snowball sampling for in depth interviews. Eligible individuals were: 1) API or Latinx; 2) undocumented with or without DACA; 3) 18-39 years old; and 4) residing in California during the study. Audio recordings were transcribed via Otter.ai and coded via DeDoose. Qualitative analysis was used to identify themes through an iterative process between two trained researchers to develop the final coding manual upon saturation of the data.

RESULTS: The COVID-19 pandemic negatively affected the economic conditions of participants and their families. Collective scarcity, self-minimizing need, and notions of low self-efficacy were upstream barriers in applying for DRAI under a climate of burden stemming from factors, such as the fear of immigration enforcement. In the process of applying, the lack of intake capacity across phone lines and language access led to further administrative burdens for individuals already stretched thin. Lastly, trusted CBOs and young adults in undocumented or mixed immigrant households can play important roles in mediating levels of burden in navigating access to needed services and resources.

CONCLUSIONS: Our findings spotlight the complex ecosystems of burden that impact the health of undocumented immigrants. Our work argues for the importance of having their voices at the policy table when developing targeted interventions. If the climate of burden that influences how undocumented immigrants navigate systems and institutions is not addressed, policies intended to provide relief may instead have detrimental impacts that outweigh the benefits. Further research must also be done to improve governmental-CBO collaborations to build up community capacity and implement scalable interventions for undocumented immigrants.

OBESITY MANAGEMENT IN PEOPLE OF COLOR: EXPLORING THE IMPACT OF RACE/ETHNICITY ON PATIENT AND PROVIDER PERSPECTIVES

Michael G. Knight²; Amanda Velazquez³; Zhaoping Li⁴; Goutham Rao⁵; Anthony Fabricatore¹

¹Medical Affairs, Novo Nordisk Inc, Plainsboro, NJ; ²George Washington University Medical Faculty Associates, Washington, DC; ³Cedars-Sinai Center for Weight Management and Metabolic Health, Los Angeles, CA; ⁴University of California Los Angeles, Los Angeles, CA; ⁵University Hospitals, Cleveland, OH. (Control ID #3874408)

BACKGROUND: Over 40% of adults in the United States live with obesity; people of color are disproportionally affected (NHANES, 2021). Race and ethnicity may affect identification and treatment of obesity. This study explored the experiences of people of color with obesity (PoCwO) and health care professionals (HCPs) in obesity management.

METHODS: Patients diagnosed with obesity were recruited for the study via health care panels. In the qualitative phase, Zoom interviews about experiences with obesity management in PoCwO (body mass index >30; n=40) helped develop the larger quantitative survey. Both PoCwO and HCPs (>70% of time in patient care with a mix of patients from various racial/ethnic groups, 63% primary care providers) completed the quantitative phase surveys.

RESULTS: A total of 1001 patients with obesity who self-identified as Black/African American (n=273), Hispanic/Latinx (n=275), Asian American/Pacific Islander (n=249), and Native American/Alaskan Native (n=204) completed the quantitative survey between Nov 27, 2021 and Mar 2, 2022. For the provider perspective, 150 HCPs were included; 77 self-identified as White/European American, 13 as Black/African American, 13 as Hispanic/Latinx, 45 as Asian American/Pacific Islander, and 2 as Native American/Alaskan Native.

Approximately 7 in 10 PoCwO reported a belief that race/ethnicity left them disadvantaged in health care interactions, and ~3 in 10 PoCwO sensed biases about race/ethnicity regarding their weight from HCPs during their first conversation. PoCwO were more likely to feel comfortable initiating conversations about weight management with an HCP of the same race/ethnicity vs a different race/ethnicity (54% vs 47%).

Conversely, PoCwO with an HCP of a different race/ethnicity were more likely to have felt the tone used was condescending (11%) or overly critical (9%) vs those seeing a same-race/ethnic group HCP (≤4% for both terms). Of PoCwO who felt HCPs made assumptions about race/ethnicity in relation to their weight, fewer than half challenged those assumptions (eg, cultural dietary preferences); however, 71% still see the same HCP as was seen at their first conversation.

Approximately 40% of PoCwO desired more tailored advice (eg, racial/ethnic considerations), and 90% of HCPs were willing to receive education on cultural factors for more tailored conversations. Surveyed HCPs suggested PoCwO may have barriers to access to care; further education about which barriers exist and how to overcome them could be beneficial to patient care.

CONCLUSIONS: In this study, PoCwO indicated that perceived HCP biases about their race/ethnicity negatively impacted the care received for obesity management. Also, PoCwO felt more comfortable initiating conversations about weight with HCPs of similar race/ethnicity. Mitigating racial/ethnic assumptions among HCPs through further education and increasing the number of HCPs of color are potential steps toward improving care of PoCwO.

ORGANIZATIONAL ASSETS AND BARRIERS TO IMPLEMENTING EVIDENCE-BASED CARDIOVASCULAR DISEASE PROGRAMMING IN RURAL AFRICAN AMERICAN COMMUNITIES: EARLY FINDINGS OF AN INNOVATIVE COMMUNITY-ENGAGED ASSESSMENT AND PLANNING PROCESS

Breanna Williams¹; Amelia DeFosset²; Veena Reddy⁷; Mysha Wynn³; Katrina Blunt³; Scott Rosas⁶; Giselle Corbie⁴; Gaurav Dave⁵

¹Social Medicine- Center for Health Equity Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC; ²Social Medicine, Center for Health Equity Research, UNC Chapel Hill School of Medicine, Chapel Hill, NC; ³Health Services, Project Momentum, Inc,, Rocky Mount, NC; ⁴Social Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; ⁵Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; ⁶Concept systems, Inc., Ithaca, NY; ⁷Social Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC. (Control ID #3875931).

BACKGROUND: African Americans in the rural southeast US experience significant cardiovascular disease (CVD) disparities. Implementing evidence-based CVD programs (EBPs) within existing local health and social support infrastructure is a strengths-based approach to reducing CVD disparities. We must examine the perspectives of organizations in rural African American communities on delivering and sustaining CVD EBPs. We employ Group Concept Mapping (GCM), a participatory mixed methods approach for synthesizing group perspectives into a detailed conceptual model. We describe early qualitative results from the GCM process and discuss practical implications for action planning.

METHODS: We recruited representatives from clinic-, community-, and faith-based organizations serving African Americans in rural counties in North Carolina using a mixed purposive and convenience sampling approach. Participants engaged in three activities: 1) idea generation in response to an open-ended prompt (i.e., brainstorming); 2) sorting and rating of ideas; and 3) collaborative interpretation of a concept map, a visual and mathematical representation of the interrelationships among their ideas. This presentation outlines results of the first activity, brainstorming, which occurred over six weeks in fall 2022.

RESULTS: Participants (n=31), representing four clinics, 13 community-, and 14 faith-based organizations,contributed 87 ideas during brainstorming. These ideas fell into seven unique categories: CVD education in the community, 2) access to resources to support CVD health, 3) sufficient program funding, 4) sufficient program personnel, 5) access to other program delivery resources, 6) participant motivation, and 7) engagement strategies. Subsequent GCM activities, and related analyses, will occur through Feb. 2023. Participants will sort these ideas into similar categories and rate each idea’s feasibility and importance. The resulting clusters will represent an overall concept map that depicts factors influencing implementation of CVD EBPs in rural communities.

CONCLUSIONS: Preliminary qualitative results highlight education, access to resources, and community support as critical contextual factors influencing the scale of CVD EBPs in rural African American communities. These early findings point to several leverage points for action, including community-engaged CVD education efforts, strengthening networks to promote resource sharing, and utilizing context-grounded marketing approaches to foster community support. Additional activities and analysis generated through this collaborative mixed methods process will provide insight into how emerging ideas should be prioritized in relation to one another to inform our local action planning and implementation effort. The GCM process and results described by this study could serve as a model for other physician leaders interested in using innovative, community-engaged approaches to disseminate and implement best practices to foster health equity.

OUTCOMES OF A PEER NAVIGATION PROGRAM FOR BLACK PATIENTS IN PRIMARY CARE WITH UNCONTROLLED HYPERTENSION

Anna M. Morenz¹; Jessica Bender¹; Babette Hairston²; Helene Starks¹; Sara L. Jackson¹

¹Department of Medicine, University of Washington, Seattle, WA; ²School of Nursing, University of Washington, Newcastle, WA. (Control ID #3874940)

BACKGROUND: Black individuals in the U.S. experience higher rates of hypertension and worse control compared to White individuals, largely driven by interpersonal, institutional, and systemic racism. We conducted focus groups in the local Black community to understand barriers to and facilitators of health and blood pressure control to inform the development of a pilot peer navigation program for Black patients with uncontrolled hypertension in our primary care clinic. Goals were to improve engagement, trust, health care satisfaction, and blood pressure control.

METHODS: Criteria for program enrollment included Black race, being born in the U.S., age over 18 years, and having two systolic readings above 150 mmHg and/or diastolic above 100 mmHg in the past year.

Eligible participants were identified via record review or direct referral from their primary care team. Peer navigators, with experience living and investing in the local Black community, outreached to eligible participants. If the patient was interested, the navigator screened for social determinants of health and connected patients to community resources, supported them for a minimum of six months, and gave a blood pressure cuff if needed. Due to the COVID-19 pandemic, outreach was mostly via phone and later, in person in clinic. Participants’ clinical information was obtained from the medical record, and baseline and exit surveys were conducted.

RESULTS: Among 499 eligible patients in the clinic, 53 (10.6%) were enrolled from 2/1/2020 to 6/5/2022. Compared to a subset of 125 matched controls, participants were more likely to have a higher body mass index (34.6 vs 30.7 kg/m2), higher mean systolic blood pressure (151 vs 140 mmHg), and higher rate of diabetes (58% vs 39%).

Only 14 participants’ post-program blood pressures were available within a month of exit from the program. For these participants, mean systolic blood pressure decreased to 142 mmHg, compared to 139 mmHg in the control group. Average difference in systolic blood pressure pre/post-program for the navigator group was -9.7 mmHg (95% CI -19.3 to -0.1) compared to -1.6 mmHg (95% CI -5.7 to 2.5) for the comparison group (p=0.11). Of the 25 participants who filled out both baseline and exit surveys, 64% (16) of participants reported taking their blood pressure medications as prescribed over the past 7 days compared to 92% (23) post-intervention (p=0.02). In exit surveys, 79% (26/33) rated the overall experience of working with a peer navigator as “very good” or “excellent.”

CONCLUSIONS: In a safety-net primary care clinic, a community-inspired peer navigation program to support Black patients with uncontrolled hypertension led to a 10 mmHg decrease in average systolic blood pressure post-intervention (versus a 1.6 mmHg decrease in matched controls), in a small number of patients in this real-world intervention. Despite challenges brought by the arrival of COVID-19 early in the program, participants reported a high level of satisfaction with peer navigation.

PATIENT PERSPECTIVES ON A HEALTHCARE SYSTEM FOOD INSECURITY INTERVENTION

Alexandra Cardy¹; Colleen Ereditario²; Suzanne Mitchell²; Tori Vallana²; Janelle Craig²; Elizabeth Cuevas^2,1; Bruce Ling²

¹Internal Medicine, Allegheny Health Network, Pittsburgh, PA; ²Allegheny Health Network, Pittsburgh, PA. (Control ID #3877116)

BACKGROUND: Food insecurity (FI) is characterized by limited access to adequate food. The relationship between chronic disease and FI makes it a meaningful investment for healthcare systems. The Healthy Food Center (HFC) in Pittsburgh, Pennsylvania is a healthcare system-based FI intervention. Patients that screen positive for FI during outpatient visits are referred by a physician to one of five HFC locations within Allegheny Health Network. Patients are offered healthy food choices including fresh produce, as well as cooking demos, nutrition counseling with a dietitian, shopping on a budget education, basic cooking utensils, produce coupons, and assistance with transportation to the HFC. This project qualitatively explores patient experiences with the HFC.

METHODS: Focus group discussions were conducted among HFC participants. Semi-structured interview questions guided discussions. Focus groups occurred via secure video due to the COVID-19 pandemic and lasted for approximately one hour. The discussions were recorded and transcribed. Transcriptions were coded for content and organized into themes by five individuals until thematic saturation was achieved.

RESULTS: Three focus groups were conducted with a total of six participants. Five themes emerged: 1) Improvement in overall health, 2) Reduced stress related to FI, 3) Moderating social determinants of health (SDOH) around FI, including financial barriers, 4) Relationships of patients with HFC staff and the healthcare system, 5) Improving the HFC for future participants.

CONCLUSIONS: This qualitative exploration suggests that participant experiences with a healthcare system FI intervention are impactful. The design facilitates meaningful interpersonal relationships and supports chronic disease management. This preliminary data suggests that participants are positively impacted at both the individual and population level, while SDOH related to FI are reduced. This data will help guide HFC delivery of optimal SDOH interventions that address population needs via direct patient engagement.

PATIENTS EXPERIENCING HOMELESSNESS HAVE LONGER HOSPITALIZATIONS AND LESS HOSPITAL FOLLOW-UP—PRELIMINARY RESULTS FROM A NOVEL DASHBOARD

Katarina Leyba¹; Amanda V. Johnson²

¹Internal Medicine, University of Colorado, Denver, CO; ²Division of Hospital Medicine, University of Colorado School of Medicine, Denver, CO. (Control ID #3877335)

BACKGROUND: Individuals experiencing homelessness have significant comorbid physical and mental illness, with a rate of chronic illness and early mortality higher than that of the general population. Individuals experiencing homelessness tend to have longer stays and associated annual costs of hospitalization that are 10% higher than individuals with housing. Overall, individuals experiencing homelessness have poorer health outcomes and increased care utilization, leading to a significant cost and resource burden on the healthcare system and representing a particular challenge for providers and hospitals caring for these patients.

METHODS: In order to track healthcare utilization patterns and identify potential quality improvement targets, we created a novel dashboard to track hospitalizations in patients experiencing homelessness who treated by the Division of Hospital Medicine (DHM) at the University of Colorado. Unhoused patients were identified through documentation across electronic medical record flowsheets. This dashboard captured data from 598 patients experiencing homelessness who were hospitalized at the University of Colorado between November 2021 and November 2022. Metrics of healthcare utilization—including length of stay (LOS), hospital follow-up rates and readmission rates—were compared to metrics of all patients cared for by the DHM.

RESULTS: The average hospital LOS for homeless patients was 5.77 days longer for than that of the general patient population (12.96 days for patients experiencing homelessness versus 7.13 days). Among patients experiencing homelessness, 40.3% had an established primary care physician (PCP), relative to 68.7% among all DHM patients. Similarly, only 76.3% of unhoused patients had a 30-day follow-up appointment scheduled at hospital discharge, whereas the average rate of 30-day follow-up scheduled at hospital discharge was 80.1% amongst all patients. Readmission rates were similar between patients experiencing homelessness and the general patient population.

CONCLUSIONS: Patients experiencing homelessness have a longer hospital LOS, are less likely to be established with a PCP and have fewer follow ups scheduled at the time of discharge relative to the general patient population. Detecting disparities that affect this patient population is essential to identifying targets for interventions to reduce those disparities moving forward.

PATTERNS OF SCREEN DETECTABLE CANCER DIAGNOSIS AMONG INCARCERATED ADULTS IN CONNECTICUT COMPARED TO THE GENERAL POPULATION

Ilana Richman¹; Pamela Soulos¹; Hsiu-Ju Lin²; Jenerius Aminawung¹; Lisa Puglisi¹; Emily Wang¹; Cary Gross¹

¹Department of Medicine, Yale University, New Haven, CT; ²School of Social Work, University of Connecticut, Storrs, CT. (Control ID #3876109)

BACKGROUND: Although incarcerated people have a constitutional right to health care including preventive services, little is known about whether they undergo recommended cancer screenings at rates equivalent to the general population. Patterns of stage at diagnosis can provide insight into whether a population is likely to have been screened. We hypothesized that incarcerated and recently released adults will have a lower incidence of early-stage screen detectable cancers, higher incidence of late-stage screen- detectible cancers, and similar incidence of non-screen detectable cancers compared to community-dwelling adults.

METHODS: We conducted a cross sectional study of cancer incidence in three populations in Connecticut:incarcerated adults, adults recently released from incarceration, and the general adult population between 2005-2015. We categorized cancers as screen-detectable (breast, colorectal, cervical, and prostate) or not. We classified stage at diagnosis as early (stages 1-2) or late (stages 3-4). We calculated the age- and sex- standardized incidence ratio (SIR) for the incarcerated and recently released populations compared to the general population, stratified by screen-detectable category and stage.

RESULTS: Among incarcerated and recently released populations, incidence of early-stage screen- detectable cancers was lower than in the general population (SIR 0.28, 95% CI 0.17-0.43; SIR 0.68, 95% CI 0.51-0.88, respectively). However, compared to the general population, incidence of late-stage screen detectable cancers was lower among incarcerated adults (SIR 0.51, 95% CI 0.27-0.88) and not different among recently released adults (Table). For non-screen-detectable cancers, incarcerated adults had a lower incidence of early-stage cancers (SIR 0.42, 95% CI 0.31-0.56), while recently released adults had a higher incidence of both early and late-stage cancers (SIR 1.27, 95% CI 1.08-1.48; SIR 2.17 95% CI 1.84-2.53, respectively) compared to the general population.

CONCLUSIONS: We found that incidence of early-stage screen detectable cancer was lower among incarcerated and recently released adults compared to the general population, suggesting less access to or use of cancer screening. However, we also observed lower incidence of late-stage screen detectable and early stage non-screen detectable cancers while incarcerated. This pattern suggests that in addition to underscreening, there may be more general under detection of cancer even when symptomatic while incarcerated.

PERSPECTIVES ON BARRIERS AND FACILITATORS OF AMBULATORY CLINICAL ACCESS FOR PATIENTS INSURED WITH MEDICAID IN AN ACADEMIC HEALTH SYSTEM

Jessica Faiz^3,2; Mariah B. Blegen^3,2; Daniel Gonzalez¹; Daniel C. Stokes¹; Kevin Truong¹; Vanessa Nunez¹; Medell Briggs-Malonson⁴; Gery W. Ryan⁵; Katherine L. Kahn¹

¹Internal Medicine, University of California Los Angeles, Los Angeles, CA; ²National Clinician Scholars Program at University of California Los Angeles, Los Angeles, CA; ³Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA; ⁴Department of Emergency Medicine, University of California Los Angeles, Los Angeles, CA; ⁵Department of Health Systems Science, Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA. (Control ID #3876567)

BACKGROUND: Substantial variation exists in access to health care for Medicaid-insured patients. This study interviewed staff and providers who work directly with Medicaid-insured patients to explore current barriers to, and facilitators of, access to care for Medicaid-insured individuals. To explore and mitigate access barriers, multi-disciplinary teams with administrative and clinical expertise collaborated to develop a Medicaid Referral Process Map outlining pathways to patient appointments.

METHODS: We used purposive and snowball sampling to identify ambulatory appointment-schedulers, nurses, social workers, and physicians with frequent exposure to patient-specific access problems in a large academic health system. We completed 16 semi-structured, qualitative 30–40-minute interviews via Zoom from March to July 2022. Interviewers prompted informants to describe specific challenges that patients had encountered from initiation to completion of clinical encounters. Using a coding scheme developed from the Medicaid Referral Process Map, detailed interview notes and transcripts were analyzed for barriers and facilitators at the system or individual level.

RESULTS: Informants held a breadth of patient-facing roles including patient navigator, care coordinator, clinical advisor, clinic director, case manager, practice manager, financial counselor, patient service representative, primary care physician, and subspecialty surgeon. Interviewees described challenges and potential solutions for the existing administrative processes including scheduling, authorizing referrals, contracting, and attending the clinical encounter. Three challenges to access were mentioned most frequently: (1) lack of awareness of formal protocols (2) restrictive policies by managed care Medicaid networks (3) patient-level communication issues. Key informants identified potential solutions for these barriers, including the need for (1) system-level policies to specifically address referral authorization barriers; (2) increased provider-level knowledge of insurance policies; and (3) consistent strategies for communicating scheduling information and declined authorizations to patients.

CONCLUSIONS: Key gaps remain in accessing care for patients in some clinics. Although this work focused on Medicaid-insured patients, our study identified barriers that are also relevant for the larger ambulatory care patient population, especially vulnerable groups such as those with low socioeconomic status or limited English language proficiency. Next steps include soliciting patient perspectives and generating consensus on improvement priorities and strategies to enhance access to ambulatory clinics by patients with Medicaid.

PHYSICAL AND MENTAL HEALTH CONDITIONS, ACCESS TO CARE, AND FINANCIAL BARRIERS TO CARE AMONG PEOPLE INCARCERATED IN US PRISONS

Emily L. Lupez^1,2; Laura Hawks³; Stephanie Woolhandler^8,5; David Himmelstein^8,5; Samuel Dickman⁷; Adam Gaffney^2,1; David Bor^2,1; Elizabeth Schrier⁶; Christopher Cai⁴; Danny McCormick^2,1

¹Harvard Medical School, Boston, MA; ²Internal Medicine, Cambridge Health Alliance, Cambridge, MA; ³General Internal Medicine, Medical College of Wisconsin, Wauwautosa, WI; ⁴Internal medicine, Brigham and Women's Hospital, Boston, MA; ⁵Medicine, Cambridge Health Alliance / Harvard Medical School, Cambridge, MA; ⁶University of California San Francisco School of Medicine, San Francisco, CA; ⁷Planned Parenthood of Montana Inc, Billings, MT; ⁸City University of New York at Hunter College, New York, NY. (Control ID #3867482)

BACKGROUND: A 2004 survey in US prisons found high rates of physical and mental health conditions and poor access to care among people incarcerated, prompting calls to improve the quality and availability of medical care for this population. Since then, little has been published on current health conditions, access to care, or the effects of copayments on such access.

METHODS: We analyzed the recently released 2016 Survey of Prison Inmates (SPI), the only nationally representative health survey of people incarcerated in US state and federal prisons. We calculated prevalence of self-reported chronic physical conditions (CC), mental health conditions (MHC), and current severe psychological distress (SPD, score >13/24 on the Kessler Psychological Distress Scale). We assessed several self-reported measures of access to care among persons with CC, MHC, or SPD. Using facility jurisdiction, state of incarceration, and published data on federal and state prison wages and copayments for prison healthcare visits, we assessed the association between copayments and receipt of a medical visit using risk ratios. Analyses were conducted for the overall US prison population and by facility jurisdiction using SPI- provided weights to generate national estimates and statistical procedures appropriate for the complex survey design.

RESULTS: Of 24,848 individuals surveyed (weighted population 1,421,700; 1,248,300 in state prisons, 173,400 in federal) 62.4% of state (56.3% of federal) incarcerated people had >1 CC (weighted estimates). Among those with >1 CC incarcerated within the last year, 22.3% in state (14.9% in federal) prisons had not seen a healthcare provider since admission. Of people with >1 CC, 91% had a medical copay and 47.4% had a medical copay >1 week’s prison wage. Compared to those with no copay, those with any copay (relative risk [95% CI]: 1.47 [1.4, 1.5]), and those with a copay >1 week’s prison wage (1.72 [1.7, 1.8]) were more likely to have not seen a healthcare provider since incarceration. The prevalence of having >1 MHC was 42.5% in state (22.9% in federal) prisons, and the prevalence of SPD was 14.1% in state (7.8% in federal) prisons. Of those with SPD, 40.5% in state (57.7% in federal) prisons had not received any mental health treatment since admission. Among those on a prescription medication for a MHC prior to incarceration, 33.6% in state (42.8% in federal) prisons were not receiving medication in prison.

CONCLUSIONS: CC and MHC remain highly prevalent among those in US prisons. Despite their unique legal right to healthcare, many incarcerated people fail to receive adequate care, and medical copayments appear to magnify this risk. In addition to improving poor carceral environmental conditions that foster CC and MHC, US prison healthcare system planning should account for incarcerated people’s high burden of CC and MHC, and ensure access to care. Elimination of copayments in US prisons could improve access to care and help fulfill incarcerated people’s legal right to healthcare.

PHYSICIAN PERSPECTIVES ON INCARCERATED INPATIENTS

Justin Vincent²; Xiaofan Huang³; Kristen Staggers³; Marc D. Robinson¹

¹Medicine, Baylor College of Medicine, Houston, TX; ²Washington University in St Louis School of Medicine, St Louis, MO; ³Institute for Clinical and Translational Medicine, Baylor College of Medicine, Houston, TX. (Control ID #3876299)

BACKGROUND: On any given day, the United States incarcerates greater than 2 million individuals, more than any other country by total numbers or on a per capita basis. Incarcerated patients are at risk for interrupted chronic care and report higher rates of some conditions such as diabetes, hypertension, asthma, and psychiatric illness. Despite data existing for patient risk factors and worsened outcomes, little is known about physician attitudes towards patients who are incarcerated.

METHODS: An electronic survey was created and distributed to a total of 70 internal medicine residents (PGY2 - PGY4) and 26 academic hospitalists who rotate through a large county hospital that cares for patients from the local jail. Likert scale answers were dichotomized as either 1) Agree or 2) Disagree/Neutral. Summary statistics were stratified by training level and close association with the criminal justice system were compared using Wilcoxon rank-sum test or Fisher’s exact test. A significance level of 0.05 was used.

RESULTS: Overall, responses between hospitalists and residents were similar, except for a few key areas. For the most part, both groups disagreed with the statement “Given the choice, I prefer not to take care of incarcerated patients” (n = 85, 89%). Both also did not believe that jailed patients fake illness more than non- jailed patients (n = 72, 75%) and did not believe their exams for these patients were briefer (n = 65, 68%). Residents and hospitalists disagreed that shackling (use of leg or handcuffs to the bed) was necessary all of the time (n = 79, 82%). Still, both rarely remove shackles while examining incarcerated patients (median percentage of time removed 15% vs. 10%, p = 0.44).

Hospitalists were more likely to know when their patients were likely to be out of custody (19% vs. 3%, p = 0.02), be aware of the services the jail has to offer (31% vs. 10%, p = 0.02), and less likely to report difficulties obtaining follow-up (58% vs. 84%, p = 0.01). Residents reported a greater propensity to consciously or subconsciously treat an incarcerated patient differently (70% vs. 38%, p = 0.01).

Those with a close association with the criminal justice system more often agreed that patients from jail were more likely fake illness (47% vs. 21%, p = 0.03) and were more likely to correctly estimate the number of days incarcerated people typically stay in county jail (47% vs. 18%, p = 0.02).

CONCLUSIONS: Overall, we find that physicians desire to care for this vulnerable population but admit potential biases and gaps in knowledge regarding the nuances of their care. Training level often As millions of adults are currently in jails and prisons, these results speak to the need for further education and training in caring for this vulnerable population.

PRACTICE VARIATIONS IN FOOD INSECURITY SCREENING: ONE SIZE DOES NOT FIT ALL Carter Baughman, Gianna Aliberti, Son Quyen H. Dinh, Elizabeth Targan, Ruth-Alma N. Turkson-Ocran, Katherine Wrenn, Kelly Graham

Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #3871969)

BACKGROUND: Screening for and addressing the social determinants of health (SDOH), including food insecurity (FI), is essential to the provision of high-quality medical care. FI impacts outcomes for a variety of chronic disease states, including diabetes, hypertension, and cardiovascular disease risk, with disproportionate effects on minoritized and low-income populations. To address these healthcare inequities, the Centers for Medicare and Medicaid Services encouraged states to implement a comprehensive assessment of the SDOH. Massachusetts, where our practice is located, is now implementing this screening protocol, however little is known about how best to incorporate this into clinical practice.

METHODS: We conducted semi-structured qualitative interviews with a convenience sample of adult primary care providers and community health workers (CHWs) in Boston, MA to better understand their screening practices for FI. We gathered information on practice demographics including provider and patient characteristics. We asked about the process of screening, including who screens, where, when, and how often, and asked practices to specify what form they use. Finally, we inquired about the perceived benefits and challenges to the screening protocol they developed and their recommendations for screening to inform practices beginning this implementation.

RESULTS: We interviewed leadership at 6 unique practices, including both academic and community health centers. Five sites (83%) screened for FI within the context of SDOH screening. The most common time to screen was at rooming (50%). The most common method of screening was a paper form using the PRAPARE tool (50%). The screen was most often input into the electronic health record (EHR) via medical assistants (66%). The most common frequency of screening was at annual visits (100%), with two sites (33%) having additional outreach for overdue screens. The most common method of CHW notification was an EHR notification (50%) followed by a physician referral (33%). All screening models ended with the patient being connected to a designated staff member(s) with expertise in food and nutrition resources, with varying numbers of steps to get there. The most common benefits of screening expressed were the ability to reach all patients, having adequate resources available for patients, and having streamlined and automated processes. The most common challenges were related to staffing and CHW task load, survey limitations (e.g., survey fatigue, lack of language options), and patients not accessing resources due to complex processes or not wanting to report FI.

CONCLUSIONS: SDOH and FI screening is essential for all primary care practices and is becoming a requirement for many states. However, it can be difficult to incorporate this screening protocol due to high workload burdens and lack of standardized processes. We evaluated different models that can be applied to various practices and found an overall benefit to streamlined processes.

PREDICTORS OF PERCEIVED HEALTH DISPARITIES IN CHRONIC ILLNESS AMONG PATIENTS OF AFRICAN ANCESTRY

David Christian³; Kelly Z. Wang³; Nihal Mohamed³; Mimsie Robinson^5,6; Dinushika Mohottige¹; Thomas A. LaVeist⁴; Carol Horowitz²

¹Institute of Health Equity Research; DOM and the Barbara T Murphy Division of Nephrology, Icahn School of Medicine at Mount Sinai Department of Population Health Science and Policy, New York, NY; ²General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ³Icahn School of Medicine at Mount Sinai, New York, NY; ⁴School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA; ⁵Beth Gospel Assembly, New York, NY; ⁶BETH-HARK CHRISTIAN COUNSELING CENTER INC, New York, NY. (Control ID #3876838)

BACKGROUND: Racial disparities in health are ubiquitous and result from racism-related inequities in patients’ socio-environmental contexts and health care. Genetic risks including APOl1 high-risk alleles, which have been associated with self-reported race/ancestry also explain some racial disparities. Yet, little is known regarding patients’ beliefs about of the existence of racial health disparities and their key causes.

METHODS: We conducted a cross-sectional analysis of baseline survey data from 1850 adults with hypertension who self-identified as Black/having African ancestry upon enrollment in the GUARD trial designed to determine effects of testing and disclosing renal genetic risks. The study was conducted in 2014-2018 across 15 ambulatory practices and federally qualified health centers in New York City. Participants were asked whether they believe Black/African American people are more likely to have chronic disease than White people (yes/no), and whether the racial disparities are caused by different genes, behaviors/culture, stress, and/or the environment. We describe the association between perceived racism in health care and belief in racial disparities, and we quantified the association between perceived causes of disparities and belief in racial disparities using logistic regression models adjusted for age, gender, income, and education.

RESULTS: Most (74%) participants perceived Black people are more likely to have chronic diseases than White people. They attribute this difference to genetics (50%), behaviors/culture (51%), stress (59%) and their environment (66%) (where they live, pollution, access to care). Adjusted odds of perceiving racial health disparities (versus not) were highest for those who believed differences are due to genes [OR=3.87, 95% CI=2.97 – 5.04]. There was no significant association between perceived racism in healthcare and a belief in racial disparities. A significant proportion (25%) of respondents believed doctors would view them more positively if their disease was caused by genetic factors.

CONCLUSIONS: A majority of Black adults perceived multi-factorial causes of racial disparities in chronic diseases including genetic and environmental factors. Perceived racism was not associated with perceived racial disparities in this study. However, nearly a quarter of participants believed their physicians would view them more favorably if their disease was due to genetic causes. Future studies are needed to further examine patients’ perceptions of the relative role of genetics vs. socio-contextual factors and racism in causing racial disparities. Studies designed to examine patient and physician perceptions and knowledge about of genetic vs. socio-contextual contributions to disease risk are also warranted.

PREFERRED COMMUNICATION STRATEGIES FOR PEOPLE WITH COMMUNICATION DISORDERS IN HEALTH CARE ENCOUNTERS

Erin Hickey¹; Bernice Man²; Kaila Helm⁴; Steven Lockhart³; Megan Morris³

¹Internal Medicine - Pediatrics (Med-Peds), University of Illinois Chicago College of Medicine, Chicago, IL; ²Academic Internal Medicine, University of Illinois Hospital & Health Sciences System, Chicago, IL; ³University of Colorado Anschutz Medical Campus, Aurora, CO; ⁴Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3874090)

BACKGROUND: In the United States, 10% of all adults identify as having a Communication Disorder (CD) which includes disabilities in speech, language, voice and/or hearing. Previous research has demonstrated that people with CDs have worse health outcomes, including more difficulties accessing high quality, equitable care compared to those who do not have CDs. Part of this difficulty is due to health care providers not being aware of patients’ CDs and not knowing what communication

strategies people with CDs prefer. We set out to answer the following research question: What communication strategies do people with CDs, their caregivers, and their providers prefer, and how do they want these strategies communicated bidirectionally?

METHODS: We performed a qualitative study utilizing focus groups and interviews with patients who have CDs, their caregivers and healthcare providers over video-conference. Each patient focus group represented a different CD, including stuttering, aphasia, hearing loss, and patients who are nonverbal. Participants were asked about how CDs affect their experiences in healthcare and what strategies are helpful in these encounters. Each focus group or interview was recorded and transcribed. The transcript was then independently coded by two researchers with inductive analysis using ATLAS. After a coding dictionary was created multiple rounds of coding occurred to reach calibration, and the entire team reconciled any discrepancies. After reviewing query summaries, themes were developed and honed over multiple team meetings.

RESULTS: Identified themes are (1) Both patients and providers preferred to have the communication disability and communication preferences disclosed prior to the appointment, (2) Preferred communication strategies should be individualized, but when this is not possible, there are some best practices for communicating with people with CDs that can be implemented and (3) There are systems level and provider level changes that can help improve the care of people with CDs

CONCLUSIONS: Patients with CDs prefer that providers are aware of their CD and know what strategies they prefer to optimize communication. We hope that the implementation of best practices for patient-provider communication will lead to better health outcomes for patients with CDs.

PREVALENCE OF HOMELESSNESS AMONG HOSPITALIZED PATIENTS: A POINT-IN-TIME SURVEY

Neelam Mistry²; Julie Knoeckel¹; Amanda V. Johnson³; Erin Bredenberg⁴; Katie Raffel³; John Cunningham¹; Ellen Sarcone¹; Gregory Misky³; Lauren McBeth⁵; Sarah A. Stella⁶

¹Hospital Medicine, Denver Health, Denver, CO; ²Department of Medicine, University of Colorado, Denver, CO; ³Division of Hospital Medicine, University of Colorado School of Medicine, Denver, CO; ⁴Hospital Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ⁵Medicine/Hospital Medicine, University of Colorado, Aurora, CO; ⁶Department of Medicine, Denver Health, Denver, CO. (Control ID #3874665)

BACKGROUND: Lack of stable housing adversely affects health outcomes, increases healthcare utilization, and increases mortality. Few studies have assessed the prevalence of homelessness and housing insecurity in hospitalized patients. The United States Department of Housing and Urban Development requires an annual point-in-time count of people experiencing homelessness (PEH) on a single night in January. This count excludes PEH who are hospitalized. To address these gaps, we conducted a hospital point-in-time study to determine the prevalence of housing insecurity and homelessness among hospitalized patients at two urban academic centers.

METHODS: Medical-surgical patients admitted to two academic hospitals on January 24, 2022 were eligible to participate. Patients were included if they were > 18 years old, available in their hospital room and able to consent. Researchers administered a survey to determine patients' housing status: stably housed, housing insecure (concerned about losing housing within 2 months or spending > 50% of income on housing), or frankly homeless (living on the street, in a shelter, or other place not intended for housing). Additional medical and sociodemographic characteristics were assessed for patients reporting housing insecurity or homelessness.

RESULTS: A total of 456 patients were approached across the two study sites and 271 consented to participate. 29.2% of these participants were found to be experiencing housing insecurity (17.3%) or frank homelessness (11.8%). 65.8% of the patients with significant housing concerns were male, and 60.8% were 55 years or older. Among surveyed patients, 69.6% reported chronic health conditions, 55.7% reported multiple hospitalizations in the preceding year and 49.4% reported a physical disability. More than a third (35.4%) had previously been in jail or prison. 38% reported a mental health concern and 39.2% reported drug or alcohol use.

Of the 47 patients experiencing housing insecurity, 57.4% had experienced homelessness in the past. The most frequently identified factors that contributed to housing insecurity were cost of living (72.3%), health conditions (70.2%), and loss of income (46.8%).

Of the 32 patients experiencing homelessness, 28.1% reporting using a shelter directly prior to admission. Of those not using a shelter the top reasons cited were safety concerns (34.4%), cleanliness (18.8%), and regulations at the shelter (12.5%).

CONCLUSIONS: Almost a third of hospitalized patients in this study were experiencing homelessness or housing insecurity. Those experiencing homelessness were not accounted for in annual community point-in- time counts, contributing to an underestimate of the true housing crisis. There is a critical need to accurately capture housing status during hospitalization and develop tailored support systems for this population characterized by high rates of physical disability, legal involvement, mental health concerns, and substance use, and low rates of shelter usage.

PREVALENCE OF STIGMATIZING LANGUAGE REFLECTING SPECIFIC TYPES OF BIAS IN MEDICAL RECORDS ACROSS 4 SPECIALTIES

Mary Catherine Beach, Keith Harrigian, Mark Dredze, Dingfen Han, Brant Chee, Ayah Zirikly, Alya Ahmad, Anne Links, Nae-Yuh Wang, Shari Lawson, Somnath Saha

Johns Hopkins University, Baltimore, MD. (Control ID #3877145)

BACKGROUND: Previous studies have documented racial bias in the use of stigmatizing language in medical records. We aimed to build on this literature by evaluating racial differences in physicians’ use of positive adjectives to characterize patients, and by distinguishing racial differences in patterns of negative language reflecting distinct types of bias.

METHODS: Based on previous literature, we developed a taxonomy of positive and negative language used to describe patients within medical records: positive descriptors (e.g. pleasant, charming, delightful), negative descriptors (e.g. belligerent, aggressive, uncooperative), and disbelief/dismissal of patient’s testimony (e.g. claims, insists, poor historian). We searched ambulatory and inpatient notes within our health system’s electronic medical record system across 4 clinical disciplines – internal medicine, emergency medicine, OB/GYN, and surgery – to identify use of terms. Two reviewers annotated a sample of 2440 notes containing these terms to differentiate references that were in-context versus out-of-context (e.g. insurance claims, aggressive tumor). These annotated notes were then used to develop machine learning algorithms that classified term usage with 96% accuracy. We then used these algorithms to classify notes within a large corpus, based on appearance of the relevant terms. We tested associations of patient race with each category of language, using logistic regression to adjust for age and gender, and generalized estimating equations to account for clustering of notes within patients and clinicians.

RESULTS: Our analysis included 109,633 notes in the records of 19,681 patients who had a mean age of 50, and of whom 56% were Black, 37% white and 64% women. Within notes, 13.0% had a positive descriptor, 4.3% had a negative descriptor, and 1.6% had a marker of disbelief. Compared with non-Black patients, notes written in the records of Black patients had a lower odds of containing a positive descriptor (OR 0.87, 95% CI 0.83-0.92), similar odds of a negative descriptor (OR 1.03, 95% CI 0.95-1.12), and a higher odds of indicating disbelief (OR 1.50, 95% CI 1.33-1.70). These patterns were similar across the 4 specialties.

CONCLUSIONS: Our study demonstrates that bias in medical record documentation across specialties may manifest more in the use of positive descriptors and markers of disbelief than in the use of overt negative descriptors. Reducing use of negative descriptors is important to improve the quality of care for all patients, and efforts to promote racial equity in healthcare should also focus on raising awareness of specific biases in who gets positively appraised and whose testimony gets dismissed.

PROVIDER PERSPECTIVES ON HOW SOCIAL DETERMINANTS INFLUENCE HEPATITIS C CARE

Christopher J. Gonzalez¹; Shashi N. Kapadia²; Stephane Labossiere²; Jeff Niederdeppe³; Andrew Talal⁴; Martin F. Shapiro²; Elaine Wethington³

¹Internal Medicine, Weill Cornell Medicine, New York, NY; ²Medicine, Weill Cornell Medicine, New York, NY; ³Cornell University, Ithaca, NY; ⁴Medicine, University at Buffalo, Buffalo, NY. (Control ID #3876125)

BACKGROUND: Hepatitis C virus infection (HCV) continues to disproportionately affect racially minoritized and socioeconomically disadvantaged communities. Disparities in curative treatment uptake may be driven by social determinants, including the behavior of healthcare providers. Our objective was to describe provider perspectives on how social determinants influence HCV treatment uptake and provision.

METHODS: Using purposive sampling between 9/2021 and 9/2022, we recruited healthcare providers in two states with divergent health care systems and policies, Alabama and New York. We sampled for diversity in provider specialty, training, and region of practice. We conducted interviews remotely using a semi- structured interview guide informed by Andersen’s model of health services utilization, prior literature, and expert experience. Interviews were professionally transcribed, and transcripts were analyzed using NVivo software. Each transcript was independently coded by two researchers, then reconciled using a summative approach. Similar codes were combined into categories, which were then consolidated into broader themes.

RESULTS: Nearly half of the 34 providers practiced Primary Care (47%); the remaining practicing providers specialized in Infectious Diseases (26%) and Gastroenterology (12%). The majority (67%) held an MD or DO, whereas 33% were advanced practice professionals (e.g. RN, NP, PA). Four major themes emerged: (1) Numerous sociodemographic factors influence patients’ capacity to initiate HCV treatment- “One of the most important barriers to treatment is lack of shelter, stable homes, or support systems, friends, because of substance abuse.” (2) Providers face their own challenges with providing treatment- “Some people don't recognize that we should treat hepatitis C early and defer until they have very advanced liver disease.” (3) Providers advocate for patient-centered approaches, feeling provider perceptions could create additional barriers to HCV treatment- “Often times, there is a certain negative connotation that these are difficult patients to treat and some providers won't treat them.” (4) Organizational, insurance, and public policies continue to influence access to treatment- “With Medicaid, if your drug screening is not cleared, including cannabinoids, then they won't pay for it.”

CONCLUSIONS: HCV treatment initiation is influenced by the social determinants of health at several levels. Patient sociodemographic factors influence the capacity to initiate treatment, and provider factors create challenges to providing treatment. Many providers advocate for accessible care and treatment, acknowledging that provider practices and larger overarching policies often create additional barriers for patients living with HCV. Overcoming these complex barriers may require multi-faceted interventions targeting multiple levels. Further work will examine how the influence of social determinants vary across specific patient groups and geographic regions.

QUANTIFYING THE IMPACT OF NIGHTTIME GUNSHOTS ON COMMUNITIES IN MAJOR US CITIES, 2015 TO 2021

Rebecca Robbins^1,6; Mahmoud Affouf³; Peter Masiakos^2,5; Jay Iyer⁴; Cornelia Griggs^2,5; Elizabeth B. Klerman^7,1; Chana A. Sacks^8,5

¹Division of Sleep Medicine, Harvard Medical School, Boston, MA; ²Pediatric Surgery, MGH, Boston, MA; ³Mathematics, Kean University, Union, NJ; ⁴Departments of Molecular and Cellular Biology and Statistics, Harvard College, Cambridge, MA; ⁵Harvard Medical School, Boston, MA; ⁶Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA; ⁷Department of Neurology, Massachusetts General Hospital, Boston, MA; ⁸Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #3876933)

BACKGROUND: Gunshots affect not only those directly involved in the incident but also those in the surrounding community exposed to the noise of gunshots and the subsequent emergency response. Nighttime gunshots may interrupt and/or delay sleep of nearby community members.

METHODS: We used publicly available cross-sectional datasets detailing timing and location of gunshots in 6 US cities (Baltimore MD; Boston MA; Washington DC; New York NY; Philadelphia PA; and Portland OR) between 2015 and 2021. Datasets from Baltimore, Philadelphia, New York City and Portland reported only gunshots with victims; datasets from Boston reported gunshots both with and without victims; Washington DC provided data from gunshot detection surveillance technology (victim status unknown). We computed Rate Ratios (RR) to compare nighttime (6:00pm-5:59am) to daytime (6:00am- 5:59pm) gunshots. We use geospatial mapping to estimate the number of person-nights affected by the noise of the gunshots each year and the relationship between nighttime gunshots and median household income at the location of each gunshot.

RESULTS: We analyzed 72,236 gunshots. Gunshots were more common during the nighttime than daytime (RR=2.5). Geospatial analysis demonstrated that the average number of annual person-nights impacted by nighttime gunshots were 0.35 million in Baltimore, 1.62 million in Boston, 5.91 million in Washington, 2.9 million in New York City, 1.29 million in Philadelphia, and 0.40 in Portland. There was an inverse relationship between nighttime gunshots and median household income in each city.

CONCLUSIONS: Nighttime gunshots are prevalent and predominate in locations characterized by low median household income.

RACE-BASED MEDICINE IN MEDICAL TRAINING: ELICITING JUSTIFICATIONS PROVIDED IN THE FORMAL AND INFORMAL CURRICULUM

Jorge A. Caceda¹; Kessy Joseph²; Khalil Savary¹; Ping-Hsin Chen¹; Rachel Rosenberg¹

¹NJMS, Rutgers Biomedical and Health Sciences, Newark, NJ; ²Newark Beth Israel Medical Center, Newark, NJ. (Control ID #3874060)

BACKGROUND: Race-based medicine and race-based correction factors pervade many areas of medicine despite clear evidence that race is a social, not biological, construct. It is unknown what the impacts of race- based medicine are on learners, or how race-based medicine may play into learners’ implicit and explicit biases. It is also unclear what learners may be learning about race-based medicine through the implicit or hidden curriculum. This study seeks to elucidate what learners are being taught in medical school about race- based medicine, particularly through the informal curriculum.

METHODS: We utilized a cross-sectional survey to ask medical residents open-ended questions about what they were taught about the reasoning behind race-based medicine during medical school. For example, one question asked participants to describe the explanations they received in medical school to explain race-based calculations of glomerular filtration rate and identify the resource from where they remember obtaining this information. Participants’ answers to open-ended questions were coded using qualitative data analysis methods. The survey was anonymous and open to residents from all specialties. Residents were recruited through emails and social media. The study was approved by the Rutgers Institutional Review Board. RESULTS: Fifty-four resident physicians participated in the study. Participants were asked to self-identify their race/ethnicity; 16 unique self-descriptors were used. Four main themes emerged regarding the teaching that residents received about race-based medicine in medical school: (1) Race as biology (2) Medical heuristics (3) Othering Black people (4) Left to their own conclusions.

CONCLUSIONS: The explanations that learners are given for race-based medicine and race-based correction factors reinforce the incorrect concept of race as biology. Furthermore, learners are encouraged to use race to make short-cuts in decision-making. Our study suggests that exposure to race-based medicine, and the justifications provided for it through the informal curriculum, could deepen biases among medical students and worsen disparities in medical care.

RACIAL AND ETHNIC DISPARITIES IN OPIOID PRESCRIBING ON HOSPITAL DISCHARGE AMONG OLDER ADULTS WITH CANCER

Koushik Kasanagottu^1,2; Kenneth J. Mukamal¹; Bruce E. Landon³

¹General Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Harvard Medical School, Boston, MA; ³Health Care Policy, Harvard Medical School, Boston, MA. (Control ID #3874920)

BACKGROUND: Disparities in opioid prescribing among racial and ethnic groups have been observed in outpatient and emergency department settings. However, it is unknown whether similar disparities exist at discharge among older adults hospitalized for cancer, for whom opioids are recognized as an effective treatment for pain.

METHODS: We performed a retrospective cohort study of Medicare beneficiaries age 65 years or older who were hospitalized in 2016 with a primary discharge diagnosis of cancer. We excluded beneficiaries with hospice claims, and those admitted from or discharged to a skilled nursing facility (SNF), owing to inability to capture medication claims in these patients. Our primary outcome was presence of an opioid claim within 2 days of hospital discharge. Secondary outcomes among patients discharged with an opioid included total morphine milligram equivalents (MME) and quantity of opioids prescribed. To determine the adjusted relative risk of each outcome by race/ethnicity, grouped as Black, White, Asian, Hispanic, and other (native Hawaiian/American Indian/Alaska Native/other), we fitted multivariable generalized estimating equation models accounting for demographics, disability status, Medicaid dual-eligibility, presence of an opioid claim in the 90 days prior to hospitalization, comorbidities, area deprivation index, hospitalization characteristics, primary diagnosis/procedure codes, and hospital characteristics.

RESULTS: There were 13,095 hospitalizations with cancer as the primary discharge diagnosis. Among these encounters, 82.5% were White, 7.8% were Black, 4.4% were Hispanic, 2.8% were Asian, and 2.6% were Other. Overall, 5,343 (40.8%) had a claim for an opioid within 2 days of hospital discharge: 41.4% of White, 37.5% of Black, 34.6% of Asian, 38.1% of Hispanic, and 46.4% of other beneficiaries (p=<0.0001). After adjustment, there were no significant differences in filled opioids by race/ethnicity. However, among beneficiaries who filled an opioid prescription, Hispanic beneficiaries filled lower total MMEs when compared to White beneficiaries (mean adjusted relative difference [RD] -10%, 95% CI -17% to -2%).

CONCLUSIONS: In a national cohort of Medicare beneficiaries hospitalized with cancer, we did not identify racial/ethnic disparities in the proportion of patients with a filled opioid prescription after discharge. However, when prescribed opioids, Hispanic beneficiaries received less total MMEs when compared to White beneficiaries. Given demonstrated disparities in other settings and non-cancer patient populations, these findings suggest that future research should examine whether perceived strength of the indication for opioid prescribing may attenuate opioid prescribing disparities.

RACIAL BIAS IN DOCUMENTATION OF PATIENT ADHERENCE IN MEDICAL RECORDS Somnath Saha³; Keith Harrigian²; Mark Dredze²; Dingfen Han³; Brant Chee²; Ayah Zirikly¹; Anne Links²; Alya Ahmad⁴; Shari Lawson⁵; Nae-Yuh Wang³; Mary Catherine Beach³

¹Medicine, Johns Hopkins Medicine, Baltimore, MD; ²Johns Hopkins University, Baltimore, MD; ³General Internal Medicine , Johns Hopkins University, Baltimore, MD; ⁴General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD; ⁵Johns Hopkins Medicine, Baltimore, MD. (Control ID #3877121)

BACKGROUND: Prior studies examining language in medical records have found that clinicians more commonly describe Black patients as nonadherent or not accepting recommended treatment compared to White patients. The degree to which this finding reflects racial differences in patient adherence vs. racial bias among clinicians is unclear.

METHODS: We searched ambulatory and inpatient notes within our health system’s electronic medical record system across 4 clinical disciplines – internal medicine, emergency medicine, OB/GYN, and surgery – to identify use of terms referring to patient adherence to recommended care, including all forms of the words (non)adherence, (non)compliance, refuse, and decline. Two reviewers annotated a sample of 2177 notes containing these terms to differentiate references to patient adherence as positive (e.g., adherent) vs. negative (e.g., not adherent, refuses), and to exclude uses of these terms with other meanings (e.g., adherent bandage). These annotated notes were used to develop machine learning algorithms that classified term usage with 96% accuracy. We then used these algorithms to classify notes within a large corpus, based on presence or absence of the relevant terms. We tested associations of patient race with positive and negative references to adherence, using logistic regression to adjust for age and gender, and generalized estimating equations to account for clustering of notes within patients and clinicians. We also tested for racial differences in the use of what we considered more vs less paternalistic terms (compliant vs. adherent, refuse vs. decline).

RESULTS: Our analysis included 109,633 notes in the records of 19,681 patients, of whom 56% were Black and 64% were women, with a mean age of 50. Positive and negative references to patient adherence appeared in 3.7% and 14.8% of notes, respectively. The notes of Black patients were more likely than those of non- Black (predominantly White) patients to include both positive (OR 1.98, 95% CI 1.83-2.16) and negative (OR 1.46, 95% CI 1.39-1.53) references to patient adherence. This disparity was greater when examining the use of more paternalistic (OR 1.74, 95% CI 1.64-1.85) vs. less paternalistic language (OR 1.21, 95% CI 1.14-1.28).

CONCLUSIONS: We found that clinicians comment on both adherence and nonadherence more commonly among Black vs. non-Black patients. Our findings indicate that clinicians are more focused on ascertaining adherence with Black patients, and use more paternalistic language when doing so, suggesting racial bias in clinicians’ assumptions about and attitudes towards patient adherence. The embedding of this bias in patients’ medical records contributes to structural racism within health systems and may negatively impact the care of Black patients.

RACIAL DIFFERENCES IN LOW-VALUE CARE AMONG MEDICARE BENEFICIARIES IN HEALTH SYSTEMS

Ishani Ganguli¹; Matthew B. Mackwood²; Ching-Wen W. Yang²; Maia Crawford²; Kathleen L. Mulligan¹; A. James O'Malley²; Elliott S. Fisher²; Nancy E. Morden²

¹Division of General Medicine and Primary Care, Brigham and Women's Hospital, Chestnut Hill, MA; ²Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH. (Control ID #3876398)

BACKGROUND: Black patients are less likely than white patients to receive high-value care, but evidence on racial differences in low-value care is scant and conflicting; the role of health care systems in these differences is unknown. We characterized racial differences in receipt of low-value services overall and within health systems among system-attributed Medicare beneficiaries.

METHODS: This was a retrospective cohort study using 100% Medicare Fee-For-Service administrative data (2016-2018) for Black and white Medicare beneficiaries aged 65 or older as of 2016 and attributed to 595 US health systems. We used established, claims-based definitions to measure receipt of 40 low-value services among Black and white beneficiaries. For each service, we built linear probability models to estimate Black-white differences in receipt with and without adjustment for patient age, sex, and prior healthcare use. In additional models, we included 1) health system fixed effects to assess racial differences within health systems, and separately, 2) racial composition of the health system’s population to assess the relative contributions of individual race and health system racial composition in low-value care receipt.

RESULTS: Our cohort included 9,833,304 beneficiaries (6.8% Black; 57.9% female). Compared to white beneficiaries, Black beneficiaries had higher adjusted receipt of 11 of 40 low-value services and lower receipt of 20 services. Specifically, Black beneficiaries were more likely to receive low-value acute diagnostic tests, including imaging for headache (6.9% of eligible beneficiaries vs 3.2%) and head CT scans for dizziness (3.1% vs 1.9%). Black beneficiaries had lower rates of low-value screening tests including preoperative laboratory tests (6.5% vs 10.3%), screening electrocardiograms (1.7% vs. 5.1%), and prostate specific antigen tests in men >70-years-old (25.6% vs. 31.0%) (all p<.001). The direction and magnitude of these differences were similar in models including system fixed effects or racial composition.

CONCLUSIONS: Black beneficiaries were more likely to receive low-value acute diagnostic tests and less likely to receive low-value screening tests. Differences were largely due to differential care within health systems rather than to Black and white beneficiaries receiving care in different systems. These patterns suggest potential individual, interpersonal, and structural factors that researchers, policymakers, and health system leaders might further investigate and address to improve care quality and equity.

RACIAL DISPARITIES IN HOSPITAL-ASSOCIATED DISABILITY AND PHYSICAL THERAPY REFERRAL

Maylyn Martinez¹; Matthew Cerasale¹; Mahnoor Baig¹; Marla Robinson²; Andrew W. Schram¹; Monica E. Peek¹; Vineet M. Arora¹; David O. Meltzer²

¹Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ²Medicine, The University of Chicago, Chicago, IL. (Control ID #3876936)

BACKGROUND: Hospital-associated disability (HAD) is the new loss of ability to complete one or more activities of daily living (ADLs) without assistance after hospital discharge and occurs in 31% of hospitalized patients. HAD and low mobility during hospitalization are associated with higher risk of readmission, permanent disability, new institutionalization, and death. Black patients face disadvantages with respect to rehabilitation services and mobility outcomes in outpatient and surgical settings. However, little is known about HAD and PT referrals for Black patients hospitalized for acute medical illness. We aimed to assess racial differences in HAD and PT referral in patients hospitalized for medical illness.

METHODS: This was a cross-sectional study of patients admitted to medicine services 10/2018 – 3/2021.

HAD was defined as admission AMPAC score of > 18 with discharge AMPAC score ≤ 18. Change in mobility (HAD surrogate) was calculated as discharge AM-PAC score – admission AM-PAC score. Differences in HAD, functional impairment, and PT referral by race were analyzed by chi squared test. Differences in mobility change by race was assessed by two-sample T test. Logistic regression was used to analyze association of Black race with referral to PT, controlling for age, sex, baseline mobility, mobility change, and length-of-stay. Linear regression was used to analyze the association of Black race with mobility change controlling for age, gender, baseline mobility, and length-of-stay. Subgroup analyses were stratified by age (<65 and 65+) and baseline mobility (AM-PAC >18 vs. ≤18).

RESULTS: Of the 20,810 patients included in the study, 55% were female, 83% were Black, 42% were > 65 years old, and 55% received referral for PT. Black patients had more functional impairment on admission [48.1% vs 42.0% X² (2, N = 20,810), = 34.1, p < 0.001]. Compared to White patients, Black patients with functional mobility impairment on admission had less mobility gain during hospitalization [-0.69 points t(9.349) = 2.5, p < 0.05]. Fewer Black patients with functional impairment on admission received PT referral [78.3% vs 81.4% X² (2, N = 20,810), = 5.5, p < 0.05]. Black race was associated with a negative effect on mobility change during hospitalization [F(20,810) = 471.8, p < 0.001, R² = 0.15]. The association of Black race with mobility change was stronger for seniors and those with functional impairment on admission. There was no difference in PT referrals or HAD overall by race.

CONCLUSIONS: Our study suggests that Black seniors and those with functional impairments have lower rates of PT referral and less mobility gain during hospitalization. Future studies will assess a broader patient population and control for social determinants of health. Hospitalists may consider Black race a risk factor when prescribing physical therapy.

RACIAL DISPARITIES IN OPIOID PRESCRIBING, PATIENT SATISFACTION AND DOWNSTREAM OPIOID MISUSE RISK AFTER E.D. VISIT FOR ACUTE KIDNEY STONE OR BACK PAIN: SECONDARY ANALYSIS OF A MULTISITE NATIONAL RCT

Max Jordan Nguemeni Tiako¹; Abby Dolan²; Frances S. Shofer²; Eugenia South²; Marilyn M. Schapira³; Zachary Meisel²

¹Department of medicine, Brigham and Women's Hospital, Boston, MA; ²emergency medicine, University of Pennsylvania, Philadelphia, PA; ³Internal Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #3876802)

BACKGROUND: Black patients receive opioids for pain less often than similar White patients. Some suggest this disparity may have initially protected them from opioid overdoses, but overdose rates among Black people have risen. We hypothesized that underprescribing opioids to Black patients may unwittingly contribute to downstream opioid misuse. In a multicenter, national longitudinal opioid risk communication RCT, we identified disparities in opioid prescribing: Black patients had greater negative preference mismatch & were less likely to receive opioids vs White patients, regardless of expressed preference communicated to providers. We examined the association between negative preference mismatch (henceforth referred to as underprescribing), patient satisfaction & downstream opioid misuse risk.

METHODS: This is a secondary analysis of participants with complete data in an RCT of 1301 patients with no recent opioid use or misuse who presented to the emergency department (ED) for acute kidney stone or back pain. The outcome for this secondary analysis was current opioid misuse measure (COMM), a self- report 17-item measure of opioid misuse risk among people prescribed opioids for pain, measured 90 days after the index ED visit. A COMM score ≥ 9 suggests opioid misuse. We used descriptive statistics & logistic regressions to determine whether opioid underprescribing & patient satisfaction (0-10) predicted opioid misuse risk, by race/ethnicity.

RESULTS: Our sample included 735 (56.5%) participants: 46.4% (n=341) White, 36.9% (n=271) Black, & 16.7% (n=123) Non-Black people of color (NBPOC). Undertreatment was rare (17.4%,n=128) but more common among Black vs (21.8%,n=59) vs White (15%,n=51) & NBPOC (14.6%, n=18) participants. Black participants had higher mean (SD) COMM scores [8.2(10.2)] vs White [4.3(5.7)] participants, & lower satisfaction scores [6.5(6.3)] vs White participants [7.1(3.1)].

Black (vs White) participants had greater opioid misuse odds (OR 2.87,95%CI 1.84-4.46,P<0.001).

Underprescribing was associated with misuse (aOR 1.85,95%CI 1.58-2.18,P<0.001). Greater satisfaction was associated with lower misuse odds (aOR 0.88 per point increase, 95%CI 0.85-0.90,P<0.001). In a model with interactions terms between race, patient satisfaction & underprescribing, race & undertreatment weren't independently associated with misuse, unlike satisfaction (aOR 0.86, 95% CI 0.77-0.97, P=0.02). The interaction between underprescribing & Black (vs White) race was associated with misuse (aOR 3.07,95% CI 1.74-5.41, P<0.001), as was the interaction between greater satisfaction, underprescribing & Black race (aOR 0.86, 95%CI 0.78-0.95,P=0.003).

CONCLUSIONS: Opioid underprescribing was associated with increased downstream opioid misuse risk 90 days post ED visit for acute back/kidney stone pain; conversely, greater patient satisfaction was associated with lower opioid misuse risk, both with a larger effect on Black patients. Opioid underprescribing may thus create racial disparities in opioid misuse.

READMISSIONS AND POST-DISCHARGE MORTALITY BY RACE AND ETHNICITY AMONG MEDICARE BENEFICIARIES WITH MULTIMORBIDITY

Melissa Y. Wei^1,2; Jinmyoung Cho^3,4

¹Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ³Texas A&M School of Public Health, College Station, TX; ⁴Baylor Scott & White Health, Temple, TX. (Control ID #3853306)

BACKGROUND: Medically and socially complex patients, including those with multimorbidity, disability, and unmet social needs, have among the highest rates of 30-day readmissions. Racial disparities in readmission risk have also been documented but have yielded conflicting results. We sought to examine the risk of readmissions and post-discharge mortality by race and ethnicity after rigorous adjustment for multimorbidity, physical functioning, and sociodemographic and lifestyle characteristics.

METHODS: We used Medicare Parts A and B (inpatient, outpatient, carrier) files between 1991-2015 to obtain ICD-9-CM diagnostic codes to compute the ICD-coded multimorbidity-weighted index (MWI-ICD).

Participants must have had at least one hospitalization between January 1, 2000 and September 30, 2015 and continuous enrollment in fee-for-service Medicare Part A 1-year prior to hospitalization. We used multivariable logistic regression to assess the association of MWI-ICD with 30-day readmissions and mortality 1-year post-discharge. Using Health and Retirement Study data linked to Medicare, we adjusted for age, sex, BMI, smoking, physical activity, education, household net worth, and living arrangement/marital status, and examined for effect modification by race and ethnicity.

RESULTS: The final sample of 10,737 participants had mean±SD age 75.9±8.7 years. Hispanic adults had the highest mean MWI-ICD (16.4±10.1), followed by similar values for White (mean 14.8±8.9) and Black (14.7±8.9) adults. A 1-point increase in MWI-ICD was associated with a 2% statistically significant higher odds of readmission (OR=1.02, 95% CI: 1.02-1.03), and there was no significant effect modification by race and ethnicity (p=0.27). For post-discharge mortality, a 1-point increase in MWI-ICD was associated with a 3% higher odds of mortality (OR=1.03, 95% CI: 1.03-1.04), which did not significantly differ by race and ethnicity (p=0.89).

CONCLUSIONS: Multimorbidity was associated with a monotonic increased odds of 30-day readmission and 1-year post-discharge mortality across all race and ethnicity groups. There was no significant difference in readmission or mortality risk by race and ethnicity after robust adjustment. To help reduce health disparities, interventions and policies must be implemented and targeted earlier in multimorbidity onset and progression, much prior to less modifiable sequelae such as functional decline, hospitalization, and premature mortality.

RELATIONSHIP BETWEEN SOCIAL RISK INDICATORS AND CLINICAL OUTCOMES FOR ADULTS WITH TYPE 2 DIABETES: A LATENT CLASS ANALYSIS

Joni S. Williams¹; Sebastian Linde²; Rebekah J. Walker³; Leonard E. Egede⁴

¹Medicine, Medical College of Wisconsin, Milwaukee, WI; ²Medicine, Medical College of Wisconsin Department of Medicine, Milwaukee, WI; ³Medicine, Medical College of Wisconsin, Milwaukee, WI; ⁴Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3875585)

BACKGROUND: Social risk factors are the adverse social conditions associated with poor health such as housing instability, food insecurity, transportation challenges, and social isolation. Despite studies showing social risk is associated with poor diabetes outcomes, evidence is lacking on how to classify social risk indicators in diabetes. Therefore, the objective of this study was to identify subgroups of social risk among adults with diabetes.

METHODS: Latent class analysis (LCA) is a statistical methodology used to identify different subgroups within populations. Cross-sectional data of 615 adults with diabetes recruited from two primary care clinics were used for the analyses. In this study, we used responses to 19 social risk indicators: employment, financial stability, financial hardship based on income, neighborhood safety, violence in neighborhood, neighborhood rating, neighborhood problems, highest education, health literacy, food insecurity, healthy food access, social isolation, racial discrimination, perceived stress, depression, serious psychological distress, diabetes fatalism, diabetes distress, smoking and alcohol/drug use. Each social risk was dichotomized with high risk as 1 and low risk as 0. A three-step process was then used to identify the best fitting model that captured patterns of social risk indicators across individuals and investigate the relationship of those latent classes with clinical outcomes. First, 2, 3, 4, and 5-class LCA models were tested and compared to identify the best fit model based on AIC and BIC scores. Then, posterior probability was used to classify individuals into their true latent class, with accuracy of classification determined based on entropy score. Finally, using the best fit classification, the relationship with HbA1c, blood pressure and quality of life was investigated. Stata v16 was used for analyses with p<0.05 indicating statistical significance.

RESULTS: Mean age of the sample was 61.3 years with 64.9% Non-Hispanic Black, 38.4% women, and 20.2% having an income less than $10,000. The best fit model identified 2 classes, used an income cut-point for financial hardship of <$10,000 and included covariates of age, sex, race/ethnicity, marital status, duration of diabetes, and self-reported health status. Using the 19 social risk indicators, adults with diabetes were classified into 2 classes: low social risk (64.1% of the sample) and high social risk (35.9% of the sample). The entropy score of 0.96 indicated high accuracy of classification. The high social risk classification was associated with higher HbA1c and lower mental health related quality of life.

CONCLUSIONS: These findings suggest that latent class analyses can be used to classify individuals into high and low social risk categories. In addition, these categories are significantly associated with clinical outcomes for adults with type 2 diabetes.

REVIEWING INSTITUTIONAL ANTI-BIAS INTERVENTIONS- CONTRIBUTIONS FROM THE HEALTH EQUITY COMMITTEE

Sydni I. Williams¹; Elizabeth H. Zeichner¹; Tracey Henry²; Marshall Fleurant²

¹School of Medicine, Emory University School of Medicine, Atlanta, GA; ²General Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #3874010)

BACKGROUND: Anti-racist or anti-bias interventions are of interest to the academic medical community. The literature base is expansive. To undertake a high-yield review of these interventions, we chose to focus on the body of work produced by the Society of General Internal Medicine’s Health Equity Commission (HEC). HEC is a committed group of health equity experts, researchers, and educators whose work focuses on social justice, eliminating health disparities & promoting equity. We conducted a scoping review of articles produced by HEC members detailing anti-racism interventions within academic medicine initiated at the institutional level as an attempt to understand the scope of interventions within academic medicine. METHODS: We identified members of the Health Equity Commission who were active as of April 2022. Using SCOPUS (an abstract and citation database), we tagged HEC members using specific author IDs; we used broad search terms focusing on anti-racism, bias, and ethnicity. Overall we identified 2831 publications. After duplicates were removed, we were left with 2276. We excluded articles with settings outside of an academic medical center or a primary focus on COVID-19. This left us with 221 publications for Title and Abstract review. Only 32 publications were subject to the full review. In full review- we discussed these articles and removed articles we determined only focused on increasing diversity but lacked initiatives to address bias or racism by consensus. In total, we were left with eight pieces.

RESULTS: We found four perspective pieces, one book chapter, one qualitative study, and two observational studies. We identified 35 different interventions across these eight publications.. The most common interventions were developing pipeline programs, implicit bias training, establishing DEI (Diversity Equity & Inclusion) leadership, or strategic planning centered on equity. Most interventions were aimed at trainees, whereas those aimed at institutions were the fewest. In each paper, interventions were multiple, stressing the need for numerous strategies to push forward anti-bias/ anti-racist agendas.

CONCLUSIONS: Within this group of papers, we have identified a broad range of strategies to reduce bias and racism within academic institutions. These strategies tend to be multi-modal and most frequently target trainees rather than faculty or specific programs. Institutional-level initiatives tended to focus on creating a DEI leadership structure or strategy. A DEI leadership structure appears to be an essential component to anti- bias or anti-racist initiatives. We suggest that institutions take a more significant role in intervening in anti- racist/ anti-bias interventions while supporting personnel in changing the environment.

SKILLED NURSING FACILITIES ARE LESS LIKELY TO ACCEPT PATIENTS WITH OPIOID USE DISORDER

Ifedayo O. Kuye¹; Laura Prichett²; Rosalyn W. Stewart³; Scott A. Berkowitz⁴; Megan Buresh⁵

¹Hospital Medicine, Johns Hopkins Medicine, Baltimore, MD; ²Pediatrics, Johns Hopkins Medicine, Baltimore, MD; ³General Internal Medicine, Johns Hopkins, Baltimore, MD; ⁴Medicine, Cardiology, Johns Hopkins Medicine, Clarksville, MD; ⁵Division of Chemical Dependence, Johns Hopkins School of Medicine, Baltimore, MD. (Control ID #3854194)

BACKGROUND: An increasing number of patients with Opioids Use Disorder (OUD) are hospitalized and referred to Skilled Nursing Facilities (SNFs). The Department of Justice has stated that the American Disabilities Act protects patients with OUD who are not currently engaged in illicit drug use from discrimination by SNFs. However, prior single center studies have identified that patients with OUD encounter more barriers to SNF placement when compared to patients without OUD. In this study, we analyzed SNF referral data from two academic hospitals Maryland. We hypothesized that patients with OUD would have more SNF referrals than those without OUD and referrals sent for patients with OUD would be less likely to be accepted.

METHODS: We examined electronic referrals from Johns Hopkins Hospital and Johns Hopkins Bayview Medical Centers, two academic medical centers in Baltimore, Maryland from January 1 to December 31, 2019. We linked referral data to the corresponding hospitalizations and downloaded clinical, demographic, disposition, and insurance data from the Epic Clarity Warehouse. The main outcomes of interest were the number of SNF referrals sent and the proportion of referrals accepted. OUD status was determined by receipt of medications for OUD(MOUD) during admission, upon discharge or the presence of a diagnosis code for OUD. Multivariate multilevel mixed regression models were constructed using a modified forward stepwise approach, adjusting for age, race, gender, non-English as primary language, type of insurance, psychiatric consult, Elixhauser score, contact precautions during admission, and alcohol use disorder for all outcomes.

RESULTS: Cohort included 6,047 hospitalizations (5422 without OUD and 625 with OUD). Patients with OUD had more SNF referrals sent (8.8 vs 5.6, p<0.001), had a lower proportion of SNF referrals accepted (31.3% vs 46.9%, p<0.001) and were less likely to be discharged to a SNF (65.6% vs 70.3% p<0.001). The effect of OUD status on the number of SNF referrals and the proportion of referrals accepted remained significant in the multivariate analyses. Our sub-analysis showed that reduced acceptances were driven by patients who were discharged without MOUD and on methadone. Those discharged on buprenorphine were accepted at the same rates as patients without OUD.

CONCLUSIONS: This multicenter retrospective cohort study found that patients with OUD had more SNF referrals, fewer referrals accepted and were less likely to be discharged to a SNF compared to those without OUD. Patients with buprenorphine had similar acceptance rates to patients without OUD, while acceptance rates were lower for patients receiving methadone and those not receiving MOUD. Our study highlights the need for more work to address disparities in the access to and quality of post-acute care for patients with OUD. This will require innovative interventions and policies to decrease provider stigma, improve the quality of SNF care and lift barriers to MOUD access, specifically methadone, at SNFs.

SOCIAL SUPPORT ASSOCIATION WITH DIABETES OUTCOMES FOR ADULTS WITH AND WITHOUT FOOD INSECURITY AT AN URBAN FEDERALLY QUALIFIED HEALTH CENTER Nicole Luche¹; Ann-Marie Rosland^2,3; Edith C. Kieffer⁶; Stephanie Perez⁴; Michele Heisler^7,8; Denise Deverts²; Gretchen Piatt^5,7; Felix M. Valbuena⁴; Jonathan Yabes²; Christina M. Lalama²; Margaret Zupa¹

¹Internal Medicine, UPMC, Pittsburgh, PA; ²Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ³Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; ⁴Community Health and Social Services Center, Inc., Detroit, MI; ⁵School of Public Health, University of Michigan, Ann Arbor, MI; ⁶School of Social Work, University of Michigan, Ann Arbor, MI; ⁷School of Medicine, University of Michigan, Ann Arbor, MI; ⁸Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI. (Control ID #3873005)

BACKGROUND: Adults with type 2 diabetes (T2D) and food insecurity have worse glycemic control and more diabetes distress than those without food insecurity. However, high social support is associated with better glycemic control and less diabetes distress in adults with T2D. Social support may also protect against the development of food insecurity and its associated negative effects through direct provision of food, financial support, and increased awareness of community resources. It is unknown whether increased social support buffers the negative impacts of food insecurity on diabetes distress and HbA1c for adults with T2D. We examined the impact of social support on these outcomes in adults with T2D with and without food insecurity.

METHODS: Data were collected from baseline assessments of 204 primarily Latino/a adults with T2D participating in a diabetes self-management support study at an urban federally qualified health center. All patients were enrolled with a family or friend ‘support person.’ Assessments included HbA1c, as well as validated survey instruments for food insecurity (Hunger Vital Sign, y/n), perceived social support (ENRICHD Social Support Instrument, 4-point scale), and diabetes distress (Problem Areas in Diabetes-5, 20-point scale). We used multiple linear regression models to examine the independent associations of food insecurity and social support with diabetes distress and HbA1c. An interaction term (food insecurity*social support) was then added to assess for moderation effects. Models were adjusted for patient age, sex, and insulin use.

RESULTS: Almost half (45%, n=92) of patients reported food insecurity. In bivariate analysis, a 1-point increase in social support was significantly associated with reduced odds of food insecurity (OR 0.75, 95% confidence interval [0.57, 0.99]). In adjusted models, food insecurity was significantly associated with a 3.38 (1.77, 4.99) point increase in diabetes distress score and 0.66% (0.15, 1.16) increase in HbA1c. In the same models, a 1-point increase in social support was independently and significantly associated with less diabetes distress (-0.79 [-1.59, 0.01] points), but not with HbA1c (0.08% [-0.15%, 0.31%]). Social support did not moderate the association of food insecurity with HbA1c or diabetes distress.

CONCLUSIONS: In this primarily Latino/a population of adults in a low-resource community with at least one support person, higher social support was associated with lower diabetes distress among both food secure and food insecure participants. However, higher social support did not mitigate the negative impacts of food insecurity on diabetes distress and HbA1c. This study provides evidence that enhancing social support may be a viable approach to improving diabetes outcomes for adults with food insecurity, but efforts to directly address food insecurity may also be necessary to achieve the greatest impact.

SOCIOECONOMIC AND RACIAL DISPARITIES IN COVID-19 ASSOCIATED HOSPITALIZATIONS AMONG VETERANS IN FIVE NEW ENGLAND STATES

Ya Haddy Sallah^1,2; Kate Ferencsik^3,2; Shaili Gupta²

¹Medicine, Massachusetts General Hospital, Boston, MA; ²Internal Medicine, Yale University School of Medicine, West Haven, CT; ³Augusta University, Augusta, GA. (Control ID #3875376)

BACKGROUND: Race-based COVID-19 outcomes have been reported. Few studies have explored the impact of neighborhood socioeconomic disadvantage (nSED), a key determinant of many health conditions, on COVID-19 outcomes and its interplay with race. We aim to 1) describe the distribution of nSED among Veterans diagnosed with SARS-CoV-2 in the New England area using Area Deprivation Index (ADI) 2) determine the association between ADI and hospitalization, and 3) investigate the interplay between ADI, race and hospitalization.

METHODS: A prospective cohort study was performed using Veteran’s Affairs electronic medical records in five New England states (CT, MA, ME, NH, RI) between 3/1/2020 and 6/30/2022. Patient’s addresses were geocoded and linked with ADI, a validated composite measure of nSED (Higher ADI reflects more disadvantage). ADI terciles were used for statistical analyses. The primary outcome was hospitalization with a positive COVID-19 test 7 days prior to 48 hours after admission. Logistic regressions were performed using STATA 15.

RESULTS: Of 8,538 veterans with COVID-19 (45% in MA, 29% in CT, 12% in RI, 7.3% in NH, 7% in ME), 80.3% identified as White, 10.8% as Black, 0.8% as Asian, 0.7% as American-Indian/Alaskan Native, 0.45% as Native Hawaiian/ other-Pacific-Islander, and 6.9% were unknown. Ethnicity was Hispanic in 6.5%. The mean age was 58.6 years (SD 17.4). Only 9.2% were female. ADI scores ranged from 1 to 98 with a mean of 38.5 (SD 20). ME had the highest average ADI score (58.3; SD 17.8) and MA had the lowest (27.5; SD 15.3). Hispanic patients had a higher mean ADI score (44.1 vs 38.3; p<0.05), but no association with hospitalization. Black patients had higher mean ADI scores compared to White patients (43.6 vs 37.8, p<0.05), and were 42% more likely to be hospitalized (OR 1.42, 95% C.I:1.15-1.78, p<0.05). ADI score did not differ by gender and age. Compared with patients living in the least disadvantaged neighborhoods, those living in the most disadvantaged neighborhoods were 27% more likely to be hospitalized (OR: 1.27, 95% C.I: 1.06-1.51, p<0.05), after adjusting for medical comorbidities. Older age, diabetes, COPD, CHF and cirrhosis were associated with being hospitalized. Among Black patients alone, ADI tercile was not significantly associated with hospitalization. However, among white patients, those living in more disadvantaged neighborhoods had increased odds of hospitalization (OR: 1.34, 95%: 1.11-1.62, p<0.05).

CONCLUSIONS: Hospitalization from COVID-19 was significantly associated with nSED. Black patients had higher odds of hospitalization independent of nSED. Interestingly, the relationship between hospitalization and nSED was only seen among White patients. These findings highlight the importance of assessing the interaction between race and nSED when investigating disparities in health outcomes.

SPANISH ADVANCEMENT FOR LEARNERS UNDERSTANDING DISPARITIES (SALUD): PILOT STUDY OF AN INSTRUCTOR-LED MEDICAL SPANISH CURRICULUM PROMOTING LANGUAGE CONCORDANT CARE

Miguel Tusa Lavieri, George S. Corpuz, Chimsom Orakwue, Andrea Cabassa Miskimen, Christopher J. Gonzalez, Shweta R. Iyer, Maria Lame, Joy D. Howell

Medical College, Weill Cornell Medicine, New York, NY. (Control ID #3877202)

BACKGROUND: The US population is growing progressively more diverse and people from LatinX cultures are the fastest growing segment of the population. Limited English Proficiency (LEP) is a barrier to health equity. Given the impact of language-concordant care on patient safety, high quality language education should be accessible to medical students. Herein, we evaluate the impact and feasibility of SALUD, a five-week intensive Medical Spanish (MS) pilot course implemented at an academic medical center in New York City.

METHODS: A five-week virtual course was led by an experienced medical Spanish instructor. Students met with the instructor thrice weekly and participated in six standardized patient encounters throughout the course. Student self-assessment as well as an informal assessment of baseline conversational competency was performed by the instructor prior to the course. Upon completion of the course, the instructor administered formal evaluations of MS core competencies, including: self-introduction, culturally-appropriate history- taking, effective information transfer, and student-patient dynamic. Focus groups were used to elicit student feedback and reflections immediately after the course.

RESULTS: Fifteen students completed the course. Eighty percent (12 of 15) of students self-reported their overall Spanish competency and comprehension abilities as “intermediate” prior to the course. Eighty-seven percent (13 of 15) of students received a post-course instructor rating of “outstanding,” determined by an average score across all four core competencies. The main themes identified by student focus groups include: (1) enhanced understanding of how to appropriately use medical Spanish versus a certified interpreter and (2) cultural nuances relevant to working with a variety of Hispanic/Latino patients with Limited English Proficiency (LEP) in a clinical setting.

CONCLUSIONS: The implementation of a rigorous medical Spanish curriculum is feasible within the UME curriculum with robust faculty and institutional support. Medical Spanish education is perceived by students as beneficial to their ability to care for Spanish-speaking patients with LEP. Future iterations of SALUD will include formal pre and post course medical Spanish competency assessed by students, instructor and standardized patients. Rigorous educational outcomes can be used demonstrate the impact of future/ similar courses on learners and patients.

SPATIAL EXPLORATION OF NEIGHBORHOOD-LEVEL SOCIAL DETERMINANTS OF HEALTH AND DIABETES MORTALITY IN CHICAGO

Andrew S. Palmer¹; Marynia Kolak²

¹Biological Sciences Division, University of Chicago Pritzker School of Medicine, Chicago, IL; ²Geography and Geographic Information Science, University of Illinois Urbana- Champaign, Urbana, IL. (Control ID #3871928)

BACKGROUND: Within Chicago, the prevalence of diabetes is higher in neighborhoods with larger minority populations and lower socioeconomic status. While the relationship between various Social Determinants of Health (SDOH) and diabetes mortality are well established, relatively little work has been done to examine the spatial heterogeneity of these effects.

METHODS: A conceptual model was developed following a survey of the literature that identified twenty publicly available neighborhood-level variables to capture dimensions of pathways by which SDOH impact disease burden. Datasets represented in this study range from 2007 to 2021. In this cross-sectional study of Chicago, 77 community areas were used for the creation of multidimensional indices of SDOH using Principal Component Analysis (PCA) which retained 5 axes using the Kaiser criterion. The relative contribution of each SDOH factor into a principal component was used to characterize each component: economic/neighborhood stressors, health literacy/language proficiency, neighborhood built resources and healthcare deprivation, healthcare utilization, and air pollution (particulate matter 2.5 microns in size) and community belonging. Six regional typologies were created through K-means clustering with neighborhood PCA index scores. ANOVAs were used to identify which clusters of neighborhoods had significantly different diabetes mortality rates from the rest of Chicago.

RESULTS: Regional typologies with both higher and lower-than-average diabetes mortality did not vary along the principal components in a uniform way. For example, one cluster comprised mainly of neighborhoods with large Black populations, including west Chicago and south-central Chicago with higher diabetes mortality (36.19 vs 24.61 per 100,000; p <0.001), had higher economic/neighborhood stressors, health literacy/English proficiency, neighborhood physical resources and healthcare deprivation, healthcare utilization, and air pollution/community belonging. Another cluster of neighborhoods in far south Chicago (comprised mainly of neighborhoods with large Hispanic/Latino populations) with higher diabetes mortality (39.18 vs 24.61 per 100,000; p= 0.022) had higher economic/neighborhood stressors, higher health literacy/English proficiency, lower neighborhood physical resources and healthcare deprivation, lower healthcare utilization, and lower air pollution/community belonging.

CONCLUSIONS: A deeper understanding of the spatial heterogeneity of the factors that impact diabetes mortality may allow for more spatially targeted allocation of limited public health monies. By elucidating typologies of SDOH and their association with diabetes mortality, neighborhood-specific interventions may improve outcomes more than interventions that treat populations as homogenous.

START: A COLLEGIATE PROGRAM TO BRIDGE THE DIGITAL TELEHEALTH DIVIDE

Zakaria N. Doueiri¹; Rika Bajra²; Erika Schillinger³; Malathi Srinivasan⁴; Nancy L. Cuan²

¹Human Biology, Stanford University, Palo Alto, CA; ²Internal Medicine, Stanford Medicine, Palo Alto, CA; ³Family Medicine, Stanford Medicine, Palo Alto, CA; ⁴Medicine, Stanford University School of Medicine, Palo Alto, CA. (Control ID #3875599)

BACKGROUND: Technology-enabled patients have improved access to care through telehealth. However, telehealth is not available to many vulnerable patients due to issues with technology literacy or access. We partnered with Primary Care and a Federally Qualified Health Center (FQHC) to develop START, a collegiate program to bridge the patient digital divide, while providing a valuable student learning experience.

METHODS: Our Primary Care group partnered with our academic medical center’s Digital Solutions and Technology and Compliance teams to create a program that trained students to help vulnerable patients access video visits during the COVID-19 pandemic. Undergraduate and graduate students learned about social determinants of health, design thinking, and working with community partners and developed their communication skills. Students contacted patients from electronic medical system lists, generated from searches for patients without an electronic medical portal account or who never utilized video visits. Six patients were referred directly to START by clinicians. To extend our services to the community, we partnered with an FQHC to connect community patients with telehealth. During the course, students submitted weekly reflections on their experiences with patients or guest speakers. Student reflections were coded for thematic content, using a rapid cycle methodology.

RESULTS: Over 6 academic quarters, 57 students outreached to 1185 patients to assist with telehealth technology. Sixty percent of the patients were at our institution and 40% were from an FQHC. Of the 229 patients reached, 141 patients wanted access to telehealth. Seventy-nine percent (n=111) of patients successfully established an electronic medical portal account and/or set up a video visit. Reasons for inability to establish access included lack of access to Wi-Fi or a device (n=11), absence of an interpreter (n=4), and a disability that precluded the patient’s use of video visits (n=2). Students reported (n=134 reflections) impact on future career goals and an improved awareness of health equity disparities, differential privilege in technology access, and the impact of the pandemic on health care.

CONCLUSIONS: Amongst patients whom we reached who desired access to telehealth, the START program improved access to telehealth for 79% of patients. Undergraduate and graduate students found that START broadened their understanding of health disparities and social determinants of health and influenced their future career goals.

STORIES FOR CHANGE PROTOCOL: A RANDOMIZED CONTROLLED TRIAL OF A DIGITAL STORYTELLING INTERVENTION FOR HISPANIC/LATINO INDIVIDUALS WITH TYPE 2

DIABETES

Lohr M. Abby^1,2; Katherine Vickery⁸; Valentina Hernadez⁷; Becky R. Ford⁸; Crystal Gonzalez⁷; Silvio Kavistan⁸; Christi A. Patten^4,2; Jane Njeru¹; Paul Novotny⁵; Linda K. Larkey⁶; Davinder Singh⁷; Mark L. Wieland¹; Irene G. Sia³

¹Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic Minnesota, Rochester, MN; ²Center for Clinical and Translational Science, Mayo Clinic Minnesota, Rochester, MN; ³Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic Minnesota, Rochester, MN; ⁴Department of Psychiatry and Psychology, Mayo Clinic Minnesota, Rochester, MN; ⁵Division of Biomedical Statistics and Informatics, Mayo Clinic Minnesota, Rochester, MN; ⁶Edson College of Nursing and Health Innovation, Arizona Board of Regents, Phoenix, AZ; ⁷Mountain Park Health Center, Phoenix, AZ; ⁸Health, Homelessness & Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN. (Control ID #3874301)

BACKGROUND: Hispanic/Latino adults are disproportionately impacted by type 2 diabetes mellitus (T2D). Innovative approaches that arise from affected communities are needed. Community-based participatory research (CBPR) has been successful in addressing health issues among Hispanic/Latino and immigrant populations as an engaging and effective approach for addressing health behaviors in a sociocultural and socio-ecological context. The Stories for Change (S4C) Diabetes digital storytelling intervention, developed with and for Hispanic/Latino adults, promotes T2D self-management. We describe the S4C protocol and participant baseline characteristics of participants.

METHODS: Study eligibility criteria included being Hispanic or Latino, age 18 - 70 years, with ≥1 office visit within the previous year at a participating clinic (in the midwest and southwest US), with T2D diagnosis for ≥6 months, HbA1c≥8%, and intention to continue care at the recruitment clinic. We used a two-group, parallel randomized controlled trial design and a community-based participatory research approach. All participants received usual diabetes care and two cards describing how to engage healthcare teams and access diabetes-related resources. At baseline, the intervention group additionally viewed the 12-minute, intervention video (four stories about diabetes self-management). To encourage subsequent video viewing, participants received five monthly text messages. The messages prompted them to self-rate their motivation and self-efficacy for managing their T2D. The control group received no additional intervention. Bilingual (English/Spanish) staff collected data at baseline, six weeks, three months, and six months including biometric measurements and a survey on diabetes self-management outcomes, theory-based measures, and the number of video views. We reviewed the number of diabetes-related appointments attended using electronic medical record data.

RESULTS: Participants (n=451; 70% women, mean age=53 years) had an average HbA1C ≥9%. There were no significant sociodemographic or health-related differences between the intervention and control groups, apart from the use of insulin and other diabetes medications, with more of the intervention participants (61%) compared to the control participants (52%) on insulin. While on average participants had a BMI in the obese range (>30 kg/m2), their low-density lipoprotein (LDL) cholesterol was optimal (<130 mg/dL). On average, most study participants reported excellent diabetes medication use but suboptimal diet, exercise, and blood glucose testing. Participants in both groups described similar levels of self-efficacy, social support for diabetes, and diabetes-related quality of life. The intervention group reported high story identification and transportation after viewing the S4C digital story.

CONCLUSIONS: We present a digital storytelling intervention protocol that will provide a template for future health promotion interventions prioritizing healthy disparity populations.

STRESS EXPOSURE AS A MEDIATOR BETWEEN RACIAL IDENTITY AND HEALTH AMONG LATINO INDIVIDUALS

Jordan J. Juarez¹; Rachel A. Zajdel¹; Erik Rodriquez¹; Eliseo J. Perez-Stable²

¹Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, MD; ²NIMHD, National Institutes of Health, Bethesda, MD. (Control ID #3874146)

BACKGROUND: The objective was to identify disparities in mental and physical health for Latinos who are differentially racialized, and to test stress as a mechanism linking racialization to health.

METHODS: We used data from Visit 1 (2008-2011), Visit 2 (2014-2017), and the Sociocultural Ancillary Study of the Hispanic Community Health Study/Study of Latinos, a multi-center cohort study of Latino adults. Participants (n=3907) were: White (n=1645), Multiracial (n=664), Black (n=135), American Indian/Alaska Native (AI/AN) (n=125), and Unknown/Not Reported (n=1338). Generalized structural equation modeling used racial identity (main predictor), discrimination stress (mediator), and depressive symptoms, anxiety symptoms, diabetes, and hypertension incidence (outcomes).

RESULTS: Mean age was 42, 52% were female, 39.9% had greater than a high school education, 76.5% were first generation immigrants, 51.8% were uninsured, and 40.1% were obese (BMI ≥ 30). Mean depressive and anxiety symptoms were 6.46 and -0.02, respectively. Identifying as AI/AN (β=0.39; CI=0.17-0.82), Multiracial (β=0.07; CI=0.01-0.16), or not racially identifying (β=0.08; CI=0.02-0.18) was associated with greater increases in depressive symptoms due to discrimination (ref=White, Table 1).

Individuals who identified as AI/AN (β=0.05; CI=0.02-0.10), Multiracial (β=0.01; CI=0.0-0.02), or no racial group (β=0.01; CI=0.0-0.03) reported greater increases in anxiety symptoms due to discrimination. Diabetes and hypertension incidence were 16.2 and 11.5 new cases per 100 respondents, respectively. Identifying as AI/AN or not racially identifying was associated with greater diabetes (β=0.12; CI=0.02-0.33; β=0.02;

CI=0.0-0.07, respectively) and hypertension (β=0.16; CI=0.03-0.43; β=0.03; CI=0.0-0.10, respectively; Table 1) incidence due to discrimination.

CONCLUSIONS: Findings suggest discrimination stress is a potential mediator linking racialization to mental and physical health, especially among AI/AN, Multiracial, and racially unspecified Latinos.

TEMPORARILY DE-CENTERING THE PATIENT TO REIMAGINE PATIENT-CENTERED CARE: ENGAGING COMMUNITY EXPERTS AND HEALTH SYSTEM PERSONNEL TO INFORM IMPLEMENTATION STRATEGIES FOR REDUCING HYPERTENSION DISPARITIES IN A MULTI-ETHNIC SAFETY-NET HEALTH SYSTEM

Utpal Sandesara¹; Savanna L. Carson²; Alex Dopp³; Lilian Perez³; Atkia Sadia²; Soma Wali⁵; Nina Park⁶; Alejandra Casillas⁴; Gloria Kim²; Maria Morales²; Ejiro Ntekume²; Priya Gandhi³; Anthony Wafford⁸; Arleen F. Brown⁷

¹Internal Medicine, University of California Los Angeles, Los Angeles, CA; ²University of California Los Angeles, Los Angeles, CA; ³RAND Corporation, Santa Monica, CA; ⁴Medicine, David Geffen School of Medicine @ UCLA, Los Angeles, CA; ⁵Medicine, UCLA Medical Center Olive View, Sylmar, CA; ⁶Los Angeles County Department of Health Services, Los Angeles, CA; ⁷Medicine, University of California Los Angeles, Los Angeles, CA; ⁸I Choose Life Health and Wellness Center, Los Angeles, CA. (Control ID #3875878)

BACKGROUND: Despite advances in evidence-based practices (EBPs) for managing hypertension (HTN), few implementation efforts systematically incorporate community and healthcare engagement strategies for reducing HTN disparities. In parallel, research on HTN has historically overemphasized patient-level factors (such as knowledge, beliefs, and individual behaviors) while underemphasizing community, social structural, and health system factors. Gathering perspectives from community and health system experts can take us beyond individual patients to confront the historical and sociocultural contexts that affect implementation of HTN EBPs in real-world settings.

METHODS: We conducted a multi-modal qualitative study in partnership with a large U.S. municipal health system. We convened 5 race/ethnicity-specific community advisory boards (CABs), each of which met 5 times (25 total meetings) to discuss HTN disparities, treatments, and cultural considerations. We also conducted semi-structured qualitative interviews (SSQIs) with 41 health system personnel about patient, community, and health system characteristics influencing HTN management. We solicited implementation recommendations from both groups. We summarized findings using rapid content analysis, followed by a pile-sort to identify higher-level content themes.

RESULTS: CABs and SSQIs identified historically and socially constituted conditions that act as barriers/facilitators for evidence-based HTN management in the current state. They also identified considerations for culturally/contextually tailoring EBPs. The conditions and considerations identified spanned 7 themes distributed across the 4 domains of the EPIS framework for implementation science: 1) social needs and 2) medical/health engagement needs (Outer Context); 3) dynamics of patient interactions and 4) health system operational factors (Inner Context); 5) standardization/flexibility in EBP implementation and 6) education materials (Innovation Factors); and 7) partnerships and funding (Bridging Factors).

CONCLUSIONS: The conditions and considerations identified will inform a randomized trial to test multi- level implementation strategies for cultural/contextual tailoring of HTN EBPs in our partnered municipal health system. More broadly, this study offers a model for community-engaged, health system-partnered research that can inform multi-level efforts to reduce disparities in HTN and other chronic diseases. By temporarily de-centering the patient as the primary agent (and hence locus of responsibility, blame, etc.) in HTN control, engaging community and health system experts puts the focus on complex processes that span multiple social levels. Amid significant sociocultural and medical challenges to patients achieving transformations in their health-related knowledge, attitudes, behaviors, and outcomes, this epistemological de-centering offers a method for tailoring implementation of EBPs to reshape health systems and community contexts in a way that is truly patient-centered.

THE ASSOCIATION BETWEEN AGE AND FUNCTIONAL DISABILITY IN US ADULTS WITH LIFETIME EXPOSURE TO THE CRIMINAL LEGAL SYSTEM, 2015-2019

Laura Hawks¹; Sanjay Bhandari²; Rebekah J. Walker³; Leonard E. Egede⁴

¹General Internal Medicine, Medical College of Wisconsin, Wauwautosa, WI; ²Internal Medicine, Medical College of Wisconsin, Milwaukee, WI; ³Medicine, Medical College of Wisconsin, Milwaukee, WI; ⁴Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3874619)

BACKGROUND: Due to the long legacy of mass incarceration, a burgeoning number of older adults have a history criminal legal involvement (CLI). Prior CLI is associated with worse chronic disease control and poorer outcomes, though the exact nature of this relationship is not well understood. Functional disability is an important predictor of disease control, and while CLI and older age are both associated with disability, the nature of this relationship is understudied. Therefore, we examined the association between age and functional status in adults with CLI, hypothesizing that older adults in this group would have greater disability.

METHODS: Using data from the National Survey of Drug Use and Health (2015–2019), we included 37,279 US adults who reported lifetime history CLI (ever been arrested, or on probation or parole). We categorized respondents by age: 18-49 years (younger adults); 50-64 years (middle-aged adults); and 65+ years (older adults). Functional status was measured with the World Health Organization Disability Assessment Schedule (WHO-DAS 2.0), for which higher scores equal greater functional disability. Using multivariate linear regression, we tested the association between age category and functional disability score controlling for relevant sociodemographic and clinical covariates.

RESULTS: In our sample of US adults with lifetime CLI, there were 59.9% younger adults, 28.5% middle- aged adults and 11.5% older adults. The youngest group was more likely to be female, was more racially and ethnically diverse, more likely to be working but also poorer than the middle-aged and older groups. The older group reported higher rates of most comorbid conditions, but fewer substance use disorders or mental health conditions. The unadjusted association between WHO-DAS 2.0 score and age found that functional disability decreased as age increased: with younger adults as the referent, the coefficient for middle aged adults was -0.7 (95% CI -1.0 - -0.5) and for older adults was -1.8 (95% CI, -2.1 - -1.5). After adjustment for all confounders, this association persisted: with younger adults as the referent, the coefficient for middle-aged adults was -0.4 (95% CI -0.5 - -0.3); for older adults with was -1.2 (95% CI, -1.5 - -0.9).

CONCLUSIONS: The pattern of functional decline with age for the general population does not hold true for Americans with lifetime history of CLI, in which younger adults have greater functional disability than middle-aged adults, who have greater functional disability than older adults. These findings persisted after controlling for sociodemographic and clinical covariates and contradicted our hypothesis. They suggest that greater attention should be paid to functional status after exposure to CLI. Interventions which aim to identify and treat causes for functional disability, particularly in younger populations with CLI, may be an important component to reducing health disparities for this highly marginalized group.

THE BURDEN OF PREMATURE CORONARY HEART DISEASE AMONG ADULTS WITH LOW SOCIOECONOMIC STATUS IN ARGENTINA.

Maria V. Salgado¹; Joanne Penko³; Alicia Fernandez³; Francine Rios-Fetchko³; Raul Mejia^1,2

¹Health, Economy and Society, CEDES, Buenos Aires, Argentina; ²Ambulatory Medicine, Hospital de Clinicas Jose de San Martin, Buenos Aires, Argentina; ³University of California San Francisco, San Francisco, CA. (Control ID #3872384)

BACKGROUND: There is an inverse relationship between socioeconomic status (SES) and risk of developing coronary heart disease (CHD). This association cannot be explained solely by differences in the prevalence of traditional cardiovascular risk factors. The objective of this study is to model the role SES plays in the burden of premature coronary heart disease (CHD) in Argentina.

METHODS: We used the CVD Policy Model – Argentina, a Markov computer simulation model, to project incident CHD events and mortality in low-SES adults 35 to 64 years of age from 2015 to 2024. We used data from the 2018 National Risk Factor Survey (NRFS). We defined low SES as not finishing high school and/or reporting a household income in quintiles 1 or 2. We designed simulations to apportion CHD outcomes in low SES adults to: (1) differences in traditional risk factors (hypertension, smoking, diabetes and obesity) observed in adults with low compared with higher SES; (2) risk observed for low SES independent of traditional risk factors; (3) events that could be prevented if risk factors were improved to ideal levels; and (4) underlying age- and sex-based risk not explained by traditional risk factors or SES (unmodifiable risk)

RESULTS: Over half (56%) of adults aged 35 to 64 years have low SES according to the NRFS. We observe that risk factor control was far from ideal among both low and higher SES populations, and that this inadequate management explains more than half of the preventable CHD events in Argentina s population. Simulations 1 and 2 estimate that low SES adults compared to those of higher SES have an overall excess of 28.7 incident CHD events per 10000 person-years (men: 37.9; women: 20.4), and 2.7 excess CHD deaths per 10000 person-years (men: 4; women: 1.4) from 2015-2024. The independent risk associated with Low SES (simulation 2) accounts for 73.5% and 70.4% of this event rate gap between SES levels for incident CHD and CHD mortality rates respectively; this finding represents the disparity that would remain even if levels of traditional risk factors were similar among low and higher SES populations

CONCLUSIONS: Adults with low SES have rates of incident CHD and CHD deaths that are nearly two- fold higher than those of higher SES adults. Most of this disparity is explained by the independent effect of low SES and not by differences in traditional risk factors. Nevertheless, both low and higher-SES Argentinian adults have poor management of cardiovascular risk factors. CHD prevention policies should explore how to address contextual aspects linked to SES, as well as aim to improve preventable risk factor control in all socioeconomic levels.

THE CUMULATIVE BURDEN OF SOCIAL DETERMINANTS OF HEALTH AND THE 10-YEAR CHANGE IN QUALITY OF LIFE.

Ro-Jay Reid²; Monika M. Safford²; W. Marcus Lambert¹; Joanna B. Ringel²; Laura Pinheiro²; Madeline R. Sterling²; Barrett Bowling⁶; Emily B. Levitan³; Samprit Banerjee⁴; Raegan Durant⁵; Michael Kim²; Jennifer D. Lau²; Parag Goyal²

¹Epidemiology and Biostatistics, SUNY Downstate Health Sciences University, New York City, NY; ²Medicine, Weill Cornell Medicine, New York, NY; ³Epidemiology, University of Alabama at Birmingham, Birmingham, AL; ⁴Population Health Sciences, Weill Cornell Medicine, New York, NY; ⁵Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL; ⁶Medicine, Duke University, Durham, NC. (Control ID #3875951)

BACKGROUND: Americans are not necessarily enjoying a higher quality of life (QoL). Social determinants of health (SDOH) have shown to have a significant association on QoL. Yet it is unknown how the cumulative effect of SDOH affects QoL. This study will determine the impact of the cumulative effect of SDOH on patient reported mental and physical health status over 10 years

METHODS: Data was obtained from Black and White participants of age ≥ 45 years old from REasons for Geographic and Racial Differences in Stroke (REGARDS) – a population-based observational cohort study. Exposure: 1) Annual income <$35,000; 2) education < high school; 3) zip code with >25% residents living below Federal poverty line; 4) no health insurance; 5) living in a state with poor public health infra- structure); 6) living in rural areas; 7) living in a health professional shortage area; 8) seeing fewer than 2 friends or family in the past month; 9) having no one to care for you if you fell ill.

Outcome: Decline > 5 points in physical component summary (PCS) and mental component summary (MCS) scores from the Short Form-12 over 10 years.

Statistical analysis: The sample was stratified by race. SDOH associated with decline in PCS and separately MCS (RR > 1.0) were examined and then used to create a SDOH count of (0, 1, ≥2). Poisson regression analyses were used to estimate RR and 95% CI for the age-adjusted and fully adjusted associations between the count of SDOH and each outcome, adjusting for demographics, health behaviors and medical conditions.

RESULTS: At baseline, the mean age (SD) was 62.9 (8.34) years and 56.2% were female. A total of 9085 participants self-identified as White while 5316 participants self-identified as Black. Among White participants 36.4% had a decline in PCS while 15.8% had a decline in MCS. Among Black participants 35.4% had a decline in PCS while 19.2% had a decline in MCS.

White participants.

Compared to those without SDOH in the age-adjusted model for PCS, those with ≧2 SDOH had RR of 1.26 (95% CI 1.17-1.35). In the fully adjusted model, the RR was 1.19 (95% CI 1.09-1.29) when compared to those without SDOH.

Compared to those without SDOH in the age-adjusted model for MCS, those with ≥2 SDOH had RR of 1.48 (95% CI 1.31-1.68). In the fully adjusted model, the RR was 1.32 (95% CI 1.15-1.51) when compared to those without SDOH.

Black participants

Compared to those without SDOH in the age-adjusted model for PCS, those with ≥2 SDOH had RR 1.18 (95% CI 1.06-1.30). In the fully adjusted model, the RR was 1.15 (95% CI 1.04-1.28) when compared to those without SDOH.

Compared to those without SDOH in the age-adjusted model for MCS, those with ≧2 SDOH had RR of 1.32 (95% CI 1.10-1.59). In the fully adjusted model, the RR was 1.26 (95% CI 1.05-1.53) when compared to those without SDOH.

CONCLUSIONS: Exposure to a greater number of SDOH may accelerate impairments in quality of life over time.

THE EXPERIENCE OF VISITING INCARCERATED FAMILY MEMBERS

Louisa Holaday^2,3; Cerella Craig³; Kimberly Stone²; Emily Wang^1,3

¹Internal Medicine, Yale University School of Medicine, New York, NY; ²Icahn School of Medicine at Mount Sinai, New York, NY; ³Yale University SEICHE Center for Health and Justice, New Haven, CT. (Control ID #3876631)

BACKGROUND: The United States currently incarcerates approximately 2 million people. Over 40% of Americans have had an immediate family member incarcerated, including over 60% of Black and Indigenous Americans. Having had an incarcerated family member is associated with lower well-being, and living in a community with high incarceration rates is associated with a higher risk of anxiety and depression. Non- incarcerated people with incarcerated loved ones may visit. Visitation has benefits for incarcerated people, including better mental health, and fewer behavioral infractions in the weeks leading up to visitation. Moreover, after release, formerly incarcerated individuals who experienced visitation are less likely to re- offend or be re-incarcerated. Yet, few studies have examined the experience of visiting for the non- incarcerated person.

METHODS: We performed a cross-sectional analysis of mixed methods data from the nationally- representative FamHIS survey, conducted by NORC in 2018. We examined rates of visitation overall, and odds of visitation by age, gender, income, financial impact of incarceration, race/ethnicity, region, and duration of incarceration using logistic regression. We used thematic analysis to evaluate responses to an open-ended question about the experience of visitation.

RESULTS: Our sample included 1,991 people with family incarceration experience, 22% (n=446) of whom visited. 100% of visitors provided a qualitative response about the experience. In the fully-adjusted model, older age (ORs 2.39-5.10 for 55-75+ years old vs <25), non-Hispanic Black race/ethnicity (OR 1.64 vs NH White), those financially affected by the incarceration (ORs 2.54-2.88 for those negatively affected & 4.83-5.10 for those positively affected vs. not affected), and those whose family member was incarcerated a longer time (ORs 6.96-18.19 for duration >1 month-10+ years vs <1 month) had significantly greater odds of visitation. Qualitative analysis revealed 5 major themes: “Negative emotional reaction”, “Outrage at unjust treatment of incarcerated person”, “Negative logistics”, “Positive experience”, and “Negative feelings about crime/incarcerated person”. Only 8.1% of responses included a code in the “Positive experience” theme, whereas the vast majority consisted of a combination of negative themes.

CONCLUSIONS: Despite evidence of the benefits of visitation for incarcerated people and society as a whole, our analysis reveals harms for non-incarcerated family members doing the visiting. These harms are not equally distributed, given the substantial racial and socioeconomic patterning of incarceration. Further, only about one in five people with an incarcerated immediate family member visit at all. Given the negative health effects of incarceration itself; having an incarcerated family member; and living in a community with high rates of incarceration, further research should be done on how to improve the experience of visitation, and policy makers should act to improve visitation logistics.

THE IMPACT OF THE COVID-19 PANDEMIC ON COLORECTAL CANCER SCREENING PREVALENCE IN BOSTON NEIGHBORHOODS

Roopa Bhat¹; Suzanne Brodney¹; Yuchiao Chang¹; Meghan Rieu-Werden¹; Folasade May³; Jennifer Haas²

¹General Internal Medicine, Massachusetts General Hospital, Boston, MA; ²Medicine, Massachusetts General Hospital, Boston, MA; ³Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #3851585)

BACKGROUND: Colorectal cancer (CRC) is the third leading cause of cancer-related death in the United States. The prevalence of CRC screening in a neighborhood can reflect unique challenges in accessing screening tests. The COVID-19 pandemic has inhibited CRC screening due to colonoscopy cancelations, one of the primary CRC screening methods, and the limited screening capacity of health systems. The study’s objective was to identify how neighborhood-based disparities in CRC screening prevalence changed during the COVID-19 pandemic.

METHODS: We abstracted CRC screening completion from Massachusetts General Brigham electronic health records for adults due for CRC screening in 27 Boston neighborhoods on 3/1/2020 and 3/1/2022. We calculated whether individuals ages 50-75 were up to date with CRC screening, defined by completion of a fecal immunochemical test (FIT) within 1 year, FIT-DNA within 3 years, sigmoidoscopy within 5 years, or colonoscopy within 10 years. Neighborhoods were characterized by their Center for Disease Control Social Vulnerability Index (SVI), an aggregate measure of socioeconomic status, household characteristics, and race/ethnicity. We examined disparities in CRC screening prevalence using multivariable logistic regression models adjusted for SVI.

RESULTS: Of the 15,762 eligible patients in 2020, 10,253 (65.0%) were up to date. Of the 18,464 eligible patients in 2022, 10,646 (57.7%) were up to date. Results showed that screening prevalence dropped to a similar range in all neighborhoods regardless of pre-pandemic prevalence. There were no statistically significant differences in CRC screening prevalence by SVI: a decrease of 8.3% among neighborhoods with SVI ≤80 compared to a decrease of 6.0% among the neighborhoods with SVI >80 (p=0.56), indicating that neighborhoods with higher vulnerability were not impacted differently than neighborhoods with lower vulnerability. Overall, our results suggest that the COVID-19 pandemic uniformly depressed CRC screening prevalence in all neighborhoods.

A complete map of CRC screening prevalence by neighborhood will be displayed in the presentation.

CONCLUSIONS: Our findings reveal that the COVID-19 pandemic equalized the prevalence of CRC screening across Boston neighborhoods despite pre-existing disparities. As we recover from the pandemic, we must “build back equal” by developing effective strategies to ensure equitable participation in screening.

THE IMPACT OF THE HEALTH TECHNOLOGY NAVIGATORS ON PATIENT PORTAL UPTAKE- A NOVEL HEALTH WORKFORCE ADDRESSING THE DIGITAL DIVIDE IN A SAFETY-NET HEALTH SYSTEM

Cristina Valdovinos^1,2; Jihan Awad³; Veronica Penate³; Anshu Abhat^3,4; Alejandra Casillas⁵

¹University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Charles R Drew University of Medicine and Science College of Medicine, Los Angeles, CA; ³Office of Patient Access, Los Angeles County Department of Health Services, Los Angeles, CA; ⁴Internal Medicine, Harbor-UCLA Medical Center, Torrance, CA; ⁵Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #3875299)

BACKGROUND: Significant disparities in the uptake of digital health tools have been previously described. Studies have found that low perceived confidence to engage with digital health resources among medically underserved patients partially account for this. To address barriers to digital health engagement (specifically around patient portal enrollment and use), the Los Angeles County Department of Health Services (LAC DHS) introduced the Health Technology Navigators program. To our knowledge, this is the first formal digital health workforce implemented in a safety net system. The study objectives are to describe the core functions of the health technology navigators and to evaluate their early effects on patient portal uptake.

METHODS: The Health Technology Navigators program was introduced at various sites in the LAC DHS in November 2021. The program is based on the community health worker model, with many navigators being bilingual (Spanish) members from the local communities home to LAC DHS sites. Navigator essential roles include helping patients enroll in the patient portal and download the portal application, and teaching patients how to navigate patient portal functions.

From January 2022-October 2022, 11 navigators worked at 11 LAC DHS sites (hospital and ambulatory care settings). We tracked unique portal registration invitations initiated by navigators, as well as portal account activations during this period. We compared the percent of invitations converted into successful account activations by a navigator versus conversion rates by all other staff types combined (e.g. medical assistants, clerks, nurses, doctors, volunteers). We examined age and language trends of patients invited into the patient portal by navigators.

RESULTS: A total of 72,474 invitations to enroll in the patient portal were sent during the study period. Navigators sent 8,053 unique invitations and 69% resulted in successful account activations. Only 49% of invitations sent by other staff resulted in successful account activations (p<0.05). Among patients enrolled by navigators, there were no noted trends by age: 67% of invitees who were 18-35 years activated an account versus 70% and 65 % for those 36-55 and 56-75 years old, respectively. Of note, Spanish-speaking patients had a higher rate of successful account activations (75%) than English-speaking patients (62%) (p<0.05)

CONCLUSIONS: The Health Technology Navigators Program is an innovative, patient-centered intervention designed to increase digital health engagement among patients in a safety-net health system. The program has been effective in increasing patient portal enrollment across different age groups and especially effective with Spanish-speaking patients. More research will be needed to examine how health technology navigators may affect sustained enrollment and portal use.

THE INFLUENCE OF GENDER, RACE, AND THE COVID PANDEMIC ON THE EXPERIENCES OF ASIAN AMERICAN AND PACIFIC ISLANDER WOMEN HEALTHCARE WORKERS: A QUALITATIVE STUDY

Qian Leng¹; Stephanie Maeda³; Megan Chang³; Monica Pan³; Samuel T. Edwards²; Megan Lafferty²; Belinda McCully³

¹CIVIC, Portland VA Medical Center, Portland, OR; ²Center to Improve Veteran Involvement in Care (CIVIC), VA, Portland, OR; ³Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Lebanon, OR. (Control ID #3870988)

BACKGROUND: In the US, there are 1.17 million Asian American & Pacific Islander (AAPI) women who work in health care. Studies show that microaggressions and discrimination impact workers’ sense of safety, wellness, and burnout. Despite AAPIs making up a large portion of healthcare workers, with 1 in 5 physicians and 1 in 11 nurses identifying as AAPI, there has been little research into AAPI women’s experiences working in health care. Our study investigates the experiences of AAPI women healthcare workers with attention to how gender, race and the Covid pandemic have shaped their day-to-day interactions with other healthcare workers and patients.

METHODS: We conducted semi-structured interviews with 22 participants who identified as AAPI women, resided in WA or OR, and were employed as a CNA, MA, RN, NP, or physician. The interviews were held via videoconferencing and lasted an average of 65 minutes. Interviews were recorded, transcribed verbatim and uploaded to Taguette software for coding and analysis. Each transcript was coded for content and analyzed for themes by a two-member dyad of the research team. The dyad met on a bimonthly basis to discuss the content of each transcript and identify emerging themes, which were then refined through discussion with the rest of the research team.

RESULTS: Our study revealed that both microaggressions and overt discrimination are commonly experienced by AAPI women in health care. Microaggressions centered around the following themes: Patient perceptions of lower competence and respect for AAPI women providers, stereotyping as the perpetual foreigner, sexualization of participant’s race, and expectations that AAPI women be willing to work harder without additional compensation or recognition. Experiences of overt discrimination included patient refusal of care, harassment regarding national origin or accent, exclusion from leadership positions, and threats of violence.

Individuals who experienced these negative encounters reported anxiety, decreased work satisfaction, and about half of participants felt it impacted their decision of whether to stay with or to leave their current employer. Interestingly, the Covid pandemic had negative effects, such as the scapegoating of AAPI health workers, but participants also reported some positive changes, such as more opportunities for remote work and the perception that anti-Asian racism has been brought to light as an issue of national importance.

CONCLUSIONS: Microaggressions and discrimination based on gender and race are often experienced by AAPI women healthcare workers. These frequent, negative interactions affect workers’ morale and employee retention. We need evidence-informed efforts by organizations to decrease the frequency of microaggressions and boost inclusivity of AAPI women in health care.

THE LOW-INCOME HOUSING TAX CREDIT (LIHTC) MODERATES ASSOCIATIONS BETWEEN RACE/ETHNICITY AND HYPERTENSION IN CHICAGO

Tiffany H. Xie, Monica E. Peek, Corey Tabit, Elizabeth L. Tung

Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #3872165)

BACKGROUND: Housing instability is a social risk factor for racial inequities in hypertension. Literature has focused on pathophysiological mechanisms between housing instability and hypertension, emphasizing stress pathways. Few studies have examined effects of housing policy on health. This study investigates the Low-Income Housing Tax Credit (LIHTC), the largest U.S. program incentivizing affordable housing development, as a moderator between race/ethnicity and hypertension.

METHODS: We conducted a retrospective cohort study of 15,340 patients and 161,451 outpatient encounters at an academic medical center. We paired electronic health records (2018-2019) with LIHTC data from the U.S. Department of Housing and Urban Development (2009–2019). We geocoded patient addresses to census tracts and created a binary variable based on the presence of LIHTC in a tract. We used mixed- effects logistic regression models to examine hypertension (BP≥140/90) as a function of the interaction between race/ethnicity and LIHTC availability, adjusting for age, sex, insurance status, and neighborhood poverty. We also examined free/low-cost health resources, such as health education classes, gyms, and grocery stores, as a function of LIHTC.

RESULTS: In our population, the mean age was 50 years and 63.2% were female; 57.6% were non-Hispanic Black, 23.6% were non-Hispanic White, and 4.3% were Hispanic/Latinx. Only 9.9% lived in a census tract with LIHTC units and 54.8% lived in a poor neighborhood (>20% households in poverty). 29.3% of patients had hypertension. Black (OR = 2.6, 95% CI = 2.3–2.9) and Latinx (OR = 1.3, 95% CI = 1.0–1.5) patients had higher hypertension odds compared to White patients. We observed a significant interaction effect for Black patients: living in neighborhoods with LITHC reduced the odds of hypertension by 31% (aOR = 0.7, 95% CI = 0.5–1.0). However, the odds of hypertension were higher for Black patients compared to White patients (aOR = 1.9, 95% CI, 1.3–2.8) in LIHTC neighborhoods. Neighborhoods with LIHTC had 2.2 times higher odds of having free/low-cost health resources versus those without (95% CI = 1.3–3.5).

CONCLUSIONS: LIHTC may moderate hypertension inequities in Black neighborhoods, perhaps by promoting housing stability and health resources. Aligning healthcare goals of addressing individual social risks (e.g. housing instability) with policy that mitigates historical effects of discrimination (e.g. residential redlining that led to segregated, under-resourced neighborhoods) will be critical to achieving health equity for racially minoritized communities, particularly for pervasive, pernicious diseases like hypertension.

THE POWER INITIATIVE: IMPLEMENTING AN ANTI-RACISM CURRICULUM FOR MEDICAL RESIDENTS

Nisha Sunku¹; Daniel Georgie²

¹Medicine, UCLA Medical Center Olive View, Sylmar, CA; ²Internal Medicine, UCLA Medical Center Olive View, Sylmar, CA. (Control ID #3875483)

BACKGROUND: When examining the social determinants of health, racism has only been recently incorporated into the discussion. While there is still more research to be done at the intersection of racism and healthcare, it is already well established that racism leads to poorer health outcomes and perpetuates health inequities. Although racism has been declared a public health crisis, the medical education system is lacking on how to train physicians to be antiracist. Health professionals are calling for antiracism to be integrated into medical training. Some programs have begun to implement such curricula and have found that longitudinal teaching can be effective. At our institution, members of the Internal Medicine faculty implemented a novel anti-racism curriculum, with aspirations to educate ourselves and the internal medicine residency program. Through this initiative, we strove to shed light on racist practices and biases in medicine as a means of providing more equitable healthcare for our patients.

METHODS: A comprehensive anti-racism curriculum was implemented for the Internal Medicine Residency Program at the start of the 2021-22 academic year. The curriculum consisted of ten, 45-minute sessions covering a breadth of topics including privilege and disadvantage, biases in medical documentation, medical mistrust, race-based medical practices, and immigration health. An anonymous feedback survey was conducted at the end of the year to assess curriculum reception and ease of clinical application. This study looks at 17 participant responses from that survey. The survey prompts assessed curriculum content, participant reception (feeling included and respected), and applicability of the curriculum to clinical practice. RESULTS: The primary outcome was to assess if this curriculum would influence clinical practice positively. The secondary outcomes assessed if the sessions met the objectives, if the content was clear and organized, and if facilitators were knowledgeable about their topics. 100% of survey participants felt that these sessions would help improve their clinical practice. 100% strongly agreed that the facilitators were knowledgeable. 94% agreed that the content was clear and 82% agreed it met the objectives

CONCLUSIONS: Based on the survey responses, we found that this curriculum was well received and would positively impact clinical practice and patient care. The supporting data was also reflective of widespread acceptance. Moving forward, we hope to expand this lecture series into a three-year rolling curriculum that other residency programs could easily adopt at their institutions.

TRAINING PRIMARY CARE RESIDENTS TO PROVIDE MEDICATIONS FOR STIGMATIZED CONDITIONS: A NATIONAL SURVEY OF PROGRAM LEADERS

Nina Tan¹; ADELAIDE H. MCCLINTOCK¹; Helene Starks³; E. B. Schwarz²

¹Internal Medicine, University of Washington Department of Medicine, Seattle, WA; ²Internal Medicine, University of California San Francisco, San Francisco, CA; ³University of Washington School of Medicine, Seattle, WA. (Control ID #3864610)

BACKGROUND: Stigma in health care impairs diagnosis and treatment and adversely affects health outcomes. As quality healthcare requires thoughtful training to minimize stigma, we surveyed residency program directors to compare approaches to training primary care residents in the use of medications to treat four stigmatized conditions that impact large numbers of US patients: opioid use disorder (OUD), high risk sexual activity warranting pre-exposure prophylaxis for HIV, gender affirming care, and undesired pregnancy. METHODS: We identified 244 program leaders of internal medicine (IM) primary care residency programs using the American Medical Association’s FREIDA database. We distributed anonymous unique links to a 15-question, institutional review board approved REDCap survey to program leaders, offering a $35 gift card for survey completion. We sent five reminders to encourage survey completion.

RESULTS: Surveys were completed by 68 program leaders (28% response rate). The majority of respondents felt that medications to manage these conditions fall within the scope of primary care (96% OUD, 100% HIV prevention, 72% gender affirming care, 63% undesired pregnancy) and recognized that patients currently have difficulty accessing these medications (88% OUD, 72% HIV prevention, 87% gender affirming care, 87% undesired pregnancy). While most programs reported training residents to prescribe medications for OUD (72%) and HIV prevention (84%), and 47% provide training in gender-affirming care, only 19% provide training in managing undesired pregnancy with over half of programs reporting no plans to offer this training (51%). The most common barrier to providing training was “lack of trained faculty preceptors” with over 50% of programs reporting that less than 10% of faculty were trained to manage gender affirming care and undesired pregnancy.

CONCLUSIONS: In this national survey of IM primary care residency program leaders, we found that most believe that medications for common stigmatized conditions are within the scope of primary care and that access to medications for these conditions remains limited. However, while most programs train residents to prescribe medications for OUD and HIV prevention, few offer training on medication abortion for undesired pregnancy with a commonly cited barrier being lack of trained faculty preceptors. This suggests that limited access to primary care for stigmatized conditions may be perpetuated and amplified without adequately trained physicians in the rising workforce. It also suggests that faculty development to learn and teach new clinical skills, such as medication management of gender affirming care and undesired pregnancy, may help improve residency training and primary care of these common stigmatized conditions.

TRANSITIONING HOME: EXPLORING PATIENT SOCIAL RESOURCE ENGAGEMENT AT DISCHARGE

Sonja Raaum¹; Alycia A. Bristol²; Kirsten Schmutz²; Katie Feldner²; Erin P. Johnson²; Andrea Wallace²

¹Internal Medicine, University of Utah Health, Salt Lake City, UT; ²College of Nursing, University of Utah Health, Salt Lake City, UT. (Control ID #3876043)

BACKGROUND: Hospital discharge is a vulnerable time for patients that requires engaging social resources to effectively self-manage medical conditions. COVID-19 disrupted patients’ social networks, but factors impacting patients’ preparation and navigation of the discharge process during COVID-19 have not been explored. The purpose of this study was to explore patient experiences with hospital discharge, the transition to home, and how COVID-19 impacted post-discharge processes.

METHODS: As part of a parent study (n=3815) examining the effect of implementing a systematic assessment of social needs and support in acute medical-surgical settings, patients were asked for their willingness to be interviewed 1-2 months after discharge. 38 interviews were conducted in April-May 2020 that concerned discharges from February-March 2020. Interviews were recorded and transcribed. Qualitative content analysis was performed using individual and family self-management theory (IFSMT) to code context and process factors that patients identified. Each transcript had a primary and secondary coder to reach a consensus, and subsequent coder meetings identified themes.

RESULTS: Several themes were identified according to the IFSMT framework. Themes that impacted patient self-management in the context of discharge planning included: timing discharge education to allow presence of support system, clearly communicating pain management expectations, and considering discharge location distance from the hospital. Those who expressed needs related to social resources were more likely to describe challenges associated with the discharge experience. Once home, COVID impacted the process of self-management by way of paid and unpaid support. For paid support, most valued the ability to meet via telehealth and to stay at home, but some reported difficulties accessing adequate support services (e.g., physical therapy). For personal support, several noted that an unexpected loss of support from family or friends would hinder self-management and ability to cope. Throughout, patients provided examples of unexpected support and concrete examples of how personal networks aid patients in anticipating needs in the context of transitions from hospital to home.

CONCLUSIONS: COVID-19 provided an opportunity to explore the role of social resources in successful patient transitions home. Our findings identified specific areas where the healthcare team can improve patients’ self-management – prioritize having support present during discharge, robust anticipatory planning around pain management and logistics, and explore reliance on both paid and unpaid support at home. Anticipating medical needs remains elusive for many patients but is key to a successful transition home from the hospital.

TRENDS IN FOOD INSECURITY AMONG ADULT PATIENTS BEFORE, DURING, AND AFTER THE NEW YORK CITY COVID-19 SHUTDOWN

Ines M. Robles Aponte^1,2; Ngoc Duong^1,2; Dodi Meyer^1,2; Nathaniel Kratz^1,2; Sandra S. Albrecht³; Maria Baquero⁴; Aldo Crossa⁴; Francesca Gany⁵; Elizabeth Kelman⁴; Morgan A. Finkel^1,2; Evianna Cruz Herrera^1,2; Amelia Shapiro²; Patricia Peretz²; Ying Kuen K. Cheung^1,2; Jennifer A. Woo Baidal^1,2

¹Columbia University, New York, NY; ²NewYork-Presbyterian, New York, NY; ³Mailman School of Public Health at Columbia University, New York, NY; ⁴NYC Department of Health and Mental Hygiene, New York, NY; ⁵Memorial Sloan Kettering Cancer Center, New York, NY. (Control ID #3855372)

BACKGROUND: Food insecurity has consistently been associated with adverse health outcomes, but sparse information exists on food insecurity among broad adult patient populations. We tested the hypotheses that the proportion of adult patients with food insecurity would increase during the COVID-19 shutdown anddecrease after the shutdown. We also examined differences in food insecurity according to race/ethnicity.

METHODS: Using an interrupted time series design, we examined electronic health records in an urban academic multi-site healthcare system in New York City (NYC) predominantly serving Hispanic/Latino neighborhoods with high food insecurity prevalence. We included a sequential sample of patients age >18 years with a Hunger Vital Sign™ food insecurity screening questionnaire completed as part of routine clinical care between March 2019 and June 2022. We defined food insecurity as a response of “always” or “sometimes” to either of 2 questions. We estimated monthly food insecurity as the proportion of screened patients with food insecurity. We defined three time points: before (Mar 2019-Feb 2020), during (Mar 2020- May 2020), and after (June 2020-June 2022) the COVID-19 NYC shutdown. We fit segmented regression models to estimate monthly food insecurity and changes over time with clustered standard errors, adjusting for patient demographics (age, sex, and race/ethnicity). We tested for effect modification by race/ethnicity using a 2-way interaction term between race/ethnicity and change over time (continuous months) in adjusted models.

RESULTS: Among 47,566 eligible patients, mean age was 43.6 ±18.4 years; 78.1% were female. 64.2% reported Hispanic/Latino, 10.6% non-Hispanic Black, 7.4% non-Hispanic white, and 5.6% other race/ethnicity. Patients completed mean 2.1 ± 1.7 food insecurity screens over 3 years. Average monthly food insecurity was 27.6% overall (32.1% before, 32.8% during, and 24.8% after the shutdown). In adjusted models, food insecurity increased 2.4% per month on average (95% CI: 0.3%-4.4%) during the shutdown compared to before. After the shutdown, food insecurity decreased by 0.1% per month (95% CI: -0.3% to 0.2%) compared to before the shutdown. After the shutdown, food insecurity was higher among Hispanic/Latino and non-Hispanic Black patients than non-Hispanic white patients (26.6%, 24.5%, and 15.0%, respectively; p-value < 0.001). Food insecurity among Hispanic/Latino and non-Hispanic Black patients decreased less than non-Hispanic white patients after the shutdown (p-interaction 0.003 and 0.03, respectively).

CONCLUSIONS: Despite overall improvements in food insecurity, racial/ethnic disparities in food insecurity widened after the COVID-19 shutdown. Clinical screening can be used to identify patient populations disproportionately burdened by food insecurity for future interventions.

UNCOVERING AND MITIGATING RACIAL BIAS IN MORTALITY PREDICTION MODELS USING HEALTH CARE DATA

Amol S. Navathe^1,2; Kristin A. Linn^3,2; Sae-Hwan Park¹; Caleb M. Hearn¹; Matthew Maciejewski⁴; Craig J. Kreisler⁵; Christopher B. Roberts⁶; Sumedha Chhatre⁷; Mateo U. Rosania²; Ravi B. Parikh¹

¹Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; ²Leonard Davis Institute of Health Economics, Philadelphia, PA; ³Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA; ⁴HSR&D, Durham VA Medical Center, Durham, NC; ⁵VA Medical Center Corporal Michael J Crescenz, Philadelphia, PA; ⁶VA Center for Health Equity Research and Promotion, Pittsburgh, PA; ⁷Psychiatry, University of Pennsylvania, Philadelphia, PA. (Control ID #3875913)

BACKGROUND: Mortality risk prediction models are used widely in health care for risk-stratification and risk-adjustment. Such models may be vulnerable to bias against minority groups. We investigated racial bias in population-level mortality prediction models used by the Veterans Administration (VA), Medicare, and other policymakers.

METHODS: Our initial focus was the VA Care Assessment Needs (CAN) score, which primary care teams use in patient management and resource allocation. The mortality CAN score predicts 1-year all-cause mortality for Veterans using more than 100 clinical and administrative variables. First, we investigated the CAN for 2 common bias metrics: (1) equality of opportunity, which requires equivalent false negative rates (FNRs); and (2) demographic parity, which requires equivalent proportions of Black and White patients to be classified as high-risk. Second, we systematically applied several literature-based methods to mitigate observed bias toward Black patients. Third, we simulated the impact of an “Equitable CAN” score on the racial distribution of palliative care referrals. Fourth, we examined other mortality risk scores (Medicare Hierarchical Condition Categories (HCC), Elixhauser comorbidities) in VA and Medicare data for similar racial bias.

RESULTS: We found consistent evidence of inequity in predictions against Black patients across both bias metrics. Among 989,977 Black and 3,945,605 White Veterans, mean CAN score was lower for Blacks (41.6 vs. 52.1; P <0.001). Using a CAN threshold of 75 to indicate high risk, the FNR was 53% higher for Black vs White Veterans (29.6% vs. 19.4%; P<0.001). Age was a leading mechanism of bias: Black Veterans were younger than Whites (mean age 58.2 vs. 64.5 years, p<0.001), despite similar comorbidity (mean comorbidity number 2.5 vs 2.3). Black Veterans died at younger ages than Whites (72.0 vs. 78.6 years, P<0.001). An "Equitable” CAN that normalized age distributions to a common mean resulted in similar CAN scores (mean score difference of original vs. Equitable CAN: 10.3 vs. 3.0) and mitigated inequity (FNR difference: 10.3 vs. 1.3 percentage-points [pp]), while other statistical approaches did not. In simulations, an Equitable CAN increased the percentage of Black Veteran decedents who would receive palliative care by 8.1pp from a baseline of 15.5% (a 52% increase). Our findings replicated across other risk-scores and populations (e.g., Original vs. Equitable HCC FNR gap 4.1 vs. 0.1pp).

CONCLUSIONS: We uncovered a generalizable mechanism of inequity in mortality prediction related to faster aging of Black individuals – a “weathering effect” likely related to adverse social drivers of health. Age normalization markedly reduced bias and is currently being tested in the VA to ameliorate disparities in areas like palliative care and hospice referral. Our findings highlight pervasive unintended racial bias against.

Blacks and inform mitigation approaches in other mortality prediction models.

UNEVEN VA MENTAL HEALTHCARE EXPERIENCES AMONG TRANSGENDER VETERANS WITH DEPRESSION

Joy L. Lee¹; Claire E. Williams³; Masheka Fuqua⁴; Diana Natividad⁴; Michael Weiner²

¹General Internal Medicine, Indiana University School of Medicine, Indianapolis, IN; ²Department of Medicine, Indiana University, Indianapolis, IN; ³Health Services Research, Regenstrief Institute, Indianapolis, IN; ⁴Richard L Roudebush VA Medical Center, Indianapolis, IN. (Control ID #3874746)

BACKGROUND: Transgender Veterans experience higher rates of depression than cisgender Veterans. They also often report delaying seeking mental healthcare, citing fear of discrimination. The VA, the largest integrated healthcare system in the US, has made a stated commitment toward reducing health disparities for transgender Veterans and delivering gender-affirming care. In this study, we describe the mental healthcare experiences of transgender Veterans with depression, including identifying facilitators and barriers toward the delivery of gender-affirming care.

METHODS: We conducted in-depth, semi-structured interviews with transgender Veterans with depression to understand their mental healthcare experiences within and outside of the VA. Data collection took place in 2021 and included Veterans from different US regions. Each interview was audio-recorded, transcribed, and coded for themes using an immersion/crystallization approach.

RESULTS: Twenty-six Veterans with depression participated in the study. The participants appeared very knowledgeable about the parameters of VA care for transgender Veterans, often quoting exact VA directives on available services. Health system facilitators cited included the LGBTQ+ program, mental health provider availability (relative to non-VA providers), and ease of connecting with services. Barriers included perceived lack of provider knowledge about transgender experiences, and lack of available providers. Interpersonal facilitators included participant experiences with a wide range of involved specialties (e.g. speech pathologists, physical therapists, mental health counselors) with providers who went “above and beyond” to deliver care, while barriers included Veteran experiences with mis-gendering and misnaming by VA staff. Given that study enrollment took place during the COVID-19 pandemic, many participants had experience with receiving care through video visits. Video visits were valued not only for their convenience, but the “safe space” that they created. One patient said, “Being able to do [video visits] in the space where I’m most comfortable, I’ve been able to express myself a lot easier. It makes for a more productive session. When you go somewhere that’s not your personal space, I never felt comfortable just sharing things.”

CONCLUSIONS: While the VA has made a commitment toward improving care experiences for transgender Veterans, mis-gendering by VA staff remains common. Notably, clinician availability and knowledge were cited by some participants as facilitators and some as barriers to care, suggesting system (clinician availability) and interpersonal (clinician knowledge) variations across VA sites. Greater availability of mental healthcare providers and education on gender affirming mental healthcare may be needed to improve care experiences.

USE OF COMPANIONS WHO SUPPORT MEDICAL COMMUNICATION AMONG OLDER ADULTS WITH COMMUNICATION DISABILITIES

Jennifer Y. Oshita

Medicine, Clinical and Translational Sciences, University of Vermont Larner College of Medicine, Burlington, VT. (Control ID #3876209)

BACKGROUND: Persons with communication disabilities (CDs) experience multiple healthcare disparities including increased likelihood of emergency department visits, increased risk of an adverse medical event, and decreased satisfaction with care. Prior literature indicates that companionship during medical encounters increases patient satisfaction, autonomy related behaviors and patient safety. Little is known about utilization of companions who aide medical communication among older adults with CDs. We aimed to: 1) Describe the prevalence of using a companion who aids communication at doctors’ visits among older adults, by no, single, and multiple CDs; 2) Compare the adjusted likelihood of bringing a companion by presence of CDs; 3) Identify social factors impacting use.

METHODS: Cross-sectional analysis of the 2015 cohort of the National Aging Health and Trends Survey, a longitudinal, nationally representative survey of Medicare beneficiaries. The predictor of interest was the presence of no, single, or multiple CDs (hearing, expressive and/or cognitive). The outcome was bringing someone to the doctor who helped with communication. NHATS analytic weights were utilized. Descriptive statistics were used in the unadjusted analysis. We used a generalized linear model with a Poisson family distribution to obtain an adjusted prevalence ratio (APR), while controlling for sociodemographics, health, and other disability factors. As a secondary analysis, we stratified the population by race, gender, and income, to assess if they moderate companion use. Finally, we calculated adjusted predictive probabilities using the Stata margins command.

RESULTS: An estimated 60% (CI: 56.9-62.9) of older adults with CDs do not bring someone with them who aides communication to doctors’ visits. After adjustment, having CDs increases the likelihood of companionship when compared to no CD (Single CD APR: 1.40 [CI 1.25-1.57]; Multiple CDs APR: 1.47 [CI 1.26-1.72]). However, when stratified by social groups the predicted probabilities of using a companion differed from the entire population. Older black adults were less likely than white adults to use a companion

(No CD: Black 19.2%, White 21.9; Single CD: Black 24.8%, White 30.7; Multiple CDs: Black 24.3%, White 32.6%). While having more than one CD increased the predicted probability of using a companion among all groups, among older black adults, those with multiple CDs were no more likely to use a companion when compared to those with single CDs.

CONCLUSIONS: Slightly over half of older adults with CDs do not bring a communication companion to medical visits. Beyond presence of CDs, social factors also impact use of a companion.

UTILIZING A REMOTE POVERTY SIMULATION IN MEDIAL EDUCATION

Bethany M. Langner

Shilpa Register, Dawn Taylor Peterson. The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL. (Control ID #3860021)

BACKGROUND: Social determinants of health have a complex impact on patient care and outcomes.

Therefore, an understanding of poverty and how it relates to patient care is critical to medical student training. With the transition to online platforms in education, a remote version of the poverty simulation allows for a more cost effective and time efficient mode of delivery than an in-person poverty simulation

METHODS: A remote version of the poverty simulation was implemented for first year medical students at the beginning of their training. The learning experience consisted of content review and a simulation prebriefing lasting 30 minutes, the virtual simulation which lasted 30 minutes, and a structured debriefing led by trained faculty members lasting 45 minutes. All of these activities were online. In the simulation experience, students were provided $1000 to get through the month, which forced them to make financial compromises. Students were allowed to redo the simulation and make different choices to see how this altered the outcome of their living situation. After the virtual simulation, students engaged in a live, structured debriefing session over a web conferencing platform with trained faculty members. A qualitative survey analysis was used to examine anonymous survey data from medical students that participated in the poverty simulation.

RESULTS: A total 337 students from two different cohorts completed the poverty simulation and post-test surveys, which consisted of nine Likert scale questions and two open-ended questions. Students overwhelmingly agreed or strongly agreed that objectives for the event were met (97%), the learning experience was valuable (96%), the feedback session was valuable (94%), the experience will improve their performance in a clinical setting (92%), and they would recommend this event to others (94%). Statements such as, “I learned about the difficulties of being moral and ethical when survival is difficult to achieve” and “the simulation was more engaging than just reading studies” were common in the post-test surveys. A theme for improvement in the simulation was to “include mental health and/or addiction,” while another student said, “I wish the simulation could have been lengthened to see longer-term outcomes.”

CONCLUSIONS: Implementing a poverty simulation during the first year of medical school ensures that medical students receive this knowledge early in their training even before they see their first patient. A barrier to offering these critical simulations in-person is coordinating time with preceptors and participants to participate in the simulation. We found that a remote simulation can overcome these barriers and still provide appropriate training to students.

VA FACILITY-LEVEL VARIATION IN RACIAL DISPARITIES IN ANTICOAGULATION FOR ATRIAL FIBRILLATION

Utibe R. Essien, Nadejda Kim, Leslie R. Hausmann, Maria K. Mor, Chester ". Good, Terrence Michael A. Litam, Walid F. Gellad, Michael J. Fine

Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA. (Control ID #3874307)

BACKGROUND: Although anticoagulation reduces stroke risk in atrial fibrillation (AF), prior nationwide VA studies conducted at the patient-level show significantly lower prescribing rates for any anticoagulant and direct oral anticoagulant (DOAC) therapy in Black than White individuals. Because little is known about whether disparities in anticoagulant prescribing for AF exist at the facility level, we compared anticoagulant initiation for White and Black patients with AF across VA facilities.

METHODS: We identified a national cohort of patients enrolled in VA with a new outpatient diagnosis of non-valvular AF from 1/1/2020 to 12/31/2021. We excluded patients with an AF diagnosis or anticoagulant therapy in the 2 years prior to their index AF diagnosis, pre-existing valvular heart disease, and those receiving hospice care or who died within 180 days of an index AF diagnosis. For all VA facilities with at least 10 Black patients with AF, we calculated facility-level rates of anticoagulant initiation (any or DOAC) within 180 days of an index diagnosis and assessed the difference in anticoagulant initiation between White and Black patients. We characterized variation across VA facilities using risk differences by percentile points, adjusted for year of AF diagnosis, area deprivation index, VA enrollment priority group, CHADS₂VA₂Sc stroke risk score, bleeding risk, and comorbid renal and liver disease.

RESULTS: We identified 28,434 patients with AF at 82 VA facilities with at least 10 Black patients with AF.

The facility-level ranges of the number of Black and White patients were 2.7% to 56.5%, and 37.0% to

96.1%, respectively. The facility-level percentages of patients initiating any anticoagulant therapy for Black and White patients were, 40.4% to 93.3%, and 51.0% to 88.0%, respectively; for DOAC therapy, these ranges were 40.0% to 90.9% for Black patients and 49.0% to 86.8% for White patients. The adjusted White-Black facility-level differences ranged from -29.3% to 13.8% for any anticoagulant therapy and -27.4% to 14.2% for DOAC therapy (Figure). Only 4/82 facilities had a statistically significant risk difference for either any anticoagulant or DOAC therapy, with 3 of 4 of these facilities showing higher prescribing frequencies in Black than White patients.

CONCLUSIONS: Despite wide variation in VA facility-level adjusted racial differences in any anticoagulant or DOAC therapy for patients with AF, statistically significant racial differences were uncommon and more often favored Black versus White patients at the facility-level.

VALIDITY EVIDENCE FOR THE PHYSICIAN ORAL LANGUAGE OBSERVATION MATRIX AS A MEASURE OF MEDICAL SPANISH PROFICIENCY

Pilar Ortega²; Steven Gregorich³; Leah S. Karliner⁴; Javier González⁵; Cristina Pérez-Cordón⁶; Reniell Iñiguez²; José Alberto Figueroa⁷; Karen Izquierdo¹; Lisa C. Diamond¹

¹Immigrant Health and Cancer Disparities Service, Memorial Sloan-Kettering Cancer Center, New York, NY; ²University of Illinois Chicago, Chicago, IL; ³University of California San Francisco, San Francisco, CA; ⁴Medicine, UCSF, San Francisco, CA; ⁵Immigrant Health and Cancer Disparities, Memorial Sloan Kettering Cancer Center, New York, NY; ⁶United Nations, New York, NY; ⁷Northwestern University, Evanston, IL. (Control ID #3875132)

BACKGROUND: The lack of a standardized language assessment process for medical students and physicians communicating in Spanish threatens patient safety and quality of care. Many medical students and physicians take medical Spanish courses and/or report having and using some Spanish skills. However, most never have their skills formally assessed and rely on self-reported proficiency, which can be inaccurate. The purpose of this study is to evaluate the validity of the Physician Oral Language Observation Matrix (POLOM) in assessing medical student communication with Spanish-speaking patients.

METHODS: Forty-one medical students completed standardized patient (SP) encounters in Spanish. The students’ performance on the videorecorded encounters was scored by trained, reliable raters. We examined the POLOM’s convergent validity via correlations with other medical Spanish proficiency measures: (1) self- rating on the Interagency Language Roundtable scale for healthcare (ILR-H) and (2) score on the Clinician Cultural and Linguistic Assessment (CCLA). We measured Criterion validity via the POLOM’s correlations with clinical outcomes of the students’ SP encounters: (1) an SP scale about the student’s communication/interpersonal skills, (2) an SP checklist about the completeness of the interview, and (3) a faculty rating of the clinical note the student wrote after the encounter. We report Pearson correlations (r), and—for criterion validity—canonical correlations (r) representing the association of each language proficiency measure with all three clinical outcomes, simultaneously.

RESULTS: Students in the sample were mostly female (56%), 48% white, 27% Hispanic/Latinx, 17% Asian, and 7% Black. The POLOM was strongly correlated with student ILR-H self-rating (r=.72) and CCLA Objective score (r=.59), providing evidence of convergent validity. In addition, the POLOM was substantially correlated with the SP scale (r=.35), the SP checklist (r=.32), and the faculty scoring of the student’s clinical note (r=.25), providing criterion validity evidence of POLOM scores. Of the three language proficiency measures, the POLOM had the stronger multivariate relationship with the three clinical outcomes, r=.46 versus r=.44 (ILR-H) and r=.41 (CCLA).

CONCLUSIONS: The POLOM is the first observational tool that can be used to assess oral Spanish proficiency during an SP encounter. The POLOM has demonstrated evidence of convergent and criterion validity as a measure of medical students’ Spanish proficiency during SP encounters. Compared to other available healthcare language examinations or tools, POLOM ratings were more strongly correlated with clinical objectives of medical Spanish curricula. Future work will expand the scalability of the POLOM to make it available as a medical Spanish proficiency assessment. Additional research is needed to evaluate how the POLOM can be implemented with resident and practicing physicians, applied to other health professions, and adapted to other languages.

VARIATION AND CHALLENGES IN PRE-HEALTH ADVISING RESOURCES IN CALIFORNIA’S INSTITUTIONS

Francine Rios-Fetchko¹; Mariam Carson¹; Manuel Tapia²; Janet Coffman³; Alicia Fernandez¹

¹Department of General Internal Medicine, ZSFG, University of California San Francisco, San Francisco, CA; ²Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA; ³Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA. (Control ID #3876717)

BACKGROUND: California’s health professionals do not reflect the state’s population growth and increased diversity. Pre-health advising presents a modifiable factor that can help increase the diversity of the health workforce. Colleges are known to vary in resources, structure, and services invested in pre-health advising, but data are lacking and there is no estimate of any pre-health advising resource gap. We surveyed all CSU (California State Universities), University of California (UC) institutions and select private schools to quantify any gap in resources and gather perceived challenges in pre-health advising.

METHODS: We conducted structured 60-minute interviews with closed and open-ended questions from June 2022 to October 2022 via videoconference with pre-health advisors from all CSUs and UC, and selected 6 private colleges with varying student selectivity to match UCs and CSUs. Two investigators independently analyzed interviews using a Grounded Theory Approach and the full team reviewed transcripts and themes.

RESULTS: 18/23 CSU, 9/9 UC and 6/6 private colleges participated. Of 4 non-participating CSUs, one is a dedicated non-pre-health campus. Pre health advisor FTE varied from mean CSU 1: 24,620 graduates (range: 1: 1,059 – 1: 150,520) to UC 1: 4,526 graduates (range: 1: 1,912 – 1: 10,920) and privates 1:1,794 graduates (range: 1: 722 – 1: 5,300). On average, UC schools had 5.4 times more FTE pre-health advising per graduate than CSU schools. Challenges across all institutions included: advising capacity, competing priorities, difficulties in accessing clinical opportunities for students, challenges in course work navigation specific to transfer students from community college, and challenges in identifying pre-health students at opportune times for advising input. These challenges were reported as particularly common and severe by CSU participants. Both CSU and UC participants noted that advising challenges were particularly salient for students from underrepresented racial/ethnic groups and first-generation college students where financial pressures, lack of access to academic opportunities earlier in their educational careers, and familial responsibilities complicate college navigation. All participants noted local innovations to better serve their students, including leveraging peer advisors, offering health professions career exploration courses, establishing partnerships with local physicians and organizations, and developing advisor networks

CONCLUSIONS: UC schools have over five times more FTE pre-health advising per graduate than CSU schools, and both California’s public systems have far fewer advisors per student than private colleges. While pre-health advising presents common challenges on all campuses, much greater investment is needed in California’s public institutions, particularly California State Universities, to increase equity in access to advising for pre-health professional students.

Scientific Abstract - Geriatrics and Palliative Care

ADVERSE CHILDHOOD EXPERIENCES (ACES): IMPLICATIONS FOR PHYSICAL, COGNITIVE, AND FUNCTIONAL IMPAIRMENT IN A NATIONAL SAMPLE OF OLDER COMMUNITY-DWELLING ADULTS

Victoria M. Lee¹; Anita S. Hargrave²; Nadra E. Lisha²; Alison Huang²

¹School of Medicine, University of California San Francisco, San Francisco, CA; ²Medicine, University of California San Francisco, San Francisco, CA. (Control ID #3854748)

BACKGROUND: Prior research on the health implications of ACEs has focused on early or midlife adults, not older adults who bear the greatest burden of health-related functional impairment. We examined associations between ACEs and mobility impairment, cognitive impairment, and functional disability in older community-dwelling adults.

METHODS: Cross-sectional analyses of the National Social Life, Health, and Aging Project (2015-2016), a national cohort of community-dwelling older U.S. adults. Participants were interviewed about their history of ACEs (childhood experience of violence/abuse, witnessing of violence, financial insecurity, parental separation, or serious illness), underwent standardized physical performance testing (tandem balance, 3-meter walk, chair stand test) and cognitive testing (survey adaptation of the Montreal Cognitive Assessment), and reported functional disability (difficulty with activities of daily living). Multivariable logistic regression models examined associations between ACE exposures and each functional impairment and functional disability outcome, adjusting for potential demographic confounders.

RESULTS: Among the 3387 participants (ages 50-97; 54% female; 26% ethnic minority), 44% reported a history of one or more types of ACEs, including 14% reporting childhood experience of violence and 16% childhood witnessing of violence. Thirty-five percent met criteria for mobility impairment and 24% cognitive impairment, and 24% reported functional disability. After adjusting for age, gender, race, and ethnicity, participants reporting exposure to one or more ACEs were more likely to demonstrate mobility impairment (OR 1.30, 95% CI 1.11–1.52) and cognitive impairment (OR 1.26, 95% CI 1.03–1.54), as well as report functional disability (OR 1.69, 95% CI 1.38–2.07), compared to those with no history of ACEs. Participants with a history of multiple simultaneous ACEs were even more likely to have mobility impairment (OR 1.37, 95% CI 1.10–1.72) or cognitive impairment (OR 1.38, 95% CI 1.07–1.79) and report functional disability (OR 1.97, 95% CI 1.59–2.43). In analyses distinguishing between specific types of ACEs, poor childhood health was associated with a 65% to 74% increased odds of almost all measured outcomes, and childhood experience of violence was associated with a 38% greater odds of physical mobility impairment (95% CI 1.11–1.71) and 86% increased odds of functional disability (95% CI 1.49–2.33).

CONCLUSIONS: Adverse childhood experiences may be important markers of future physical and cognitive functional impairment late in life, suggesting that efforts to screen for or mitigate ACEs may have implications for aging-associated functional decline. Clinicians may be able to provide more thoughtful and compassionate care to older adults by exploring the potential role of early life traumatic experiences in shaping or further complicating their functional challenges.

AN AUDIOLOGY AND GERIATRICS COLLABORATION TO IMPROVE HEARING CARE SERVICE UTILIZATION AMONG OLDER VETERANS

Lindsey Ulin¹; Hema Pingali¹; Andrea W. Schwartz^2,3; Michelle Martinchek²; Danielle L. Stiles²

¹Internal Medicine, Brigham and Women's Hospital, Boston, MA; ²VA Boston Healthcare System, Boston, MA; ³New England Geriatrics Research Education and Clinical Center, Boston, MA. (Control ID #3869246)

BACKGROUND: Hearing loss is associated with increased mortality, a higher risk of dementia and depression, and worse quality of life in older adults. Hearing loss is prevalent among older veterans but is undertreated. The Veterans Affairs (VA) health care system provides universal access to audiology care but many veterans may not be accessing benefits. We report lessons learned from a quality improvement initiative to increase the use of audiology services by veterans in a Geriatrics clinic.

METHODS: Geriatrics schedules were reviewed weekly by an audiology team to identify and electronically communicate to Geriatrics providers the audiology needs of veterans with upcoming appointments. Geriatrics providers could then discuss hearing care needs during the visit and place appropriate referrals including audiology and/or ear cleaning, if indicated. We reviewed 50 charts randomly selected via convenience samples from 2017-2018 to determine the impact of the audiology and geriatrics partnership on veterans' access to appropriate audiology care.

RESULTS: The audiology review of the 50 charts sampled revealed that 18 patients never had audiology testing (36%), and 14 patients had hearing aids older than 2 years and were due for updates (28%). Of the 50 patients reviewed, 10 (20%) no showed their Geriatrics appointment. Of the 40 who presented to Geriatrics, 8 received referrals to audiology (20%) and 3 received referrals for ear cleaning (8%). Of the 8 veterans referred for audiology, 2 no showed (25%), 1 did not qualify for hearing aids (13%), 1 declined hearing aids (13%), and 4 received new hearing aid prescriptions (50%). Of the veterans referred for ear cleaning, 1 no showed (33%). Of the 50 veterans, 39 had a diagnosis of dementia on their problem list (78%), 25 had a diagnosis of hearing impairment (50%), and 30 died during the follow-up period to 2022 (60%).

CONCLUSIONS: Hearing loss was highly prevalent in a sample of veterans in a Geriatrics clinic, most of whom had dementia. An Audiology-Geriatrics partnership led to provision of new hearing aids or ear cleaning in 5 veterans of the 50 charts reviewed (10%). However, audiology referrals were not consistently placed when indicated by audiology review, in some cases because of patients declining. There was also a 20% or greater no show rate to geriatrics and audiology appointments. This review highlights possible barriers to receiving audiology care among older veterans and suggests that even if care is free and accessible, a dedicated review to identify high-risk patients may be insufficient to ensure care is received.

High rates of dementia among the clinic population may contribute to high no show rates, as well as the need to address multimorbidity taking precedence over hearing impairment. Given hearing impairment’s impact on memory, mood, mobility, and more, and as hearing aids have recently been approved to be available over the counter, the need to characterize and address the barriers to hearing care is all the more urgent.

AN RCT OF GAMIFICATION WITH SOCIAL SUPPORT TO INCREASE PHYSICAL ACTIVITY IN OLDER ADULTS AT RISK FOR ALZHEIMER'S: THE STEP 4 LIFE TRIAL

Scott R. Greysen¹; Gavin Turner²; Ai Leen Oon¹; Kristin Harkins³; Jason H. Karlawish³

¹DGIM, University of Pennsylvania, Philadelphia, PA; ²University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ³Division of Geriatrics, University of Pennsylvania, Philadelphia, PA. (Control ID #3872361)

BACKGROUND: Higher levels of physical activity are associated with reduced risk of cognitive and functional decline in Alzheimer’s Dementia and Related Dementias (ADRD). Remote gamification interventions informed by behavioral science using participants’ social networks are effective in populations at risk for cardiovascular disease but have not been studied in populations at risk for ADRD. Innovative and scalable approaches that achieve sustained increases in physical activity have great potential to impact the risk of developing ADRD.

METHODS: 18-week RCT with 12-week intervention and 6-week follow-up using gamification with social incentives among participants already enrolled in a national cohort of older adults (age 55-75) at risk of developing ADRD. All participants (n=90) were supplied with a Fitbit device to track daily steps. The control group (n=49) set daily step goals and received feedback from the device but no other interventions. The intervention group (n=41) entered a 12-week game designed using insights from behavioral economics that assigned points and levels for achieving daily step goals and was reinforced by a support partner (family/peer) who received information on the participant’s progress and agreed to provide support and encouragement. During the follow-up period, daily steps were monitored for both groups. The primary outcome was mean change in daily step count from baseline through the 12-week intervention, and the secondary outcome was sustained change in step counts over the follow-up period. Exploratory outcomes included a-priori subgroup analyses of participants with higher social support and feasibility of collecting remote functional and cognitive performance measured by Timed Up-and-Go (TUG) and MOCA exams

RESULTS: We recruited 90 participants: mean age 70.4 (SD 2.9), 78% female, 71% married, 81% retired, 29% income >100k, 69% prior wearable use. Participants in the intervention arm had significantly greater change in mean daily step count (adjusted difference, 1792 (95% CI: 1238, 2346; p<.0001), which was sustained in the follow-up period (adjusted difference, 1216 (95% CI: 440, 1993); p=0.002). Mean daily step counts for Participants with higher social support were not significantly different than other participants. Follow-up TUG and MOCA scores were not significantly different than baseline scores for either arm.

CONCLUSIONS: A 12-week remote intervention using gamification and social incentives in a cohort of older adults at risk for ADRD was effective in promoting higher physical activity that was sustained during follow-up. Remote, repeated assessments of functional and cognitive measures were feasible but did not change significantly for control or intervention participants over 18 weeks. Future studies with longer intervention and follow-up should explore impact of sustained physical activity on prevention and progression of functional and cognitive changes associated with ADRD.

ASSOCIATION BETWEEN PHYSICIAN AGE AND PATTERNS OF END-OF-LIFE CARE DELIVERED TO PERSONS WITH DEMENTIA

Jessica J. Zhang¹; Hiroshi Gotanda²; David B. Reuben³; Anne Walling^4,5; Haiyong Xu⁴; Yusuke Tsugawa^4,6

¹Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los

Angeles, CA; ²Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; ³Multicampus Program in Geriatric Medicine and Gerontology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁴Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁵Greater Los Angeles Veterans Affairs Healthcare System, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁶Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA. (Control ID #3874674)

BACKGROUND: Physician age may be associated with patterns of end-of-life (EOL) care delivered to persons with dementia. Given the projected increase in persons with dementia and increasing concerns about the quality of EOL care received by persons with dementia, we determined whether patterns of EOL care differ by physician age.

METHODS: Using a nationally representative sample of Medicare fee-for-service beneficiaries aged 66 years and older with dementia who died in 2016-2019, we conducted a cross-sectional study examining the association between physician age and patterns of EOL care. We attributed beneficiaries to a physician who had the largest number of primary care visits during the last 6 months of life. Physician age was categorized as <40, 40-49, 50-59, or ≥60 years old. Our outcome measures included: (i) advance care planning (ACP) and palliative care (ACP, palliative care counseling, and hospice enrollment in the last 90 days of life), and (ii) high-intensity EOL care (emergency department visits, hospital admissions, intensive care unit [ICU] admissions, mechanical ventilation, cardiopulmonary resuscitation, or feeding tube placement in the last 30 days of life).

RESULTS: We included 287,514 beneficiaries with dementia who died in 2016-2019. Beneficiaries with dementia under the care of younger physicians had a higher proportion of ACP (P-for-trend <0.001 after accounting for multiple comparisons), palliative care counseling (P-for-trend <0.001), and hospice enrollment (P-for-trend<0.001) compared to those under the care of older physicians. Physician age was also associated with a lower proportion of emergency department visits (P-for-trend=0.005), hospital admissions (P-for- trend=0.002), mechanical ventilation (P-for-trend <0.001), or cardiopulmonary resuscitation (P-for- trend<0.001) in the last 30 days of life, although there was no evidence that ICU admissions or placement of feeding tubes in the last 30 days of life was associated with physician age.

CONCLUSIONS: We found that younger physician age was associated with more ACP and palliative care and less intensive EOL care for persons with dementia compared to older physician age.

ASSOCIATION BETWEEN PHYSICIANS’ GERIATRIC TRAINING AND PATTERNS OF END- OF-LIFE CARE DELIVERED TO PERSONS WITH DEMENTIA: A CROSS-SECTIONAL STUDY Jessica J. Zhang¹; Hiroshi Gotanda²; David B. Reuben³; Anne Walling^4,5; Haiyong Xu⁴; Yusuke Tsugawa^4,6

¹Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; ³Multicampus Program in Geriatric Medicine and Gerontology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁴Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁵Greater Los Angeles Veterans Affairs Healthcare System, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁶Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA. (Control ID #3874672)

BACKGROUND: Geriatric training is designed to prepare physicians to meet the complex needs of older adults, including persons with dementia at the last stages of their lives. Given the projected increase in persons with dementia and increasing concerns about the quality of end-of-life (EOL) care received by persons with dementia, we determined whether patterns of EOL care differ between physicians with versus without formal geriatric training.

METHODS: Using nationally representative data of Medicare fee-for-service beneficiaries with dementia who died in 2016-2018 (n=100,778), we conducted a cross-sectional study examining the association between geriatric training and patterns of EOL care among persons with dementia using a broad range of measures. We attributed beneficiaries to a physician who had the largest number of primary care visits during the last 6 months of life and determined whether the physician was trained in geriatrics. Our outcome measures included: (i) advance care planning (ACP) and palliative care (e.g., ACP, palliative care counseling, and hospice enrollment in the last 90 days of life), and (ii) high-intensity EOL care (e.g., emergency department visits, hospital admissions, intensive care unit [ICU] admissions, mechanical ventilation, cardiopulmonary resuscitation, or feeding tube placement in the last 30 days of life).

RESULTS: Beneficiaries with dementia under the care of physicians with geriatric training had a higher proportion of ACP (adjusted proportion, 15.5% vs. 13.0%; P=0.003 after accounting for multiple comparisons), palliative care counseling (22.7% vs. 20.7%; P=0.02), and hospice enrollment (64.5% vs. 59.9%; P<0.001). Geriatric training was also associated with a lower proportion of emergency department visits (54.2% vs. 58.1%; P<0.001), hospital admissions (49.1% vs. 52.3%; P<0.001), ICU admissions (24.8% vs. 26.8%; P=0.003), and use of mechanical ventilation (10.9% vs. 12.9%; P<0.001) in the last 30 days of life. There was no evidence that use of cardiopulmonary resuscitation or placement of feeding tubes differed between the two groups.

CONCLUSIONS: We found that persons with dementia cared for by physicians with geriatric training received more ACP and palliative care and less intensive EOL care. Our findings suggest that interventions for physicians without formal geriatric training who care for persons with dementia may be considered, if evidence emerges that short-duration training is effective in improving the quality of EOL care.

A TAILORED OUTREACH PROGRAM TO ENGAGE PATIENTS AND PHYSICIANS IN DEPRESCRIBING CHRONIC BENZODIAZEPINES IN PRIMARY CARE

Sul Gi Chae^1,3; Julia Lindenberg¹; Emma Lee¹; Kaden Shen²; Timothy Anderson¹

¹General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA; ²Northeastern University Bouve College of Health Sciences, Boston, MA; ³Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #3873927)

BACKGROUND: Benzodiazepines are commonly prescribed as chronic treatments for anxiety and insomnia despite little evidence of clinical benefit and strong evidence of increased risks for adverse drug effects. Using a population health conceptual framework, we sought to develop and evaluate a benzodiazepine deprescribing quality improvement program in a large US academic primary care clinic.

METHODS: Pharmacy data was used to develop a clinic registry of older adults prescribed chronic benzodiazepines and identify concurrent sedating medications. Outreach processes were designed to match other population health practices in the clinic. Primary care physicians (PCPs) received one email providing benzodiazepine tapering resources, offering a voluntary deprescribing training, and asking them to opt out patients not appropriate for outreach. Patients were mailed one letter including discussing benzodiazepine risks, patient-specific information regarding heightened risk, and advising them to discuss deprescribing with the clinic’s Safe Prescribing Team or their PCP. A pharmacist was available to coordinate tapering for all patients. The primary outcomes were the number of patients who discussed deprescribing and number with a benzodiazepine dose reduction at 90 days.

RESULTS: A total of 559 patients and 50 PCPs were included in the study. This registry consists of 328 female (58%), 462 (82%) white, 388 patients who are between 65-74 years old (69%) and older (31%). One PCP requested a deprescribing training, 4 PCPs (8%) opted all patients out of the program, and 21 PCP (42%) opted out some patients. In total, 133 patients (24%) were opted out. Of the remaining 426 patients, 38 (9%) patients contacted the team and received pharmacist-led education. Subsequently 15 (40%) of patients started a taper. At 90 days, 4 patients discontinued benzodiazepines, 2 patients have had 50% dose reduction, 2 patients have had a 25% dose reduction, 5 patients have had less than 25% dose reduction, and 2 patients returned to prior dose after trying taper. Retrospective chart review found that at the end of 90 days after the outreach, 110 patients (27%) had conversations about sleep, anxiety or benzodiazepine use with a clinician.

80 of those patients (73%) had the conversation with their PCP.

CONCLUSIONS: A one-time low-cost clinic-based education mailing on benzodiazepine risks led to deprescribing conversations for a minority of patients but when deprescribing conversations occurred, nearly half of patients started a benzodiazepine taper. Direct patient outreach resulted in greater engagement than PCP outreach. To make deprescribing a part of routine, primary care practice will require innovative population-health efforts to strengthen patient-engagement and team-based care.

BARRIERS ORGANIZATIONAL LEADERS FACE PREPAIRING TO IMPLEMENT GOALS OF CARE INITIATIVES IN PRIMARY CARE

Alexis Hunyh³; Matthew McCaa¹; Raziel Gamboa¹; Kieran Holzhaur⁴; Arpan Patel^4,7; Karl A. Lorenz^1,2; David Bekelman^5,6; Anne Walling^4,7; Karleen Giannitrapani^1,2

¹Center For Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA; ²Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA; ³Center for Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ⁴VA Greater Los Angeles Healthcare System, Los Angeles, CA; ⁵VA Eastern Colorado Health Care System, Aurora, CO; ⁶University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ⁷University of California Los Angeles, Los Angeles, CA. (Control ID #3875900)

BACKGROUND: Across VA nationally, most goals of care conversations (GoCCs) occur in the inpatient setting when patients are close to death; only 39% occur in the primary care. In advance of proactively facilitating GoCC uptake in a pragmatic trial to enhance implementation of the VA Life Sustaining treatment

(LST) decisions initiative, we aimed to identify current barriers primary care practices face implementing

GoCC for seriously ill patients.

METHODS: We conducted semi-structured interviews with 20 interdisciplinary organizational leaders (physicians, nurses, and social work) from three geographically disparate healthcare systems. We used the Consolidated Framework for Implementation Research (CFIR) to inform interview guide development. Our analytic approach relied on thematic analysis, leveraging CFIR in conjunction with team and role theories to inform our code schema.

RESULTS: We present 4 themes representing organizational leaders’ perspectives of barriers.

1) Providers say “why bother” to having GoCC when there are high competing demands in a PC visit with too little time to prioritize anything but immediate concerns and “people change their minds.”

2) The information documented in a LSTs note is not used by other providers to inform patient care choices: “they [Other provider] don't have time to read through all the notes, and if they're stable [when] admitted inpatient [we] will re ask those questions.”

3) Providers lack expertise in serious illness communication and lack clarity on how to coordinate sharing the tasks of completing GoCC, invoking the idea that various pieces of GOCC are better fulfilled by someone

else with either more expertise or more time.

4) Providers lack consensus on what a good quality GOCCs looks like, and challenge the notion that documentation in the LST note alone is enough to know that a quality conversation occurred. “We know when I've a good [life sustaining treatment] note…But I don't know if that is sufficient and if there's some other way to measure success….Something that's actionable that the team can go off.. You know what is a good [or] sufficient LST discussion look like?”

CONCLUSIONS: We identified key barriers for implementing GOCCs. We recently implemented a randomized controlled trial to test whether provider and patient facing strategies improve the frequency of documented GOCCs. Future work should also assess the quality of conversations documented.

CARE CASCADES FOLLOWING LOW-VALUE CERVICAL CANCER SCREENING IN VETERANS DUALLY ENROLLED IN THE VETERANS HEALTH ADMINISTRATION AND MEDICARE

Aimee N. Pickering^3,1; Xinhua Zhao¹; Florentina E. Sileanu¹; Elijah Lovelace¹; Liam Rose¹; Aaron Schwartz¹; Jennifer A. Hale¹; Loren J. Schleiden¹; Walid F. Gellad^1,3; Michael J. Fine^1,3; Carolyn T. Thorpe²; Thomas R. Radomski^3,1

¹Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; ²School of Pharmacy, University of North Carolina System, Chapel Hill, NC; ³Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #3875823)

BACKGROUND: Although low-value cervical cancer screening occurs infrequently within VA, it may lead to unnecessary services, defined as a care cascade. Our objective was to compare the rates and costs of care cascade services in Veterans dually enrolled in VA and Medicare who received low-value cervical cancer screening with those who did not.

METHODS: We constructed a cohort of Veterans dually enrolled in VA and Medicare for whom cervical cancer screening would be considered low-value: females aged ≥65 without risk factors for cervical cancer (e.g., abnormal Papanicolaou (pap) smear). Our exposure group was Veterans who underwent cervical cancer screening in VA or Medicare during the first half of FY18; our control group was Veterans who had a primary care or gynecology visit but no cervical cancer screening during this time. Six months following the initial test or outpatient visit, we identified the following cascade services within VA and Medicare: 1) subsequent cervical cancer screening; 2) outpatient gynecology visit or non-gynecology visit for an abnormal pap smear; 3) cervical procedures (e.g., colposcopy; diagnostic excisional and ablative procedures); and 4) hysterectomy. We compared the rates and costs of cascade services in the exposure and control groups, adjusting for patient and facility-level covariates using negative binomial or linear regression models with inverse probability of treatment weighting. We also determined the location of downstream care.

RESULTS: Among 19,815 Veterans in the cohort, the mean age was 74.7 (8.4); 80.1% were non-Hispanic white. Overall, 468 (2.4%) underwent low-value cervical cancer screening (260 in VA; 208 in Medicare). The exposure group received 44.6 (95% CI 26.1-63.2) additional cascade services per 100 Veterans compared to controls. The difference in rates of cascade services was highest for related outpatient visits (40.1 per 100 Veterans) and repeat screening (2.8 per 100 Veterans) while other services occurred at low rates. The exposure group incurred an additional $34.2 (95% CI 14.4-54.2) per Veteran due to cascade services. Among those who had cervical cancer screening within VA, the rate of cascade services was 35.8 per 100 Veterans in VA and 2.7 per 100 Veterans in Medicare. For those who had screening within Medicare, the rate of cascade services was 5.8 per 100 Veterans in VA and 38.0 per 100 Veterans in Medicare.

CONCLUSIONS: Care cascade services were common after low-value cervical cancer screening in Veterans, and both the initial screening and subsequent cascade services occurred within and outside of VA. These findings demonstrate the importance of identifying low-value cascade services and measuring health service utilization occurring in healthcare systems outside of VA to fully capture the burden of low-value cervical cancer screening on Veterans.

CHALLENGES EXPERIENCED BY FAMILY MEMBERS OF HOSPITALIZED OLDER ADULTS WITH DEMENTIA WHEN MAKING “IN-THE-MOMENT” DECISIONS REGARDING INTENSITY OF CARE

Rashmi K. Sharma¹; Janaki M. Torrence¹; Elizabeth W. Dzeng²; J R. Curtis³; Ruth A. Engelberg⁴

¹Medicine, University of Washington, Seattle, WA; ²Medicine, University of California San Francisco, San Francisco, CA; ³Medicine, University of Washington, Seattle, WA; ⁴Medicine, University of Washington, Seattle, WA. (Control ID #3872293)

BACKGROUND: Family members of hospitalized older adults with dementia often face complex, high- stakes, “in-the-moment” decisions about ICU care or other high intensity interventions, and experience significant psychological distress as a result. Prior studies have focused on the ethical, intrapersonal, and communication-related challenges specific to surrogate decision making, but few have explored challenges that may be specific to families of patients with dementia. We sought to understand specific challenges faced by family members of hospitalized older adults with dementia as they navigated decisions about intensity of care.

METHODS: This was a qualitative study of family members of hospitalized older adults with dementia between February 2020 and December 2020. Hospitalized patients > 50 years old with an ICD diagnosis of dementia were identified from the EHR along with their family member. Family members were then approached for a semi-structured phone interview about their experiences with decision making regarding intensity of care. Interviews were audiotaped, transcribed, and coded by seven investigators using an inductive and constant comparative approach.

RESULTS: Thirty-one interviews were conducted of which 30 comprised the analytic sample. Mean participant age was 63 years and 66.7% were female. Seventy-three percent of participants identified as white, 17% as Black, 7% as Asian, and 3% as other race. The majority of participants were either an adult child (53.3%) or spouse (26.7%). Three key themes emerged regarding specific decision-making challenges

in the presence of dementia: 1) discordance between family and clinician perceptions of the patient’s baseline function and quality of life which were central factors in the way both parties constructed decision preferences (family) and recommendations (clinicians); 2) family perceptions that clinicians attributed acute changes to dementia and were reluctant to present certain important decision options (e.g., pursuing diagnostic interventions); and 3) family’s intrapersonal tensions between wanting more comfort-focused care within the context of dementia progression and maintaining hope that their loved one may still experience an acceptable quality of life with additional interventions.

CONCLUSIONS: Family members of hospitalized patients with dementia faced several dementia-specific challenges when making in-the-moment decisions about intensity of care. Interventions that account for these dementia-specific decision-making challenges are needed to better support family members of older adults with dementia as they navigate high-stakes, “in-the-moment” decisions.

COMMUNICATION PARTICIPATION IN PRIMARY CARE VISITS: THE PHYSICIAN, PATIENT, CAREGIVER TRIAD

Leah S. Karliner¹; Jennifer Livaudais-Toman²; Celia P. Kaplan³; Lisa C. Diamond⁴; Debra L. Roter⁵

¹Medicine, UCSF, San Francisco, CA; ²Division of General Internal Medicine, University of California, San Francisco, Greenwich, CT; ³Medicine, University of California San Francisco, San Francisco, CA; ⁴Immigrant Health and Cancer Disparities Service, Memorial Sloan-Kettering Cancer Center, New York, NY; ⁵Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. (Control ID #3873987)

BACKGROUND: Family caregivers often accompany older patients to medical visits. To optimize care, it is important to understand communication during these triadic visits. In this study we examine the presence of a caregiver on the amount of biomedical and psychosocial-emotional talk during primary care visits.

METHODS: We leveraged a dataset of audiotaped primary care visits with 189 older ethnically Chinese and Latinx patients. We classified each visit according to a family caregiver’s presence (‘accompanied’) or absence (‘unaccompanied’). We used the Roter Interaction Analysis System to analyze the audiotapes, identifying and comparing frequency of biomedical and psychosocial-emotional communication elements between accompanied and unaccompanied visits. For accompanied visits, we first excluded and then included caregiver talk.

RESULTS: Of the 189 visits, 60 (32%) were accompanied. Patients who were accompanied were on average older (77.5 vs. 67.2; p<.001), and more often had limited English proficiency (87% vs 62%; p<.001). Half (n=96) of all visits were fully, and 15 partially, language concordant in Chinese, English or Spanish; 66 visits had a professional interpreter present. For 11 (18%) accompanied visits, caregivers acted as interpreters. Doctors did not vary the frequency of biomedical or psychosocial-emotional talk between accompanied and unaccompanied visits. Patients in accompanied visits had less of every talk element compared with patients in unaccompanied visits, including medical information, medical questions, psychosocial and lifestyle information, psychosocial questions, and emotional talk (all p <.02). When adding caregiver talk, there was no longer a difference between accompanied and unaccompanied visits for any element except medical questions which was higher for accompanied visits (p=.02).

CONCLUSIONS: Having a caregiver present did not change measured physician communication behavior.

Caregivers were active participants for both biomedical and psychosocial-emotional communication. It remains unclear the best ways to elicit patients’ communication preferences and to balance communication with patients and their caregivers during visits.

DETECTING BEHAVIORAL CHANGE FACTORS AMONG HEALTHCARE PROVIDERS REGARDING GOALS OF CARE COMMUNICATION

Arpan Patel^1,2; Sylvia H. Paz³; Marian L. Katz⁴; Alicia Bergman⁵; Vanessa Ryan¹; Karen L. Spritzer³; David Ganz²; Neil Wenger⁶; Anne Walling^7,2; Ron D. Hays³

¹Digestive Diseases, University of California Los Angeles, Los Angeles, CA; ²VA Greater Los Angeles Healthcare System, Los Angeles, CA; ³General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA; ⁴Research, Veterans Health Administration, North Hills, CA; ⁵CSHIIP, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ⁶Medicine, University of California, Los Angeles, Los Angeles, CA; ⁷Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #3875856)

BACKGROUND: Discussions between patients with serious illness, their families, and healthcare providers regarding goals of care (GOC) may lead to improved quality of care and outcomes, but such discussions are rarely performed. Efforts to improve GOC communication have used formal communication skills training, with the goal of increasing the comfort of healthcare providers to perform such conversations. However, training may have other effects. To help guide improvement efforts, we aimed to identify other correlates of behavior change.

METHODS: We developed an instrument to detect correlates of behavior change for GOC communication (BCGC) by adapting the Determinants of Implementation Behavior Questionnaire. We performed cognitive interviews with 23 healthcare providers across 2 institutions (West Los Angeles VA Medical Center, UCLA Medical Center) representing different disciplines (74% physicians, 17% advance practice practitioners, and 9% social workers) and specialties (52% medical and surgical specialties [non-palliative care], 39% internal medicine, 9% palliative care). Rapid qualitative analysis methods were used to iteratively adjust phrasing and content of items. We administered the modified instrument cross-sectionally (N=100) to providers across both institutions and then in a pre-post format (N=25) to providers participating in formal GOC communication skills training programs. We estimated item-scale correlations, confirmatory factor analysis, responsiveness to change, and short-form analysis.

RESULTS: The final BCGC instrument contained 34 questions and represented 9 behavior change domains (Knowledge, Skills, Beliefs about Capabilities; Organizational Context; Provider’s Expectations; Role and Identity; Beliefs about Consequences; Attention; Intention; Priority; and Perceptions about Patient Engagement). Item-scale correlations (α>0.46) and confirmatory factor analyses (Comparative Fit Index=0.94, Root Mean Square Error of Approximation=0.078) were acceptable. Five domains (Knowledge, Skills, Beliefs about Capabilities; Organizational Context; Provider’s Expectations; Priority; and Perceptions about Patient Engagement) changed significantly after a single GOC communication skills training (Effect Sizes (Cohen’s d) ranging from 0.500-1.292, p<0.05). Short-form versions of 2 domains (Knowledge, Skills, Beliefs about Capabilities [11 items to 3 items]; Organizational Context [8 items to 3 items]) also changed significantly after training (Effect Sizes 1.220 and 0.597, respectively, p<0.05).

CONCLUSIONS: The BCGC survey instrument had favorable psychometric properties but should be further evaluated in a larger sample of healthcare providers. We demonstrated that some behavior change domains (but not all) changed after a single formal GOC communication skills training. Using these domains as intermediate measures can be helpful in guiding future improvement efforts aimed at addressing provider and organizational barriers to GOC communication.

DEVELOPMENT AND PILOT TESTING OF AN ARTIFICIAL INTELLIGENCE-BASED FAMILY CAREGIVER NEGOTIATION TRAINING PROGRAM: NEGOTIAGE

Alaine Murawski¹; Vanessa Ramirez-Zohfeld¹; Allison Schierer¹; Johnathan Mell²; Jeanne Brett³; Lee Lindquist¹

¹Medicine - Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; ²University of Central Florida, Orlando, FL; ³Northwestern University, Evanston, IL. (Control ID #3874370)

BACKGROUND: Family caregivers of older people with Alzheimer’s disease (PWD) often experience conflicts as they navigate the healthcare system for their loved ones (e.g., determining treatment necessity, billing errors, home health extensions). With these conflicts, family caregivers experience unnecessary frustration, anxiety, and stress. Many family caregivers lack the negotiation training and dispute resolution skills to resolve these conflicts. We sought to develop and pilot test an artificial-intelligence negotiation training program, NegotiAge, for family caregivers.

METHODS: With NIH funding [R01AG068421], we convened a group of national negotiation experts, geriatrician, social worker, and community-based family caregivers (N=9; Illinois, Florida, New York, California). Content matter experts created short informational videos/didactics to teach negotiation skills. Family caregivers generated dialogue surrounding caregiver conflicts. Computer science experts used the dialogue with the Interactive Arbitration Guide Online (IAGO) platform to develop avatar-based agents (e.g. sibling, older adult, physician) for caregivers to practice negotiating with on their own time. We then pilot tested the NegotiAge training program with family caregivers to assess feasibility and usability.

RESULTS: NegotiAge.com was developed to facilitate negotiation skills training for family caregivers of PWD. Family caregivers progress through didactic material, then receive scenarios to negotiate (e.g. physician recommends gastric tube in PWD, sibling disagrees with home support, PWD refusing support). Caregivers negotiate in real-time with avatars who are designed to act like humans, including emotional tactics and irrational behaviors. Caregivers send/receive offers, using tactics until either mutual agreement or time expires. Immediate feedback is generated from the response chosen/tactics used to assist with the negotiation skills training. Pilot testing was conducted with family caregivers of PWD (n=15). and showed that the negotiation and conflict resolution training program was feasible and usable for family caregivers. Subjects found the program to be highly satisfying with real-world applicability.

CONCLUSIONS: NegotiAge is an Artificial Intelligence-based online Caregiver Negotiation Program, that is usable and feasible for family caregivers to become familiar with navigating conflicts commonly seen in caring for older adults with dementia. The overarching goal is to empower family caregivers to better communicate when advocating for their loved ones and make conflict resolution easier. Further Multiphase Optimization Strategy (MOST) randomized testing will be conducted next to optimize this program. Ultimately, we hope to improve the quality of care of older adults while decreasing the stress, burden, and frustration experienced by their family caregivers.

DEVELOPMENT OF A GERIATRIC MODULE FOR A SOCIAL DETERMINANTS OF HEALTH SCREENING TOOL

Naila Edwards^1,6; Meaghan Kennedy^2,3; Alicia Cohen^4,5; Andrea W. Schwartz^7,8; MICHELLE MARTINCHEK¹

¹VA New England Geriatric Research Education and Clinical Center, Boston, MA; ²VA Bedford Healthcare System, Bedford, MA; ³Department of Family Medicine, Boston University School of Medicine, Boston, MA; ⁴VA Providence Healthcare System Center of Innovation in Long Term Services and Supports, Providence, RI; ⁵Department of Family Medicine, Brown University Warren Alpert Medical School, Providence, RI; ⁶Department of Geriatrics, Harvard Medical School, Boston, MA; ⁷Geriatrics, VA New England Geriatric Research Education and Clinical Center, Boston, MA; ⁸Medicine, Harvard Medical School, Boston, MA. (Control ID #3876415)

BACKGROUND: Social determinants of health are increasingly being addressed in healthcare settings through routine screening for health-related social needs (e.g., food insecurity). Older adults face a unique set of challenges that may not be included on existing screening tools designed for general patient populations. The Assessing Circumstances and Offering Resources for Needs (ACORN) tool is a Veterans Affairs (VA) social needs screening tool that has been successfully implemented in VA clinical settings. We sought to develop a geriatric module to be used in conjunction with the core ACORN screener to assess for unmet social needs in older veterans in a VA outpatient geriatrics clinic.

METHODS: We conducted a literature review of social needs domains affecting health outcomes in older adults. From this literature review, we identified 17 domains that were applicable to this population. We then compared domains to the current geriatric clinic template and identified 14 domains that were prominent in the literature, but not being addressed. Then we compared these 14 domains to the original ACORN screener and found 3 relevant domains that were not being screened for by either ACORN or geriatric clinic template. We interviewed key informants and subject matter experts including clinicians, researchers and teams experienced in implementing social needs screening in geriatrics settings. Key informants also reviewed the current ACORN screener along with the current geriatric clinic template. Once a consensus was reached regarding the domains to be used in the ACORN-Geri screener, established screening instruments for each domain were reviewed.

RESULTS: Feedback from key informants was discussed amongst an interprofessional team. Domains selected for inclusion in the ACORN-Geri module were: 1) consistently identified as important, and 2) not routinely assessed in the geriatric clinic. The domains chosen were elder abuse/mistreatment, medication affordability, and caregiver burden. The module was then created by adapting established screening tools and developing new questions in these domains. We incorporated screening processes used in other VA clinic settings during workflow development to optimize implementation and leverage prior lessons learned.

CONCLUSIONS: Standard social determinants of health screening tools may not assess certain domains that are unique to older adults. There is an opportunity to identify vulnerable older adults, in particular older veterans, and link them with resources available within or outside the VA. Through an iterative, interprofessional process, we identified 3 domains for inclusion in a geriatric add-on module for an existing VA social needs screener. The new module will be piloted as part of a quality improvement project in a geriatric consultative clinic. The screener is intended for use in VA community-based settings with substantial older adult populations.

DOES A COLLABORATIVE PALLIATIVE CARE INTERVENTION INFLUENCE ADVANCED CARE PLANNING IN PATIENTS WITH HEART AND LUNG DISEASES?: SECONDARY OUTCOMES FROM A RANDOMIZED CLINICAL TRIAL

Allison V. Lange¹; William Feser³; Anna E. Baron³; David Bekelman^2,4

¹Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²Medicine, University of Colorado, Denver, CO; ³Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO; ⁴Rocky Mountain Regional Veterans Affairs Medical Center, Denver-Seattle Center of Innovation, Aurora, CO. (Control ID #3874456)

BACKGROUND: Chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD), and interstitial lung disease (ILD) are leading causes of hospitalization and mortality. However, few patients with these illnesses engage in goals of care conversations (GoCC). We determined the effect of a collaborative palliative care intervention for patients with CHF, COPD, and ILD on readiness to engage in advance care planning (ACP), advanced directive (AD) documentation and GoCC.

METHODS: The Advancing Symptom Alleviation with Palliative Treatment (ADAPT) study was a randomized clinical trial of a collaborative palliative care intervention. The study enrolled patients with COPD, ILD, or CHF from 2 VA health systems who were at high risk for hospitalization and death and who reported poor quality of life. As part of the intervention, a nurse and social worker had a GoCC visit with each patient. GoCC were documented in the electronic medical record. Patients were encouraged to complete an AD. At baseline and 6 months, GoCC, AD, and readiness to engage in advance care planning (ACP Engagement Survey-4, example question, “How ready are you to decide who you want your medical decision maker to be?” 1=I have never thought about it, 2=I have thought about it, but I am not ready to do it; 3=I am thinking about doing it in the next 6 months; 4=I am definitely planning to do it in the next 30 days; 5=I have already done it) were measured.

RESULTS: Of 306 randomized patients (154 intervention, 152 usual care), 57.8% had COPD, 21.9% HF, 16% both COPD/HF, 4.2% ILD. Mean age was 68.9 years, and patients were primarily white (80.1%) and male (90.2%). At baseline, patients in the intervention and control groups had similar rates of readiness to engage in ACP, AD completion, and GoCC. At 6 months, mean readiness to engage in ACP improved by 0.52 in the intervention group and 0.03 in the control group (difference, 0.49; effect size, 0.43; p=0.0005). Documented GoCC increased in the intervention group (intervention at baseline: 56/154 (36%), 6 months: 131/145 (90%), control baseline: 50/152 (39%), 6 months: 59/145 (34%), effect size 1.40; p<0.0001), while percent of patients who had a documented AD did not change (intervention at baseline: 56/154 (36%), 6 months: 58/145 (40%), control at baseline: 61/152 (40%), at 6 months: 62/145 (43%), p=0.64)

CONCLUSIONS: Nurses and social workers conducting GoCC as a part of a palliative care intervention improved readiness to engage in ACP and documented goals of care conversations. Future work should investigate GoCC quality and how GoCC contribute to person-centered care.

EDUCATING AGE-FRIENDLY RESEARCHERS

Bryanna De Lima¹; Allison Lindauer²; Elizabeth Eckstrom^1,3

¹Medicine, Oregon Health & Science University School of Medicine, Portland, OR; ²Layton Aging and Alzheimer's Disease Center, Oregon Health & Science University, Portland, OR; ³Oregon Health & Science University Oregon Clinical & Translational Research Institute, Portland, OR. (Control ID #3868155)

BACKGROUND: Older adults have a high disease burden but are often underrepresented in research studies due to recruitment and retention obstacles. Researchers with geriatric expertise have identified potential solutions to these barriers but these practices have yet to be disseminated to the general research community. Our team created an interactive webinar series for researchers to share practical tips and tools to increase inclusion of older adults in research.

METHODS: Forty researchers (e.g., research assistants, data managers, project coordinators, co- investigators) participated in a 6-session webinar series from October to November 2022. Sessions comprised of 20-30 minute didactics and 30-40 minute group discussions. Participants completed pre- and post-program surveys. Responses were analyzed to determine changes in confidence levels and to understand how participants rated the webinar series.

RESULTS: Thirty-nine participants completed both pre- and post-program surveys. Self-reported confidence levels improved across all categories (see Table). On a scale of 1-10, the average rating was 8.2 for the helpfulness of the series, 8.6 for the likeliness of utilizing what they learned, and 8.8 for the likeliness to recommend the webinar to others. Participants’ comments included: “The main takeaway I’ve gained from this series is how I can better communicate and facilitate older adults in research”; “small actions on the part of the research team can have a big impact on older adults’ comfort and willingness to participate in research”; “the real-world examples of what has occurred for others and also what they learned from the experience, and even the real-time ideas other teams had and shared were really helpful and inspiring.” The major critique received was to include more information on industry-sponsored clinical trials.

CONCLUSIONS: Participants positively responded to our Age-Friendly Research webinar series with reported improvements in confidence and knowledge. Adaptations to the series should incorporate suggestions for industry-sponsored trials.

ENCOURAGING SERIOUS ILLNESS CONVERSATIONS IN THE GENERAL MEDICINE INPATIENT SETTING

Myrna K. Serna¹; Cathy Yoon²; Julie Fiskio²; Joshua Lakin³; Anuj Dalal²; Jeffrey L. Schnipper¹

¹Internal Medicine, The University of Texas Medical Branch at Galveston Department of Internal Medicine, Galveston, TX; ²Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA; ³Psyschosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA. (Control ID #3872443)

BACKGROUND: Despite benefits of early Serious Illness Conversations (SICs), including increased satisfaction and earlier hospice referral, rates of SICs remain low. The primary aim of this study is to assess if standardized documentation of SICs increase following implementation of interventions encouraging providers to have more of these conversations in the inpatient setting.

METHODS: In this interrupted time series analysis, encounters ≥18 years old with an Epic (Verona, WI) Readmission Risk Score (RRS) of >28% admitted to a general medicine service at an academic medical center from January 2019 to December 2020 (pre-implementation), January 2021 (wash-in) or February 2021 to October 2021 (post-implementation) were included. The Expert Recommendations for Implementing Change (ERIC) framework guided development of interventions to encourage SICs and standardized documentation within a structured electronic health record module, which complemented pre-existing faculty training in SICs. A multivariable segmented logistic regression model was used to evaluate the immediate effect of the interventions (y-intercept change, “change in step”) and the difference in temporal trends (change in slope) of the odds of standardized documentation of an SIC per month. The model was adjusted for patient hospitalizations in the year prior to index admission, Elixhauser/Van Walraven comorbidity score, and COVID-19 inpatient census on day of patient admission.

RESULTS: Major interventions included stakeholder engagement to identify barriers and facilitators of implementation (using the Consolidated Framework for Implementation Research (CFIR)), weekly emails sent to providers with admitted patients who may benefit from an SIC, encouraging use of a Quality and Safety Dashboard to facilitate identification of patients with elevated RRS and SIC needs, identification of clinical champions, and educational sessions of inpatient teams, among others. An interrupted time series model did not show a change in y-intercept (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.18-1.89) but did show a statistically significant increase in the temporal trend (OR 1.20, 95% CI 1.00-1.43).

CONCLUSIONS: Implementation of context-specific interventions guided by the ERIC framework resulted in increased improvement over time in standardized documentation of SICs for encounters with elevated comorbidity burden. Continued assessment of barriers and facilitators to conducting these conversations and refinement or use of additional interventions is needed to support clinicians in conducting these conversations and providing patient-centered advance care planning.

ENHANCING COMMUNITY-DWELLING OLDER ADULTS’ SELF-CONFIDENCE TO MANAGE THEIR HEALTH AND WELL-BEING UTILIZING THE 4MS MODEL

Atreya Mishra¹; Claire T. Larkin¹; Vallari Shah²; Valerie Gruss³; Michael Koronkowski²; Memoona Hasnain¹

¹Medicine, University of Illinois Chicago College of Medicine, Chicago, IL; ²Pharmacy, University of Illinois Chicago, Chicago, IL; ³Nursing, University of Illinois Chicago, Chicago, IL. (Control ID #3875197)

BACKGROUND: The older adult population faces significant health challenges in managing chronic diseases, behavioral health, mobility, medication usage, and health literacy. To address this problem, we designed an educational workshop using the Institue of Health Improvements’s Age-Friendly 4Ms framework for high-quality care in a community-based participatory research (CBPR) partnership with the Pat Crowley House in Chicago, IL. Our objective was to explore whether education on the Age-Friendly 4Ms improved older adults’ self-confidence in managing their health and well-being.

METHODS:

A one day educational session was conducted educating the residents on each of the 4Ms: “What Matters”, “Medication”, “Mentation”, and “Mobility”. A total of 6 residents participated in the session. The effectiveness of the session was assessed using an identical pre-and-post survey identifying participants’ confidence in managing various aspects of their health related to the 4Ms. Ordinal data was collected from the surveys.

RESULTS: Participants were engaged throughout the workshop and had 100% participation in the pre- and post-surveys. Pre-post test analysis showed a positive trend towards increased self-confidence in talking with healthcare providers, managing medications, staying active, and understanding age-related cognitive changes.

CONCLUSIONS: Overall, the 4Ms model provided a valuable tool for addressing the needs of the residents at the Pat Crowley House. This community-based research project illustrates how the 4Ms model can be adapted into an interactive educational workshop for older adults. Education on 4Ms allows for them to have better conversations with healthcare providers and to increase their knowledge regarding challenges they commonly face. Our research was limited by a small sample size. There is a need for future research to study the impact of this intervention on a larger sample size and assess its long-term health outcomes. We believe that such an approach can be invaluable in improving the confidence of this vulnerable population in managing their healthcare.

EQUIPPING RESIDENTS FOR END-OF-LIFE CONVERSATIONS IN PRIMARY CARE

Brooke Wagen, Simisola Kuye, Sarah S. Mills, Rajvi Patel, Jaya Vasudevan, Heather L. Herrington, Asma Nuri, Michael Pignone, Robin Reister

Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #3873177)

BACKGROUND: Medical education programs largely lack formal teaching around end-of-life (EOL) care, despite the acknowledged need for physicians to be trained with these skills. Although there is general agreement about the importance of EOL care discussions, residency leaders highlight time constraints for teaching as a major limiting factor. We sought to develop and test an efficient outpatient educational intervention for residents in EOL care planning as part of a larger QI program.

METHODS: Our intervention took place within the Central Texas Veterans Affairs internal medicine resident clinic during the 2021-22 academic year. Curriculum was designed by resident team leaders in collaboration with palliative care faculty. Teaching was delivered over two one-hour lunch sessions – one didactic and one practice-based. Educational aims for the first session were the importance of EOL

planning in primary care (instead of in emergency settings), criteria to select appropriate patients for EOL planning visits, and differentiation of documentation for advanced care planning. We also taught the practical steps of conducting an EOL planning visit with attention to patient goals, preferences, and autonomy. The second session consisted of interactive practice for EOL planning conversations including real-time feedback from resident team leaders. Pre and post-teaching surveys were utilized to determine efficacy; all residents completed a pre-teaching survey before didactics, and took post- teaching surveys between two and four months after completion of both sessions.

RESULTS: Prior to our intervention, 41% of residents had completed an EOL planning visit and 27% had received formal palliative care education. Ninety-five percent of residents expressed desire for more teaching about how to incorporate goals of care and end of life discussions into primary care visits. By post-intervention, 68% had completed a visit and 100% of residents had formal didactics in EOL planning. Resident ability to differentiate medical power of attorney (MPOA) and medical surrogate increased from 36% to 86% and ability to distinguish advanced directive (AD) and Out of Hospital Do Not Resuscitate (DNR) increased from 59% to 95%. Residents were also asked to evaluate comfort level with risk stratifying patients and with communicating about EOL issues on a five point Likert scale. Comfort with identifying appropriate patients increased from 2.82 to 4.00 and comfort with discussion increased from 2.86 to 4.09. Overall, 100% of residents found the curriculum useful in teaching the skills needed for EOL planning in primary care.

CONCLUSIONS: A focused intervention for teaching residents EOL planning in the context of primary care increased knowledge, skills, and resident comfort. Given the efficacy of a two-hour educational intervention, this teaching could be widely adopted with minimal curricular adaptation.

EXAMINING EMERGENCY DEPARTMENT LENGTH OF STAY AMONG PERSONS LIVING WITH DEMENTIA

Stephanie Nothelle¹; Eric Slade³; Cynthia Boyd¹; Halima Amjad¹; Phillip Magidson¹; Tanya Chotrani⁴; Sarah Szanton³; Jennifer Wolff²

¹Medicine, Johns Hopkins University, Baltimore, MD; ²Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; ³Johns Hopkins University School of Nursing, Baltimore, MD; ⁴Boston Strategic Partners Inc, Boston, MA. (Control ID #3875083)

BACKGROUND: General internists are caring for a growing number of persons living with dementia (PLWD). PLWD have frequent emergency department (ED) visits. Given the challenges of caring for PLWD in the ED, PLWD may be at risk for prolonged ED length of stay (LOS), which is associated with risk of medication errors, delirium and mortality. We examined the differences in ED LOS by dementia status and factors associated with prolonged ED LOS for PLWD.

METHODS: We used data from the 2014-2018 Healthcare Cost and Utilization Project State ED Database, which includes ED visits that did not result in hospital admission statewide. We focus on data from 4 states: Arkansas (AR), Arizona (AZ), Florida (FL) and Massachusetts (MA) which report LOS. We limited analysis to visits by persons >64 years and matched visits by PLWD to visits by persons without dementia on age, race, sex, reason for visit and state. We define prolonged LOS as >90th percentile. We used mixed multilevel logistic regression to examine differences in risk of prolonged ED LOS for PLWD.

RESULTS: We included ED visits by 541,841 PLWD who were matched to 544,444 persons without dementia. Mean age was 76 years, 9% of visits were by persons of black race, 13% by persons of Hispanic ethnicity. PLWD had a mean LOS of 12.2 hours compared to 7.8 hours for persons without dementia. Twenty percent of PLWD had a prolonged ED LOS (i.e. LOS >22 hours), compared to 10% of persons without dementia. The risk of prolonged LOS varied by state (aORs: 6.9 FL, 2.9 AZ, 1.1 MA versus AR reference group, p<0.001), and was greater in EDs in metropolitan (aOR 1.8) and micropolitan (aOR 1.5) than rural areas (p<0.001), for persons from minority backgrounds (aORs: Hispanic 1.8, African American 1.5, Other 1.4 versus white non- Hispanic, p<0.001), persons with Medicaid and Medicare sources of payment (aORs: Medicaid 1.2, private 0.66 versus Medicare, p<0.001), persons with more chronic conditions (aOR: 1.3, p<0.001) and persons discharged to destinations other than home (e.g. nursing facility) (aOR 1.1, p<0.001).

CONCLUSIONS: In this study, PLWD had longer ED LOS and greater risk of prolonged ED LOS than matched older adults with similar reasons for ED visit. Personal and regional factors were associated with risk of prolonged ED LOS, highlighting a need for a deeper understanding of the causes of disparities in the prolonged ED LOS among PLWD.

HEALTH CARE CONTACT DAYS AS A PATIENT-CENTERED CARE MEASURE FOR MEDICARE BENEFICIARIES

Ishani Ganguli¹; E. John Orav¹; Emma D. Chant¹; Joyce Lii²; Ateev Mehrotra²; Christine S. Ritchie³

¹Division of General Medicine and Primary Care, Brigham and Women's Hospital, Chestnut Hill, MA; ²Harvard Medical School Department of Health Care Policy, Boston, MA; ³Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #3876498)

BACKGROUND: Days spent obtaining health care outside the home represent access to care but also substantial time, effort, and cost, especially for older adults and their caregivers. These “health care contact days” are a patient-centered measure that should inform care decisions yet has not been characterized. We assessed variation, content, and drivers of contact days among older adults in Traditional Medicare (TM).

METHODS: We studied 2019 claims data linked to nationally representative Medicare Current Beneficiary Survey data for community-dwelling adults who were ≥65-years-old, without end-stage renal disease, and continuously enrolled in TM for the year or until death. Outcomes were ambulatory contact days (days with a primary care or specialty care visit, test, imaging, procedure, or treatment) and total contact days (ambulatory days plus days in an emergency department, hospital, skilled nursing facility, or inpatient hospice facility).

We described variation in median contact days among hospital referral regions (HRRs) with ≥10 respondents. To identify patient factors (survey and claims-derived sociodemographic and clinical factors and care-seeking behaviors) associated with contact days, we used weighted multivariable Poisson regression with offset for days alive and adjustment for overdispersion and HRR random effects.

RESULTS: In 2019, 6385 older adults (weighted: 28,631,117) had a median[IQR] of 10.8[3.5, 22.3] (range 0-179) ambulatory contact days and 11.7[4.0-24.7] (range 0-256) total contact days. Across HRRs, there was also wide variation in ambulatory contact days (13.0[11.0-16.0] (range 4-23.5)) and total contact days (15.0[12.0-18.0] (range 6.0-32.0)).

Older adults spent most contact days on ambulatory care including primary care visits (1.4[0-3.8]), specialty care visits (2.3[0-5.9]), tests (3.1[0.55-6.8]), imaging (1.2[0-3.4]), procedures (0.43[0-2.6]), and treatments (0.89[0-4.8]). Adults spent 4.2[0.70-10.9] (39%) of their ambulatory contact days coming in for a test, imaging, procedure, or treatment alone; 46.5% of test days and 45.4% of imaging days were not on the same day as a visit.

In multivariable analysis, factors associated with more ambulatory contact days included younger age, female sex, white race, non-Hispanic ethnicity, urban residence, and number of chronic conditions. Those reporting they “worry about their health more than other people their age” or “go to the doctor…as soon as they start to feel bad” had more contact days; those who “will do just about anything to avoid going to the doctor” had fewer. There was no association with self-rated health.

CONCLUSIONS: Contact days were mostly ambulatory and showed wide variation associated not only with multimorbidity but also with age, sex, race, ethnicity, care-seeking behaviors, and geography. These results point to factors beyond clinical need that may drive over- and underuse of contact days and to the importance of right-sizing this patient-centered measure, eg, via telemedicine and care coordination.

IDENTIFYING HOSPITALIZED PATIENTS WHO MAY BENEFIT FROM SERIOUS ILLNESS CONVERSATIONS

Myrna K. Serna¹; Katrina Grace Sadang²; Hanna Vollbrecht³; Cathy Yoon⁴; Julie Fiskio⁴; Joshua Lakin⁵; Anuj Dalal⁴; Jeffrey L. Schnipper⁴

¹Internal Medicine, The University of Texas Medical Branch at Galveston Department of Internal Medicine, Galveston, TX; ²University of California San Francisco, San Francisco, CA; ³Internal Medicine, Brigham and Women's Hospital, Boston, MA; ⁴Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA; ⁵Psyschosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA. (Control ID #3876023)

BACKGROUND: Identifying patients who may benefit from a Serious Illness Conversation (SIC) in the hospital is an important step in increasing SIC timeliness. Epic’s Readmission Risk Score (RRS) is an electronic health record integrated composite score (0-100%) that predicts unplanned, 30-day readmission. The aim of this study is to assess if RRS combined with clinician response to the “surprise question” aids in identification of hospitalized patients who may benefit from SICs.

METHODS: In this retrospective study, patient encounters >18 y.o. with an admission to a general medicine service at an academic medical center from January 2019 to October 2021 and an RRS >28% were included and randomly selected electronically. Three clinicians (a hospitalist, a 3^rd year internal medicine resident and a 4^th year medical student) independently performed chart reviews to answer the following questions: 1) Would you be surprised if the patient died in the next 12 months? 2) Can the patient meaningfully participate in an SIC? 3) If the patient cannot participate in an SIC, why not? Each chart was reviewed by 2 clinicians with disagreements resolved by consensus-based discussion. Patient outcomes including standardized documentation of an SIC and post-discharge, 3-month mortality are reported, and Fisher Exact Test used to assess statistically significant differences.

RESULTS: A total of 202 patient encounter charts were reviewed. Clinicians felt they would not be surprised if 156 patients (77%) died in the next 12 months (i.e., answered “no” to the surprise question). Of these patients, 119 (59%) would be able to meaningfully participate in an SIC. Primary reasons for inability to participate included encephalopathy and dementia. Patients where clinicians answered “no” to the surprise question were more likely to have a documented SIC (9% vs 0%, p = 0.04), palliative care consultation (23% vs 2%, p < 0.01), change in code status from full to do not resuscitate/ do not intubate (17% vs 0%, p < 0.01), and post-discharge, 3-month mortality (8% vs 0%, p = 0.04) compared to patients where clinicians answered “yes” to the surprise question.

CONCLUSIONS: In a medical record review of patients with an RRS > 28%, clinicians felt they would not be surprised if 77% of patients died in the next 12 months, and these patients were more likely to receive advance care planning and to have higher post-discharge 3-month mortality, although rates of advance care planning were low in both groups. Most of these patients were determined to be able to meaningfully participate in an SIC. RRS, coupled with clinician acumen, may be a practical though imperfect means to identify patients who may benefit from an SIC during hospitalization. Encephalopathy and dementia were primary reasons for inability to participate in an SIC, suggesting need to perform SICs earlier in the life- course.

IMPLEMENTATION OF A GERIATRIC ASSESSMENT SMARTPHRASE: A MULTI- INSTITUTION PILOT STUDY

Eva Szymanski¹; Jessica Zuo²; Emily Fessler³; Ryan Chippendale⁴; Jennifer Ouellet²; Leah Schecter²; Richard Marottoli²; Rachel Miller¹

¹Division of Geriatrics, University of Pennsylvania, Philadelphia, PA; ²Section of Geriatrics, Yale University, New Haven, CT; ³Division of Geriatrics & Palliative Care, Weill Cornell Medicine, New York, NY; ⁴Section of Geriatrics, Boston University, Boston, MA. (Control ID #3871872)

BACKGROUND: The geriatric 5Ms are an increasingly utilized framework to communicate the complexity of the geriatric assessment (GA) to medical trainees and non-geriatricians. As the population ages, it will be important for internists to understand and perform a GA to help meet the promise of tomorrow in caring for complex older patients. The objective of this study is to pilot an electronic medical record (EMR)-based SmartPhrase using the 5Ms (Mind, Mobility, Medications, Multicomplexity, and Matters Most) to teach the GA to medical students and internal medicine/family medicine residents.

METHODS: We developed a concise Epic SmartPhrase organizing the GA within the 5Ms framework using iterative feedback from learners and educators. We incorporated the SmartPhrase into geriatrics teaching

across 3 academic institutions, including two inpatient Acute Care for Elders rotations (medical students and residents) and one geriatrics outpatient rotation (internal medicine residents only). Pre- and post-rotation surveys were used to evaluate utilization of the SmartPhrase, effects on comfort performing a GA, and influence on patient care.

RESULTS: Survey data collection is ongoing and planned to end in April 2023. Preliminary data demonstrated that 39% of learners (n=12/31) felt comfortable performing a GA prior to their geriatrics rotation and only 30% had a framework for the GA. Of the 18 learners who completed post-rotation surveys, 100% reported feeling comfortable performing a GA and 94% (n=17/18) confirmed having a framework for the GA. Out of 17 respondents (94%) who reported using the 5Ms SmartPhrase, 82% agreed that it was helpful when caring for older adults. Use of the SmartPhrase also affected clinical practice by improving interdisciplinary teamwork and aiding in identification and management of delirium, cognitive impairment, and polypharmacy.

CONCLUSIONS: An EMR-based SmartPhrase is an effective educational tool to disseminate geriatric principles and increase comfort with the GA among medical trainees. It can be used across multiple sites of care to enhance geriatrics education and patient care.

INTERNAL MEDICINE RESIDENT BARRIERS TO ADVANCED CARE PLANNING IN THE PRIMARY CARE CLINIC

Nicole Dussault¹; Katherine Henderson²; Patrick Hemming⁴; Alex H. Cho³; Jessica Ma³

¹Internal Medicine, Duke Medicine, Durham, NC; ²Chaplain Services & Education, Duke University Health System, Durham, NC; ³Department of Medicine, Duke University School of Medicine, Durham, NC; ⁴Department of Medicine, Duke University School of Medicine, Durham, NC. (Control ID #3871888)

BACKGROUND: While primary care physicians often engage patients in Advanced Care Planning (ACP), it is not well known what specific challenges resident physicians face to achieving this Accreditation Council for Graduate Medical Education (ACGME) core competency. This project assessed resident perceptions of barriers to conducting outpatient ACP in their primary care clinic, as well as potential interventions.

METHODS: We distributed an electronic survey to Internal Medicine residents at our institution at the end of the 2022 academic year. Questions addressed attitudes towards and exposure to outpatient ACP, as well as perceptions of barriers and potential interventions in several domains: structural issues, personal knowledge, and communication skills. We reported results using descriptive statistics and Wilcoxon rank-sum tests, comparing responses by year in training (interns verse second-and third-years). Likert-scale responses were dichotomized to a “not at all or slightly” vs “moderate or extreme” barrier or helpful intervention.

RESULTS: Out of 149 residents, 71 completed the survey (response rate 48%). Highest scoring barriers to outpatient ACP were structural, relating to 1) lack of time (99%), 2) need to prioritize other medical problems (94%), and 3) lack of patient continuity (62%). Discomfort with communication frameworks (21%) and responding to emotion (1%) were not major barriers. Highest scoring interventions included the ability to schedule patients for dedicated ACP visits with themselves (96%) or with another provider (82%). Residents did not desire further live trainings (37%) or online modules (12%) on outpatient ACP. When comparing interns to second-and third-years, interns were significantly less confident in their ability to conduct ACP, and more likely to report lack of knowledge in areas such as understanding ACP components, patient prognosis, or how to fill out paperwork (p < 0.05).

CONCLUSIONS: Internal Medicine residents reported significant structural barriers to conducting outpatient ACP, such as limitations in clinic time, patient continuity, and competing medical priorities. This may warrant greater Graduate Medical Education program attention to structural interventions such as clinic schedules, work-flow, and patient panel management, in order to ensure residents achieve this core ACGME competency. On the other hand, residents did not express discomfort with communication skills, possibly due to exposure to similar conversations in the inpatient setting. While residents overall did not desire further outpatient ACP training, the knowledge gaps expressed by interns suggest that additional education may be most beneficial if targeted to the beginning of intern year.

LISTENING TO MANY VOICES: A QUALITATIVE STUDY OF SERIOUS ILLNESS COMMUNICATION PREFERENCES AMONG BLACK AND LATINX PATIENTS

Carine Davila^1,3; Miranda Ravicz²; Keri Sullivan³; Jose Lizarazo Arango^1,4; Kelly Vo¹; Carolina Jaramillo⁵; Erica Wilson^1,3; Susan Edgman-Levitan¹; Christine S. Ritchie^1,3

¹Medicine, Massachusetts General Hospital, Boston, MA; ²Internal Medicine, Pediatrics, Massachusetts General Hospital, Boston, MA; ³Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA; ⁴Equity and Community Health, Massachusetts General Hospital, Boston, MA; ⁵Harvard Medical School, Boston, MA. (Control ID #3876418)

BACKGROUND: The benefits of serious illness communication (SIC) are well described. However, access to effective and culturally appropriate serious illness communication is inequitable. Historically marginalized groups participate less in advance care planning, experience lower-quality communication, and feel less understood by clinicians. Systemic racism, historically and culturally mediated mistrust, and differences in care preferences contribute to these disparities. It is not known how to optimize SIC for Black, Hispanic/Latinx, and Spanish-speaking patients. This study aimed to elucidate SIC preferences of these groups to improve SIC delivery at a community health center.

METHODS: Focus groups were conducted via Zoom with Black, Hispanic/Latinx, and Spanish-speaking patients who receive care at a community health center in a New England urban metropolitan area. Focus groups were conducted in English and Spanish. Audio transcripts were analyzed using thematic coding by two independent coders with differences resolved by consensus.

RESULTS: Six focus groups (2-5 participants) and four individual interviews were conducted with 24 participants. Fifteen participants were women (63%), 13 were Hispanic/Latinx (54%), 11 were non-Hispanic Black (46%), and 10 (42%) were primarily Spanish-speaking. They had a mean age of 55 years (range 42-73). Two participants had completed health care proxy documentation, and one had had a serious illness conversation with their clinician.

Many participants expressed their favorite thing about receiving care at the community health center was their caring and competent longitudinal primary care clinician. Participants varied in their preferences for information sharing, and most agreed that clinicians should ask patients about their individual communication preferences (e.g., how much information they would want to hear and who should be present for conversations). Participants highlighted the importance of having family members present and involved during serious illness conversations for both emotional support and assistance in hearing and remembering conversation details. They expressed a preference for having serious illness conversations with longitudinal primary care clinicians and an openness to having other clinicians present for psychosocial and communication support. They emphasized the importance of having a trusting relationship with the clinician.

CONCLUSIONS: This study explored Black and Hispanic/Latinx patient preferences for SIC. Patients expressed a desire to have serious illness conversations with clinicians who know them. Future interventions should support primary care practices in enabling high-quality SIC for patients with their longitudinal primary care clinician, where possible. Potential interventions could include engaging a social worker or community health worker, or using group visits, to introduce the concept of serious illness conversations with patients to set up future SIC with their primary care clinicians.

LONELINESS, DEPRESSION, AND MARITAL CLOSENESS AMONG SPOUSES OF PERSONS WITH DEMENTIA: EVIDENCE FROM THE HEALTH AND RETIREMENT STUDY

Kristie Hsu¹; Irena Cenzer²; Krista Harrison^2,3; Christine S. Ritchie^4,3; Linda Waite⁵; Ashwin A. Kotwal^6,7

¹Internal Medicine, University of California San Francisco School of Medicine, San Francisco, CA; ²Geriatrics, University of California San Francisco, San Francisco, CA; ³Global Brain Health Institute, University of California San Francisco, San Francisco, CA; ⁴Medicine, Massachusetts General Hospital, Boston, MA; ⁵Department of Sociology, University of Chicago Division of the Social Sciences, Chicago, IL; ⁶Medicine, University of California San Francisco, San Francisco, CA; ⁷Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Health Care System, San Francisco, CA. (Control ID #3854124)

BACKGROUND: Spouses of persons living with dementia (PWD) may be at risk for loneliness and depression. However, it is unclear how often each occur and the extent to which they are distinct. We therefore assessed the prevalence of loneliness and depression among spouses of PWD or mild cognitive impairment (MCI) and the role of marital closeness in mediating these outcomes.

METHODS: We used a nationally-representative sample of 3,960 married couples in the Health and Retirement Study (2014 and 2016). We included spouses of persons with normal cognition (N=2,890), of persons with MCI (N=851), and of PWD (N=256). Loneliness was defined using the 3-item UCLA scale and depression using the CES-D. Marital closeness was assessed with a single-item, “How close is your relationship with your spouse?” with very or quite close defined as “close” and not very or not at all close as “not close.” We determined the adjusted prevalence of loneliness using multivariable logistic regression adjusting for sociodemographic factors, then tested for interaction between marital closeness and spousal cognition. We assessed the prevalence of depression, and both loneliness and depression, using the same method.

RESULTS: The sample was 55% women and on average 67-years-old (Range: 50-97). After adjustment, spouses of PWD were more likely to be lonely (Normal: 20%, MCI: 23%, PWD: 30%; p=0.02), depressed (Normal: 7%, MCI: 15%, PWD: 16%; p<0.01), and both (Normal: 4%, MCI: 9%, PWD: 9%; p<0.01). Figure 1 demonstrates that the association between spousal cognition and loneliness differed by marital closeness (interaction p-value=0.01). Among “close” couples, spousal dementia was associated with higher loneliness levels, but no association existed between spousal dementia and loneliness among “not close” couples. The association between spousal cognition and depression did not differ by closeness.

CONCLUSIONS: Nearly 1 in 3 spouses of PWD experienced loneliness, often separately from depression. By identifying and addressing both loneliness and depression, and facilitating referrals to interventions that strengthen marital bonds and social connection, clinicians might improve the quality of life of couples facing dementia.

LONG COVID IN THE ELDERLY: MORTALITY AND HEALTHCARE UTILIZATION IN A VULNERABLE POPULATION

Dao Le¹; Neti N. Vora²; Rahul Mhaskar¹; Kyle Shaak³; Nikhil Sharma⁴

¹Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL; ²Geriatrics, Lehigh Valley Health Network, Allentown, PA; ³Biostatistics, Lehigh Valley Health Network, Allentown, PA; ⁴Internal Medicine, Lehigh Valley Health Network, Allentown, PA. (Control ID #3874856)

BACKGROUND: COVID-19 is associated with brainstem inflammation in the elderly, potentially leading to neurologic effects, such as fatigue and respiratory depression long-term.¹ Other post-diagnosis neurological manifestations include falls, delirium, and dizziness.² Another study has shown a correlation between long COVID-19 hospitalizations in the elderly and muscular weakness, which increases the risk of falls long-term.³ Our study aims to characterize complications in individuals 85 and older within a 180-day period after COVID-19 diagnosis, including emergency department (ED) visits, admissions, readmissions, and mortality to better understand the needs of one of our most vulnerable populations.

METHODS: A retrospective chart review was performed at a large community medical center in the Mid-Atlantic region to examine outcomes in 1,683 patients who were diagnosed with COVID from March 1, 2020 to April 30, 2021. Patients were excluded from the study if they were under the age of 85 or deceased within 15 days of COVID infection. Data points included demographic information, height and weight, date of initial COVID infection, ED visits, and hospital admissions and readmissions. Univariate and multivariate analyses were conducted to determine the association between age, gender, body mass index (BMI), and healthcare utilization and mortality.

RESULTS: The average age and BMI for this patient population were 90.62 and 27.31 respectively. On average, patients stayed in the hospital after their COVID diagnoses for 5.42 days. Those who passed away within a 180-day period after their COVID diagnosis averaged 59.79 days of survival before death. Falls were the most common cause of ED visits while cardiac etiologies were the most common causes of admissions. In the univariate analysis without adjusting for age, BMI, or gender, female gender was associated with a significantly higher likelihood of mortality compared to male gender (OR=7.23, p=0.007). This unadjusted analysis showed a positive association between length of hospitalization and likelihood of mortality (p=0.005). When controlling for BMI and gender, age was the only factor associated with a higher likelihood of mortality (p=0.031, 95% CI 1.005-1.118).

CONCLUSIONS: Advanced age has strongest association with mortality after COVID diagnosis for individuals over 85 years of age when adjusting for other factors. This may encourage physicians to consider advanced age as a risk factor for COVID mortality beyond the short term and choose to treat this population for COVID in the absence of other risk factors. Goals of care and advanced care planning should be addressed upon diagnosis for this population if not done priorly. Gender and length of hospitalization can be explored as further risk factors, though these factors require more investigation.

MEDICATION DISCREPANCIES AMONG OLDER HOSPITALIZED ADULTS DISCHARGED FROM POST-ACUTE CARE FACILITIES (PACS) TO HOME

Eduard E. Vasilevskis^1,2; Avantika S. Shah¹; Emily Hollingsworth¹; Silas P. Trumbo⁶; Matthew S. Shotwell⁵; Amanda S. Mixon^3,2; Sandra Simmons^4,2

¹Medicine, Vanderbilt University Medical Center, Nashville, TN; ²GRECC, VA Tennessee Valley Healthcare System, Nashville, TN; ³Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN; ⁴Medicine, Geriatrics, Vanderbilt University Medical Center, Nashville, TN; ⁵Biostatistics, Vanderbilt University Medical Center, Nashville, TN; ⁶Hospital Medicine, Duke Medicine, Durham, NC. (Control ID #3876055)

BACKGROUND: Older adults face many potential risks during transitions of care, including medication reconciliation errors that increase a patient’s risk for adverse events and healthcare utilization. The epidemiology of medication discrepancies during transitions from PAC to home is poorly described among older hospitalized adults. The objectives of this study are to describe the: (1) frequency and types of medication discrepancies among hospitalized adults transitioning from PAC to home; and (2) quantify the burden of medication discrepancies by medication class.

METHODS: This observational cohort analysis included participants enrolled in a patient-centered deprescribing trial for patients (ages 50 and older and taking at least 5 medications) transitioning from a Southeastern academic medical center to one of 22 partnering PACs to home. This study included only patients for which 7-day post-PAC discharge data were available. We assessed demographic measures and medication management measures at the initial hospitalization. The primary outcome measure was medication discrepancies with the PAC discharge list serving as reference for comparison to the participant’s self-reported medication list at 7 days following PAC discharge. Discrepancies were categorized as additions, omissions, and dose discrepancies, and were organized by common medication classes and risk of harm (e.g., Potentially Inappropriate Medications [PIMs]).

RESULTS: A total of 184 participants from the larger deprescribing trial had 7-day post-PAC discharge medication data. Patients were predominately female (67%) and Caucasian (83%). Notably, 63% received assistance with managing their medications while 24% reported difficulty paying for their medications. Participants had a median of 3 providers and 16 pre-hospital medications [IQR 11,20]. At 7-day follow-up, 98% of participants had at least one medication discrepancy, with a median number of 7 medication discrepancies [IQR 4-11] per person when compared with the PAC discharge medication list. There were 1377 total medication discrepancies including 718 omissions, 497 additions, and 162 dosing discrepancies across all medications. Medication discrepancies were most common in over-the-counter medications, antihypertensives, and diabetes drugs while PIMs represented 61% of additions and dose discrepancies.

CONCLUSIONS: The study’s findings underscore the need for interventions targeted at this critical yet overlooked transition period especially as patients resume responsibility of managing their own medications after an acute event and time in PAC. The prevalence of medication discrepancies soon after discharge from PAC warrants an early follow-up with their outpatient provider and/or pharmacist to ensure a best possible medication history and avoidance of preventable adverse medication errors.

OLDER ADULT EXPERIENCES WITH CONFLICTS ABOUT AGING-IN-PLACE AND LONG- TERM-CARE DECISION MAKING.

Alaine Murawski¹; Marianne Tschoe²; Amber Miller-Winder¹; Allison Schierer¹; Raven Relerford¹; Charles Olvera¹; Vanessa Ramirez-Zohfeld¹; Lee Lindquist¹

¹Medicine - Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; ²Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #3874314)

BACKGROUND: As older adult patients age, they are faced with making decisions regarding aging-in- place versus living in long term care communities. These decisions evolve as their health changes and may also cause conflicts with others around them. As a result of these conflicts, older adults may experience stress, frustration, anxiety, and worsening health. We sought to characterize the conflicts that older adults experience surrounding aging-in-place and decision making.

METHODS: As part of a study on decision making about aging-in-place versus moving into long term care communities (R01AG058777), we are longitudinally following a cohort of older adults with surveys every 6 months. Subjects are asked to describe any conflicts that have occurred about their living situation. Subject responses were transcribed and coded using constant comparative analysis examining type, content, and whether statements were interests, rights, or power-based. The interest-right-power based framework is widely used in negotiation literature and can be leveraged to resolve disputes.

RESULTS: We enrolled 293 subjects (mean age 73.5 yrs, SD 5 yrs, 40.4% non-white; 94.5% retention rate) and 124 conflicts were reported over 18 months. Thematic analysis revealed three types of conflicts:1.) Interpersonal (subcategories: spouse, intergeneration, other) (e.g, my son sometimes comes from Florida and tries to tell me what to do with my house), 2.) Task (e.g, Mostly the maintenance, up-keeping of the place), 3.) Value-based (e.g. downtown living in a condo versus living in a more open area) ; Content was coded into 6 themes: 1.) Location change (e.g. my sister says I can be incapacitated and she said I should live in senior housing.), 2.) Home maintenance issues (e.g., My son insisted I put in a new lower tub and I didn't want to.), 3.) Different ways of completing tasks (e.g., It is about my children and the way we do things. I don't take my time, and I don't eat the same stuff.) ,4.) Safety (e.g., The neighbor's boyfriend kicked in the door and destroyed our property.) 5.) Financial (e.g., I discovered that my spouse secretly met his attorney and changed his will so I would get nothing.), 6.) Health-related (e.g., The family next door is always having bonfires which messes with my asthma. we've argued), The majority of statements were interests or rights-based.

CONCLUSIONS: Older adults experience a wide range of conflicts pertaining to aging-in-place. Most often older adults experience interpersonal conflicts with supporters/caregivers about moving from their home into a long term care community or adapting the home for their health needs. In the future, a negotiation and dispute training program may help alleviate these conflicts between older adults and their supporters/caregivers.

OVERWHELMED: DEMENTIA CARE IN PRIMARY CARE

Halima Amjad¹; Emmanuel Angomas¹; Maura J. McGuire^2,4; Jessica Colburn¹; Quincy Samus³; Marcela D. Blinka¹

¹Internal Medicine, Geriatrics, Johns Hopkins University, Baltimore, MD; ²Medicine, Johns Hopkins School of Medicine, Baltimore, MD; ³Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD; ⁴Johns Hopkins Community Physicians, Baltimore, MD. (Control ID #3869711)

BACKGROUND: Primary care is central in dementia diagnosis and care, but quality of care and specialist access is variable. Health system and payment innovations have potential to address needs of the growing population of persons living with dementia (PLWD) in primary care. Our objective was to identify and compare staff and PLWD/caregiver perspectives on the current state of dementia care in primary care and opportunities to improve care.

METHODS: We conducted semi-structured interviews with 28 primary care team members (primary care providers [PCP] and interdisciplinary staff [nurses, medical assistants, care managers, social workers, pharmacists, practice administrators]) and 13 PLWDs and/or caregivers from community-based primary care practices in a large Mid-Atlantic health system. Maximum variation sampling was used to recruit participants diverse in race, ethnicity, location, and clinic size and demographics. We used traditional qualitative content analyses to code interview data and identify themes related to dementia care.

RESULTS: Participants worked with over 13 primary care practices. We identified 5 themes related to dementia in primary care: (1) Dementia is overlooked: PLWDs/caregivers felt PCPs did not prioritize dementia. PCPs and PLWDs/caregivers deferred dementia needs to specialists while acknowledging familiarity/rapport with primary care and sometimes inadequate specialist support. (2) Help wanted! Need for greater support in dementia was universally acknowledged. PCP and staff needs included diagnostic support, knowledge of resources, and time or staff to facilitate dementia care. PLWDs/caregivers were open to any information or guidance. (3) Disagreement on what matters most: PCPs and staff felt identification of caregiver/social support and safety were most important after dementia diagnosis. PLWDs/caregivers felt a roadmap, including what to expect, interventions, and resources, was most important. (4) Evolving opportunities are underused: Increased use of patient portals and video visits were helpful in dementia care. PCPs, staff, and PLWDs/caregivers identified interdisciplinary staff who could facilitate dementia support for PLWDs/caregivers (e.g. education, community resource referrals, medication evaluation). All groups felt the CMS cognitive assessment and care planning billing code addresses comprehensive dementia care; PCPs and staff felt it included many care domains already addressed in primary care. (5)“We’re bursting at the seams”: PCPs and staff expressed time and resource constraints; caregivers recognized time constraints for both PCPs and specialists.

CONCLUSIONS: PCPs, interdisciplinary staff, PLWDs, and caregivers acknowledge unmet needs in providing and receiving dementia care. Team-based advanced primary care, telehealth and patient portals, and CMS billing codes, alongside dementia training and resource knowledge, may help address dementia care needs. Strategies to improve dementia care must consider time and resource burden in primary care.

PATIENT-IDENTIFIED REASONS TO DISCONTINUE CANCER SCREENING IN OLDER ADULTS: FINDINGS FROM THE MCBS

Olivia Belliveau¹; Ilana Richman²

¹Yale School of Medicine, New Haven, CT; ²Department of Medicine, Yale University, New Haven, CT. (Control ID #3875416)

BACKGROUND: USPSTF guidelines recommend against PSA screening in men 70 and older, and do not recommend for or against screening mammography in women 75 and older. Although screening may have harms in these groups, clinicians may be reluctant to directly counsel against screening for a variety of reasons. The goal of this study was to understand reasons why older adults stop cancer screening, including the role of physician recommendations. We hypothesized that receipt of active physician recommendations against screening would differ by patient health status and educational attainment.

METHODS: We used nationally representative data from the 2019 Medicare Current Beneficiary Survey (MCBS). We included women 76 and older without a history of breast cancer and men 71 and older without a history of prostate cancer. The primary outcome was reason for discontinuing screening, which we grouped into 3 categories: 1. participant’s doctor actively recommended against screening, 2. doctor did not provide a recommendation to screen, 3. patient-driven reason, such as patient preferences or beliefs. We evaluated reasons for screening discontinuation by self-identified health status and educational attainment (high school diploma or less, vs some college). Analyses included descriptive statistics and chi-square tests and used survey weights to account for complex survey design.

RESULTS: The study population was 3% Asian, 8% Black, 85% White, 4% another or multiple races. Among respondents, 8% identified as Hispanic or Latino. 59% had education past high school and 83% rated their health as excellent, very good, or good.

Overall, 32% of women had a screening mammogram in the past year or intended to continue screening. Among those who stopped screening, 5% reported an active recommendation against screening by their doctor, 57% reported no recommendation from their doctor, and 38% reported a patient-driven reason for

cessation. These proportions did not differ by educational attainment or health status.

For men, 58% were screened with PSA in the past year or intended to continue screening. Among those who stopped screening, 4% reported an active recommendation against screening by their doctor, 64% reported no recommendation from their doctor, and 32% reported a patient-driven reason for cessation. Men with higher educational attainment were more likely to identify doctor-driven reasons to stop PSA testing (73% vs 59%), including active recommendation against screening (5% vs 2%, p=0.005) and lack of recommendation from their physician (68% vs 57%, p=0.01).

CONCLUSIONS: Guideline-discordant cancer screening remains common. Among those who stop screening, few report a recommendation against screening from their physician, even when in poor health.

These findings suggest that few patients are directly counseled against screening, even when it is of minimal benefit or potentially harmful.

POTENTIAL MEDICATION DE-ESCALATION OPPORTUNITIES AMONG OLDER ADULTS WITH FRAIL PHENOTYPES AND STRICTLY-CONTROLLED CARDIOMETABOLIC DISEASE Alexander Chaitoff¹; Nancy Haff⁴; Julie Lauffenburger²; Niteesh K. Choudhry³

¹Medicine, Brigham and Women's Hospital, Boston, MA; ²Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; ³Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School, Boston, MA; ⁴Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA. (Control ID #3875407)

BACKGROUND: De-escalating medications that address cardiovascular disease (CVD) risk factors in older adults is controversial. However, for certain populations, such as older adults with frailty and strictly controlled diabetes, guidelines suggest risks and benefits may favor de-escalation. We characterize potential medication de-escalating opportunities by quantifying how many older adults with a frail phenotype have strictly controlled CVD risk factors and remain on medications for these risk factors.

METHODS: We included adults >65 years old taking part in the National Health and Nutrition Examination Survey (NHANES) from 2005-2018. NHANES is a cross-sectional survey with interview, exam, and laboratory components used to generate nationally representative estimates. Frailty phenotype was assessed from body mass index and respondents’ self-reported functional abilities using a previously validated scale derived from NHANES data. Medication use (anti-hypertensive medications, anti-diabetes medications, and statins or aspirin) was assessed by pill-bottle review. Strictly controlled disease was defined separately for each condition: 1) for diabetes as having a history of diabetes and HgbA1c <7%, 2) for hypertension as having a history of hypertension as well as a systolic blood pressure (SBP) <120 mmHg and diastolic blood pressure (DBP) <80 mmHg, and 3) for primary prevention of CVD as not having self-reported CVD or diabetes and having controlled SBP and DBP. Respondents were classified as having a potential de-escalation opportunity if they had a frail phenotype, had strictly controlled disease, and were on medication for the respective strictly controlled disease. Counts and frequencies were used to describe the population. Multivariable logistics regression was used to generate adjusted odds ratios (OR) comparing demographic characteristics and odds of having any potential de-escalation opportunity. Percentages are weighted and counts are unweighted unless otherwise specified.

RESULTS: In this sample of older adults, 4.2% (n=401) had a frail phenotype, representing 1,500,457 (95%CI 1,250,135 – 1,750,779) adults. Of these older adults with a frail phenotype, 42.0% (95%CI 37.4%- 52.6%, n=107) had at least one strictly controlled disease and remained on medication. More specifically,

76.6% (95%CI 66.2%-86.9%, n=56), 95.6% (95%CI 90.1%-99.9%, n=42), 25.3% (95%CI 13.2%-37.3%, n=18), and 55.9% (95%CI 47.0-64.8, n=125) were still on at least one anti-diabetes medication, anti- hypertensive, statin, or aspirin, respectively, despite having strictly controlled disease. Older age was the only demographic characteristic associated with having a de-escalation opportunity (OR 1.09, 95%CI 1.03-1.15, p=0.01).

CONCLUSIONS: Many older adults with a frail phenotype remain on medication for CVD risk factors despite having strictly controlled disease. Given the substantial at-risk population, future work should address how integrating CVD de-escalation interventions into clinical care may affect outcomes.

PREDIABETES SCREENING AND SUBSEQUENT UNNECESSARY CARE AMONG OLDER ADULTS IN AN URBAN ACADEMIC HEALTHCARE SYSTEM.

Catherine Sarkisian^2,3; Chad Villaflores²; Sitaram Vangala²; Richard K. Leuchter²; Samuel A. Skootsky¹; Tannaz Moin^4,3

¹Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA; ³Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ⁴Division of Endocrinology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #3876824)

BACKGROUND: USPTF does not recommend screening for prediabetes or diabetes for anyone aged greater than 70 years. We sought to explore whether such screening might contribute to unnecessary care in our urban academic integrated healthcare system. Our specific aims were to measure: 1) the volume and rate of prediabetes/diabetes screening among persons age >70 years; 2) among those diagnosed with prediabetes, the volume and rate in the subsequent year of: a) repeat testing; b) prescription of diabetes-related medications; c) endocrinologist visits.

METHODS: We used the electronic health record to assemble a cohort of all adults aged >70 years seen at a large urban healthcare system between Jan. 1, 2018 and Oct. 1, 2021 who met the following inclusion criteria: 1) encounters dating back 2 years; 2) no previous diagnosis of diabetes or prediabetes (on problem list, ICD-10 code, or by hemoglobin A1c (HbA1c); 3) part of the primary care registry. Since HbA1c is the lead screening test in real world settings, we used national (American Diabetes Assn) thresholds that define diabetes as HbA1c >6.5% and prediabetes as HbA1c 5.7-6.4%. We calculated: (Aim 1): the number of persons in the cohort who had a HbA1c test done; (Aim 2) among those in the prediabetes range, the volume and rate in the subsequent year of: a) repeat HbA1c testing; b) prescription of diabetes-related medications (metformin or any other medication whose primary indication is diabetes); c) 1 or more visits with an endocrinologist.

RESULTS: There were 27,809 persons who met criteria for our cohort. Mean age was 77.9; 57.9% were female; 4.0% self-identified as African-American/Black, 6.8% Asian, 5.9% Latinx/Hispanic, 65.8% White. A total of 20,950 (75.3%) had a HbA1c test within a year of the index encounter, and 12,813 (61.2% of those tested) had results in the prediabetes range, with 1675 (8.1% of those tested) having results in the diabetes range. Among the 12,813 persons with incident prediabetes, one-year utilization outcomes were as follows: 6069 (44%) had repeat HbA1c testing; 657 (5%) were prescribed diabetes-related medications, and 1585 (12%) had 1 or more appointments with an endocrinologist.

CONCLUSIONS: In this large urban academic integrated healthcare system, over three-quarters of adults >70 years without documented history of pre-diabetes or diabetes underwent HbA1c testing each year. Though some of these tests were likely ordered appropriately as part of a diagnostic workup, a huge fraction of older adults are regularly undergoing screening despite USPTF not recommending this for anyone aged 70 years or greater. Among this group, most are diagnosed with pre-diabetes, with subsequent diabetes-related healthcare utilization (blood draws, medications, and even endocrinology appointments) being very common. These findings suggest that non-recommended screening for pre-diabetes and diabetes may be driving further unnecessary care.

RACIAL AND ETHNIC DIFFERENCES IN LOW-VALUE CARE AMONG OLDER ADULTS ACROSS THE UNIVERSITY OF CALIFORNIA HEALTH SYSTEM

Carlos Irwin Oronce^1,3; Susi Rodriguez Shapiro⁵; Phyllis E. Willis^4,5; John N. Mafi^3,2; Catherine Sarkisian^1,3

¹Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²RAND Corporation, Santa Monica, CA; ³General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁴Watts Labor Community Action Committee, Los Angeles, CA; ⁵Community Advisory Board, Resource Centers for Minority Aging Research / Center for Health Improvement of Minority Elderly, Los Angeles, CA. (Control ID #3856129)

BACKGROUND: Low-value care (LVC) encompasses health services that offer no net benefit in specific clinical scenarios, and may cause harm (e.g. opioids in acute low back pain). Prior studies suggest that minoritized racial and ethnic older adults receive more LVC in some situations, but evidence is mixed and potentially outdated. This study aims to describe differences in LVC by race/ethnicity among older adults using a contemporary sample and a comprehensive set of measures.

METHODS: We conducted a cross-sectional analysis of 2019 to 2021 claims of members 55 years and older continuously enrolled in a statewide health plan who received a potentially low-value service. Our primary outcome was receipt of any low-value service among 35 LVC measures. We measured LVC using the Milliman Health Waste Calculator (HWC), an algorithmic claims-based tool that uses diagnostic, procedure, and drug codes to classify services as low-value or appropriate. The HWC measures are based on evidenced- based guidelines, such as the Choosing Wisely lists. Race was defined using the race or ethnicity recorded in the electronic medical record. Secondary outcomes included types of LVC, including preventive screening, diagnostic testing, prescription drugs, and preoperative testing. We used multivariable logistic regression models to examine the association between race/ethnicity and receipt of LVC, controlling for age, sex, prior outpatient utilization, site of care, and timeframe.

RESULTS: Over the 3-year period, 18,872 members received 88,555 measured services. The mean age was 61 years and 60% were female. Non-Hispanic White older adults comprised 72% of the sample, followed by Asian (18%), unknown race (4%), Hispanic/Latino (3%), non-Hispanic Black (3%), other race (0.1%). After adjustment, Asian (OR 0.77; 95% CI 0.73-0.81) or Black (OR 0.69; 95% CI 0.63-0.77) patients were significantly less likely to receive any LVC compared with White patients. The adjusted odds of receiving low-value preventive screening tests were 52% lower among Black patients (OR 0.48; 95% CI 0.42-0.55). For low-value prescription drugs, adjusted odds were 184% higher among Black vs White patients (OR 2.84; 95% CI 2.33-3.45). The odds of receiving low-value preoperative testing was 35% lower among Hispanic/Latino patients (OR 0.65; 95% CI 0.43-0.98).

CONCLUSIONS: In a statewide employer health plan, Asian and Black older adults were less likely to receive some types of LVC, which was driven by fewer low value preventive screening and preoperative tests. However, Black older adults were more likely to receive low-value prescriptions. These findings suggest that the direction and magnitude of racial/ethnic differences in LVC depends on the specific service measured. Further, these results underscore the need to use clinically specific measures for LVC over composite measures, which obscure underlying differences in LVC and may result in potentially harmful and inequity producing interventions.

THE EFFECTS OF PATIENT-PROVIDER COMMUNICATION ON MEDICATION NONADHERENCE AMONG MEDICARE BENEFICIARIES WITH TYPE 2 DIABETES

Daniel Keith¹; Boon Peng Ng²

¹Medicine, University of Central Florida College of Medicine, Orlando, FL; ²Disability, Aging and Technology Faculty Research Cluster, University of Central Florida, Orlando, FL. (Control ID #3875190)

BACKGROUND: Poor glycemic control, declining health outcomes, and excessive systemic financial burden can result from medication nonadherence in those with type 2 diabetes, and Medicare beneficiaries are particularly susceptible to these consequences due to factors such as increased co-morbidities and polypharmacy. However, despite the devastating outcomes of medication nonadherence in these populations, research involving the effects of both patient-provider communication and subsequent patient knowledge is scarce. Therefore, our objective was to explore how these two variables influence medication nonadherence among Medicare beneficiaries aged ≥ 65 years with type 2 diabetes.

METHODS: We analyzed the 2019 Medicare Current Beneficiary Survey PUF (n=1,100). A survey- weighted multivariable logistical regression was performed to examine how socio-demographics, co- morbidities, discussions of general health improvement, communication regarding bad reactions, and patient prescription knowledge were associated with medication nonadherence among beneficiaries aged ≥ 65 years with type 2 diabetes.

RESULTS: Overall, 10.01% of Medicare beneficiaries with type 2 diabetes reported having medication nonadherence. There were lower odds of medication nonadherence among beneficiaries who were asked how they plan to improve their general health by their providers (OR=0.53 95% CI [0.314,0.879]) and who knew "mostly everything" (vs some/none) about their prescription's benefit (OR=0.37 95% CI [0.149,0.926]). Those who had ≥1 limitation in their activities of daily living (ADLs) had higher odds of medication nonadherence (OR=3.46 95% CI [1.761,6.814]). Interestingly, there were no significant associations between medication nonadherence and race, income, gender, or whether the provider talked about bad reactions.

CONCLUSIONS: Beneficiaries with more than one limitation in their ADLs should be screened for medication nonadherence. Also, to potentially decrease medication nonadherence, it is warranted for providers to increasingly hand out educational materials that improve knowledge related to drug benefits and to increase communication regarding plans to improve the general health of beneficiaries with type 2 diabetes.

UNDERSTANDING THE EXPLICIT COSTS OF DIABETES AND DEMENTIA AMONG OLDER ADULTS – AN ANALYSIS OF MEDICAL EXPENDITURE PANEL SURVEY DATA (2000 – 2020)

Aprill Z. Dawson, Sebastian Linde, Rebekah J. Walker, Leonard E. Egede

Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3877144)

BACKGROUND: Adults with diabetes have 73 percent increased risk of developing dementia compared to adults without diabetes. Dementia negatively impacts the ability to complete diabetes selfcare activities and is associated with increased risk of mortality. Given the aging of the US population and increasing prevalence of diabetes, it is important to understand the health care costs of diabetes and dementia. Therefore, the aim of this analysis was to understand the explicit costs of diabetes and dementia in older adults.

METHODS: Medical Expenditure Panel Survey data (2000–2020) for adults aged 50 and older were analyzed. Total expenditure, office-based, in-patient, emergency department (ED), prescription, and home health expenditures were dependent variables. The primary independent variable had 4 categories: no diabetes or dementia, diabetes only, dementia only, diabetes and dementia. Covariates included age, race/ethnicity, sex, marital status, education, employment, region, poverty, smoking, comorbidities, and survey year. Analyses were conducted using Stata v17.0. A subpopulation was created for adults aged 50 and older, survey weights and survey commands were used to generate population estimates. Descriptive statistics (means, standard deviations, proportions) were calculated. Two-part models with gamma family and log link were run. First, a probit model to estimate likelihood of expenditure, followed by a generalized linear model to understand the associations between diabetes and dementia and expenditures. The margins command was used to convert coefficients to dollars. Unadjusted and models were adjusted for all covariates were run. Statistical significance was defined as p-value <0.05.

RESULTS: There were 200,539 individuals representing 99,639,922 adults aged 50 and older in the United States in the analysis. In fully adjusted models, dementia and diabetes were associated with significantly higher medical expenditures for total expenditures, prescriptions, ED, and home health costs. Total expenditures were $5267 (95%CI 5121-5413), $6284 (95%CI 6053-6515), $8226 (95%CI 7151-9302), and $8487 (95%CI 6558-10417) for patients with neither condition, diabetes only, dementia only, and comorbid diabetes and dementia respectively. Similarly, prescriptions were $1,043, $1,073, and $1,754 higher on average for patients with diabetes only, dementia only, and comorbid diabetes and dementia respectively compared to older adults with neither condition. Interestingly, having diabetes alone was not associated with higher home health costs, while older adults with dementia had $592 in higher costs and those with diabetes compared to older adults with neither condition.

CONCLUSIONS: Adults aged 50 and older with comorbid diabetes and dementia have significantly higher total medical expenditures and prescription costs compared to older adults with neither condition nor diabetes alone after adjusting for relevant covariates.

USE OF DIRECT-TO-CONSUMER MEDICAL TESTS AMONG OLDER US ADULTS: A NATIONALLY REPRESENTATIVE SURVEY

Joshua Rager^1,4; Matthias Kirch⁵; Dianne Singer⁵; Erica Solway⁵; Preeti Malani²; Scott Roberts⁵; Jeffrey T. Kullgren³

¹National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; ²Internal Medicine, University of Michigan, Ann Arbor, MI; ³Internal Medicine and Health Management and Policy, University of Michigan, Ann Arbor, MI; ⁴Veterans

Affairs HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy, Ann Arbor, MI; ⁵Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI. (Control ID #3876350)

BACKGROUND: The availability of direct-to-consumer, at-home medical tests has steadily risen over the last decade. The COVID-19 pandemic and the increased availability of at-home tests for COVID and other health concerns has made home testing a more realistic option for many patients. Despite these trends, it is unknown how frequently at-home tests are used by older adults, the factors associated with this use, and their perceptions of and intentions to use these tests in the future.

METHODS: In July 2022, we conducted a cross-sectional, nationally representative survey of US adults aged 50-80 (n=2,105) about their previous use of, perceptions of, and future intentions to use at-home medical tests. Multivariable logistic regression was used to estimate associations between respondents’ age, gender, race/ethnicity, income, education, marital status, and health status with previous use of at-home tests, perceptions, and interest in future use of these tests. Marginal estimates of the adjusted prevalence of each outcome are reported as a function of respondents’ characteristics. Unadjusted descriptive statistics were used to report the frequency of sharing test results with primary care providers. All analyses used sample weights to generate nationally representative estimates.

RESULTS: 48.1% of older adults have purchased some form of at-home medical test (95% CI 45.2%- 51.0%). 32.0% (95% CI 29.3%-34.8%) have purchased a COVID-19 test, 16.6% (95% CI 14.7%-18.7%) have purchased an at-home DNA or genetic test, 5.6% (95% CI 4.5%-7.0%) have purchased a screening test for cancer, and 4.4% (95% CI 3.4%-5.6%) purchased a test for an infection other than COVID-19. Compared with white adults, black adults were less likely to have purchased an at-home test (35.5% v. 49.6%, p<.05). Those with a college degree (vs. high school or less) and those with a household income greater than $100K (vs. less than $30K) were more likely to have purchased at-home tests (55.5% vs. 42.0%; 60.6% vs. 39.0%, respectively, both p<.05). Most older adults agreed that at-home medical tests are more convenient than tests through their health care provider (75.1%), that they can be trusted to give reliable results (59.9%), are a good value (66.0%), and should be discussed with their doctors (93.6%). How often these results were shared with primary care providers varied considerably by the type of test (range, 8.8%-90.0%). 82.4% (95% CI 80.1%- 84.4%) of older adults expressed interest in using at-home tests in the future.

CONCLUSIONS: Nearly half of older US adults have already used at-home tests and the majority have positive perceptions of these tests. Some older adults shared results of these tests with their primary care providers and many expressed considerable interest in future use of at-home medical tests. Since at-home testing is now common, clinicians should be familiar with different tests that patients can purchase and be prepared to discuss with them the potential advantages and disadvantages of at-home testing.

“I WANT A DNR BUT MY DAUGHTER SAID NO:" A QUALITATIVE STUDY OF GOALS OF CARE CONVERSATIONS DURING COVID

Megan B. McCullough¹; Michael Still²; Renda S. Wiener^2,3; Jennifer Palmer^1,3; Nathan M. Mesfin⁴; Amy Linsky^2,3

¹VA Center for Healthcare Organization and Implementation Research, Bedford, MA; ²VA Center for Healthcare Organization and Implementation Research, Boston, MA; ³Boston University School of Medicine, Boston, MA; ⁴Regents of the University of Minnesota, Minneapolis, MN. (Control ID #3874435)

BACKGROUND: The Covid-19 pandemic increased the need for goals of care conversations (GoCCs) to explicitly discuss end-of-life care decisions, including preferences for life-sustaining treatments (LST; e.g., cardiopulmonary resuscitation). For multiple reasons, patients change their LST preferences. In this qualitative study, we sought to understand how the pandemic impacted decision-making during GoCCs with Veterans and explored how and why LST preferences changed.

METHODS: We identified 150 Veterans from 20 VA Medical Centers regionally distributed across the US who had a documented GoCC in March or April 2021 with a preference restricting receipt of LST and a subsequent GoCC at least 180 days later in which they rescinded LST limitations. We also identified clinicians who conducted either or both GoCCs with these Veterans. We recruited Veteran-clinician pairs and individuals for semi-structured interviews that explored how the pandemic influenced GoCCs, decision- making for LST, and reasons why LST restrictions were rescinded. We coded and analyzed data using a deductive approach based on literature and an inductive approach to personal narratives of experiences, feelings, and perceptions of GoCCs.

RESULTS: We interviewed four Veterans and seven clinicians, which included three Veteran-clinician pairs who participated in the same GoCC. We identified four themes related to how the Covid pandemic created challenges for conducting high-quality GoCCs: 1) Lack of time required to conduct high-quality GoCCs, 2) Modality of care (e.g., hesitancy to conduct GoCCs via video), 3) Isolation from family/friends (i.e., need for patients to make decisions alone), and 4) Clinical uncertainty (in the context of the novelty of Covid). We identified another four themes related to the impact of Covid on LST stability: 5) Patient misconceptions about LST, 6) Kinship (i.e., influence of family and friends on decisions), 7) Shared decision-making and clinicians’ willingness to make LST recommendations, and 8) Clinicians’ feelings about LST preference changes.

CONCLUSIONS: The Covid pandemic had significant repercussions on how patients and clinicians approached GoCCs and made LST decisions. Many pre-existing challenges to conducting high-quality GoCCs were exacerbated by the pandemic, including workload, modality of care, and knowledge gaps among patients (e.g., realistic benefits of LST) and clinicians (e.g., Covid outcomes and best treatment options). Addressing these challenges could yield improvements in patient-centered GoCCs during routine clinical situations and times of rapid change.

Scientific Abstract - Healthcare Delivery and Redesign

HIGHER PERCENTAGE OF VIRTUAL PRIMARY CARE BY PHYSICIANS IS ASSOCIATED WITH LOWER CARE QUALITY METRICS

Jodi B. Segal¹; Lisa Yanek¹; Maqbool Dada²; Ebele Okoli¹; Elham Hatef¹; Kevin D. Frick²

¹Johns Hopkins Medicine, Baltimore, MD; ²Carey Business School, Johns Hopkins University, Baltimore, MD. (Control ID #3850456)

BACKGROUND: The continued use of virtual primary care may improve patient access and permit an increase in a physicians’ panel size and revenue; however, care quality and health outcomes must not be adversely impacted. We aimed to test the impact of virtual care on key quality metrics applied to primary care practices in Maryland.

METHODS: We did a focused literature review and sought input from stakeholders to prioritize outcomes. We accessed electronic health record data from all patients receiving primary care across one large health system from January 2019 through September 2022. For each month, we attributed patients to clinicians and clinicians to clinics. Virtual visits were identified with Common Procedural Terminology (CPT) codes. To these visits, we linked institutional Healthcare Effectiveness Data and Information Set (HEDIS) measures for each physician, by month. The exposure was the quartile of virtual care use by physician by month. We used generalized linear mixed models that included physicians’ aggregate patient demographics, physicians’ annual counts of visits, a COVID risk indicator for the month (low, moderate, high), and a rural/urban clinic indicator. The models included random intercepts for physicians and clinics. Outcomes were lagged by one month, and the analysis accounted for autocorrelation of outcomes across months.

RESULTS: The data included 42 clinics, 683 physicians delivering primary care, and 200,108 patients over 39 months. Virtual care usage peaked in April 2020 at 78% and has stabilized at 18% recently. The incidence rate ratio (IRR) for blood pressure control comparing physicians in the highest quartile of virtual care to the lowest was 0.91 [95% confidence interval (CI) 0.87 to 0.95] and comparing the second highest to the lowest was 0.96 [95% CI 0.92-1.0]. The IRR for failing to control hemoglobin A1c was 1.4 [95% CI. 1.3 to 1.6] again comparing the highest quartile of virtual care to the lowest. The second lowest quartile of virtual use was associated with a 20% increase in risk of failing to meet the metric. The other clinical quality indicators (breast cancer screening, colon cancer screening, diabetic retinopathy screening, and completion of the Medicare Annual Wellness Visit questionnaire) did not differ significantly across quartiles of virtual care usage. The IRR for hospital admission in the next month was elevated for the highest quartile at 1.1 [95% C.I 1.1 to 1.2].

CONCLUSIONS: Despite wide-spread enthusiasm for virtual care, further work is needed to quantify the impact of virtual care on access and health outcomes at an individual patient level. Our results conflict with some other reports suggesting equivalent quality outcomes with virtual care delivery. Irrespective of whether HEDIS measures are ideal indicators of care quality, these are impactful measures given their use in value- based payment programs.

ACCESS TO LANGUAGE-CONCORDANT PHONE SERVICES FOR PATIENTS WITH NON- ENGLISH LANGUAGE PREFERENCE (NELP)

Miguel Linares¹; Jorge A. Rodriguez²; Emily Linares³

¹Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA; ²General Internal Medicine, Brigham and Women's Hospital, Boston, MA; ³Harvard University, Cambridge, MA. (Control ID #3876096)

BACKGROUND: Extensive evidence has shown worse health outcomes for the 8.6% patients with NELP in the U.S. While the COVID-19 pandemic prompted increased technology use for health communication, patients with NELP were less likely to access new tools, instead relying on communication via telephone for access to care. Despite increased availability of phone interpreters, gaps in language-concordant phone services persist when patients attempt to interface with care centers. We sought to document the existence of language-concordant phone services in Boston health centers.

METHODS: We evaluated the linguistic availability of phone services for Boston clinics, using a secret shopper approach to call primary care (PC) clinics, including FQHCs, and specialty clinics. As our primary outcome, we documented whether automated phone messages offered non-English language options. Our secondary outcome was (a) in which language(s) phone recordings were available and (b) when menu options were delivered in the target language (i.e. patient languages other than English; e.g., a Spanish option recorded in Spanish).

RESULTS: We evaluated 126 clinics, 56 in PC and 70 in specialty care. For our primary outcome, automated messages were available in a non-English language at 46/126 (36.5%) clinics. PC clinics were more likely than speciality to have a non-English language message (52% vs. 24%, p=0.001.). For PC clinics, FQHCs more frequently had non-English language automated messages compared to non-FQHC PC clinics (93% vs. 38%, p=0.0004). For our secondary outcome, Cantonese, Cape Verdean Creole, Haitian Creole, Mandarin, Spanish, and Portuguese were found in recordings. 93% (38/41) of clinics offering multilingual options delivered recording options in target languages. For clinics with multilingual options, PC clinics were no more likely to have messages in the target language than specialty (93% vs. 92%, p=0.872). For PC centers, FQHCs were no more likely than non-FQHC PC clinics to have automated messages in target languages (92% vs. 94%, p=0.879).

CONCLUSIONS: Language-concordance in health center phone recordings is suboptimal in Boston. As health care systems pursue equity, they must ensure language accessibility of all communication tools, including telephone recordings, which may serve as the gateway or roadblock to critical patient-provider communication.

ACHIEVING GREATER VALUE FOR PATIENTS THROUGH FULL COST TRANSPARENCY IN PRIMARY CARE

Victor C. Agbafe²; Nora Metzger¹; Brittani Garlick¹; Tanner Caverly^1,2; Sameer D. Saini^1,2; Eve Kerr^2,1; Jeffrey T. Kullgren^1,2

¹VA Ann Arbor Healthcare System, Ann Arbor, MI; ²University of Michigan, Ann Arbor, MI. (Control ID #3877184)

BACKGROUND: The COVID-19 pandemic led to more use of telephone and video primary care visits across US healthcare systems, including the Veterans Health Administration. A notable difference between these virtual modalities and traditional face-to-face (F2F) encounters is the copay, travel, and time costs that patients face. Making these costs of different modalities transparent to patients and clinicians could improve healthcare value by facilitating selection of encounter modalities that are not only clinically appropriate but also consider the full costs that patients will face.

METHODS: We conducted a proof-of-concept pilot study at the VA Ann Arbor Healthcare System (VAAAHS) to assess the feasibility, acceptability, and preliminary effectiveness of providing transparent personalized estimates of the copay, travel, and time costs for different primary care encounter modalities to patients and primary care physicians (PCPs). For F2F visits, the total estimated costs were the sum of estimated copays, driving costs, and time costs. For telephone and VA Video Connect (VVC) visits, the total estimated costs were the estimated time costs based on the scheduled appointment duration as copays did not apply for telephone or VVC visits during our study. We used VA Corporate Data Warehouse data to generate personalized estimates of patients’ copay, travel, and time costs for F2F, telephone, and VVC primary care visits. We then invited 11 VAAAHS PCPs to receive this information at the point of care via Microsoft Teams and 10 agreed. We recruited 96 patients of these PCPs with an upcoming primary care F2F, telephone, or VVC appointment. Before the appointment, patients were sent a personalized handout that estimated their copay, travel, and time costs for different primary care encounter modalities. After the appointment, participants were surveyed by telephone about their perceptions of the handout and their encounter.

RESULTS: The median estimated total cost for the 96 patient participants was $57 for F2F visits and $12 for telephone and VVC visits. Sixty-five patients (68%) completed the post-visit survey. Most (44/65, 70%) recalled receiving the cost handout before their visit; of these individuals nearly all (40/44, 93%) reviewed it before their visit. Among the 40 who reviewed the handout, 11 (26%) used it with their PCP during the visit. Patients who used the handout in their visit rated highly its helpfulness and willingness to receive it in the future (median 10/10 for both).

CONCLUSIONS: We found it was feasible to generate and deliver personalized cost estimates before primary care visits, this information was acceptable to patients, and those who used cost estimates during a visit found this information helpful and would want to receive it in the future. Making the copay, travel, and time costs of different visit modalities transparent to patients and clinicians should be evaluated more broadly as a strategy to improve access, inform personalized decisions, and optimize healthcare value.

ADDRESSING POST-DISCHARGE MEDICATION ERRORS AMONG SEPSIS SURVIVORS Nirja Sutaria, Natalie Reed, Megan Donaldson, Claire Morley, Peter Samuel, Anika Noorali, Stephanie Taylor, Marc Kowalkowski

Internal Medicine, Carolinas Medical Center, Charlotte, NC. (Control ID #3874070)

BACKGROUND: Post-discharge medication errors are common and costly adverse events. Post-discharge medication management is especially challenging for sepsis survivors because new medications are frequently started (e.g., antibiotics), home medications are frequently held during the acute phase, and physiologic changes may influence the dose and tolerance of medications. In the IMPACTS randomized trial, a nurse navigator-led multicomponent transition and recovery (STAR) program improved 30-day outcomes for sepsis survivors. Medication optimization was a core component of the program, but the extent and characterization of medication errors addressed by STAR navigators are unknown.

METHODS: We conducted a secondary analysis of patients enrolled in the IMPACTS trial allocated to the intervention group. Six internal medicine physicians reviewed STAR navigator notes in study patients’ medical records and recorded whether interventions related to medications occurred. We then used granular EHR review to characterize the medication errors that were addressed using standard taxonomies for medication error reporting.

RESULTS: Of 317 patients in the intervention arm of the IMPACTS trial who were discharged alive without hospice care, 87 (27%) had medication errors addressed by STAR navigators in the 30 days after discharge. The most common medications involved were antibiotics (23%), heart failure medications (9%), antidepressants (7%), diabetes medications (7%), and anticoagulants (7%). Over half (56%) of errors were of omission (patients not prescribed or not taking indicated medication). 19% of errors were of commission (patients taking medication that was deprescribed), and 25% of errors were related to wrong dose or duration.

CONCLUSIONS: In a multicomponent post-sepsis intervention that reduced mortality and readmission, nurse navigators addressed medication errors in over one-fourth of patients. Medication errors spanned multiple categories including omission, commission, and dose/duration. Medication errors in this cohort of sepsis survivors were most commonly related to antibiotics but also included medications for serious comorbidities. Addressing post-discharge medication errors through transition programs like STAR is an important step in improving outcomes for sepsis survivors.

ADVANCE CARE PLANNING (ACP) IN MEDICARE BENEFICIARIES WITH ADVANCED HEART FAILURE

Sean Riley¹; Seuli B. Brill²; Madison Hyer³; Patrick M. Schnell³; Anne Schuster¹; Beth Foreman¹; Sakima Smith¹; Jillian Gustin⁴; Wendy Xu⁵; Laura Prater⁶

¹Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²Internal Medicine, Ohio State University College of Medicine, Columbus, OH; ³Biostatistics, The Ohio State University, Columbus, OH; ⁴James Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH; ⁵Health Services Management and Policy, The Ohio State University, Columbus, OH; ⁶Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA. (Control ID #3876186)

BACKGROUND: Heart failure (HF), a condition impacting nearly 7million Americans, is a leading cause of death in the United States and results in multiple hospital admissions near the end-of-life (EOL). While robust evidence remains lacking, Advance Care Planning (ACP) may improve EOL health outcomes among patients with advanced HF, including reduction in undesired hospitalizations. Large scale claims evaluation assessing the impact of billed ACP on EOL hospitalizations among patients with HF can fill key evidence gaps to inform health policy and clinical practice. This study aims to assess the impact of billed ACP delivered to Medicare beneficiaries with advanced HF upon the type and quantity of healthcare utilization in the last 30 days of life.

METHODS: This retrospective cross-sectional cohort study used Medicare fee-for-service claims from 2016 to 2020 to assess the impact of ACP utilization on EOL healthcare utilization, including total expenditure as well as five categories of healthcare: inpatient, outpatient, hospice, skilled nursing facility (SNF), and home healthcare (HHC) utilization. For presence of utilization, multivariable logistic regression was utilized to produce odds ratios (OR) and their 95% confidence intervals (95% CIs). For outcomes of number of encounters/admissions and lengths of stay, multivariable negative binomial regression with a log link was utilized.

RESULTS: In the final cohort of 48,466 patients (median [IQR] age, 83 [76-89] years; 24,838 [51.2%] women; median [IQR] CCI score, 4 [2-5]), 4,406 patients had an ACP encounter and 44,060 patients did not have an ACP encounter.) Total EOL expenditure among patients with billed ACP encounters was 19% lower (95%CI: 0.77-0.84) compared to patients without. Patients with billed ACP encounters had 2.65 times higher odds (95%CI: 2.47-2.83) of EOL outpatient utilization with a 33% higher expected total outpatient expenditure (95%CI: 1.24-1.42) compared with patients without a billed ACP encounter. Patients with billed ACP encounters had 34% lower odds (95%CI: 0.61-0.70) of having an EOL inpatient admission and 31% lower inpatient expenditures (95%CI: 0.64-0.74) compared with patients with no ACP encounter.

CONCLUSIONS: Billed ACP delivery to individuals with advanced HF occurs infrequently, but when delivered, decreases overall EOL health care expenditures. Increases in EOL outpatient services, including home health care and hospice, accompanies reductions in EOL inpatient hospital and skilled nursing facility utilization. Systematic delivery of billable ACP encounters to patients with HF may help reduce total EOL expenditures and inpatient services through promoting use of outpatient EOL services.

ADVICE ONLY, PRIMARY CARE, URGENT CARE, OR EMERGENCY DEPARTMENT: HOW DO DOCTORS TRIAGE PATIENTS WITH URGENT NEEDS?

Aaron Fried¹; Christine Gladman³; Darren DeWalt²

¹Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC; ²Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; ³Medicine, University of North Carolina, Chapel Hill, NC. (Control ID #3875022)

BACKGROUND: Use of emergency departments (ED) for the evaluation and management of non-emergent conditions strains an already stressed healthcare system and raises costs. Physicians must use clinical judgement to select the best location for a patient with urgent concerns. Our null hypothesis was that physicians would make similar triage decisions for a given patient, and we aimed to identify strategies to increase safe evaluation of urgent concerns outside of the ED.

METHODS: We surveyed physicians (n=52) at a large healthcare system in the Southeast for their triage decisions in response to 10 patient cases, each a 9 AM weekday call with different levels of urgency for evaluation, case complexity, and needed tests. Physicians were asked to recommend advice only, primary care, urgent care, or ED and describe the anticipated workup, clinical concerns, and rationale. Physicians self-reported demographics, level of training, specialty, and current practice environment.

RESULTS: 58% of respondents were attending physicians and almost all (96%) worked in academia. Participants triaged patients to all 4 clinical locations in 80% of cases and to at least 3 locations in all cases. This surprising variability existed even across cases designed to yield consensus, such as internal hemorrhoids and simple cellulitis, which were nevertheless referred to the ED in 6%. Attendings triage patients more often to outpatient settings than residents (outpatient 69% vs 56%, p=<.01). Attendings triaged 1.57 fewer patients to the ED than residents (95% CI; 0.8-2.3, p<0.01). However, among attendings, outpatient providers triage more often to outpatient settings (72%) than inpatient providers (57%, p=0.01). Inpatient providers and residents did not differ in their preference for ED triage (ED 57% vs 56%, p=0.86). Qualitative review of open-ended questions revealed that many patients were sent to the ED for imaging, a “don’t miss” mentality, or the physician’s concerns about limited outpatient appointment availability in their own practice.

CONCLUSIONS: Individual physicians triage patients with tremendous variability. Even across cases designed to minimize variability, well-trained clinicians substantiate different choices. On average, outpatient attendings are the most likely to triage patients to an outpatient evaluation, while hospital based attendings and trainees are more likely to recommend the ED. Qualitative analysis identifies policy changes that could increase comfort with outpatient evaluation including urgent imaging availability, built in same day outpatient access, and enhanced training on triage decisions.

A MIXED-METHODS, NATIONAL EVALUATION OF VETERANS HEALTH ADMINISTRATION PAIN MANAGEMENT TEAMS

Sara Edmond^1,2; Tara McMullen³; William Becker^4,2; Mark Relyea^1,2; Daniel Rogers^1,2; Aimee Kroll- Desrosiers⁵; Rebecca L. Kinney⁵; Jennifer L. Snow⁶; Jennifer Murphy³; Kathryn Lange^7,3; Friedhelm Sandbrink^8,3

¹PRIME, VA Connecticut Healthcare System, West Haven, CT; ²Yale School of Medicine, New Haven, CT; ³US Department of Veterans Affairs, Washington, DC; ⁴Internal Medicine, VA Connecticut Healthcare System, West Haven, CT; ⁵Research & Development, VA Central Western Massachusetts Healthcare System, Leeds, MA; ⁶PRIME, VA Connecticut Healthcare System, West Haven, CT; ⁷Pharmacy, VA Boston Healthcare System, Brockton, MA; ⁸Neurology, VA Medical Center Washington DC, Washington DC, DC. (Control ID #3874313)

BACKGROUND: The Veterans Health Administration (VHA)’s goal of providing universal access to high quality pain care includes implementing interdisciplinary pain management teams (PMTs) at all VHA medical centers as mandated by the 2016 Comprehensive Addiction and Recovery Act. Guidance related to this legislation outlined four required roles for PMTs (a medical provider with pain expertise, a provider with addiction expertise, a behavioral medicine provider, and a rehabilitation medicine provider) while acknowledging the value of several other specialties. The goal of this partnered evaluation was to understand the current structure of PMTs, as well as barriers and facilitators to PMT implementation.

METHODS: We partnered with VHA’s pain management office to conduct a mixed-methods national evaluation of PMT implementation. We collected facility-level surveys (n=139 facilities) focusing on team staffing and function and conducted qualitative interviews with 22 PMT clinicians (e.g., physicians, pharmacists, psychologists) from 14 facilities. Quantitative data was collected via REDCap and analyzed in STATA. Qualitative data was audio recorded, transcribed, and analyzed in NVivo.

RESULTS: While most VHA facilities (91.4%) have a PMT, less than half (40.3%) have someone in each of the four required roles. Facility PMTs reported an average of 7 unique clinicians (SD=4.9, range: 0 to 34). The required role most often missing was a clinician with addiction expertise (missing on 32.3% of teams). On facility surveys, the most commonly reported barriers to PMT implementation were staff recruitment (74%) and retention (50%). Qualitative analyses revealed five main themes. First, clinicians spoke about team communication and mutual respect as essential components of a high-functioning PMT. Second, participants discussed the relationship between the PMT and primary care, including challenges with patient flow. Third, clinicians spoke about difficulties measuring PMT success; noting that the ideal measures of success (patient functioning or satisfaction) are not easy to systematically track. Next, participants reported enthusiasm for new PMT funding, though they also expressed concerns about barriers to hiring new staff. Finally, participants commented on leadership support – with variability in their perceived support from local and national leadership, and in some cases, a desire to receive more guidance and support in how best to implement PMTs.

CONCLUSIONS: Recent funding initiatives may help understaffed PMTs, but support for staff recruitment and retention is also needed. Leadership support and guidance, particularly related to patient flow and team cohesion, will help to strengthen these interdisciplinary teams.

AN ASSESSMENT OF INDIVIDUAL PREFERENCE FOR A NOVEL CAPILLARY BLOOD COLLECTION SYSTEM

Shirin Pourafshar¹; Monisha Parikh²; Bilal Abdallah³; James Jacobson⁴

¹Becton Dickinson and Company, Franklin Lakes, NJ; ²Becton Dickinson and Company, Franklin Lakes, NJ; ³Becton Dickinson and Company, Franklin Lakes, NJ; ⁴Babson Diagnostics, Austin, TX. (Control ID #3876315)

BACKGROUND: Typical barriers to routine venous blood collection include discomfort from its relative invasive nature, time spent, and collection site accessibility. Advantages of capillary blood collection include its less-invasive nature, its requirement for smaller blood volume, and its application at ancillary healthcare settings (e.g. retail pharmacies). This study assessed individual experience with an investigational blood collection device, the BD MiniDraw™ Capillary Blood Collection System (MiniDraw), in ancillary healthcare settings, compared to prior experience with traditional venous blood collection. Additionally, preference for blood collection at ancillary healthcare settings vs. traditional laboratory patient service centers was assessed through a survey of the user experience, including trust in and professionalism of staff, time spent, and location convenience.

METHODS: A total of 113 individuals (≥18 years) with recent experience of venous blood collection were enrolled; 107 completed the study. A pre-collection survey gathered information on demographics, past experiences with venous blood collection, and experiences with traditional patient service centers and pharmacies. MiniDraw collection was conducted at three retail sites (including two pharmacies) by trained healthcare workers. A follow up survey was performed two weeks later to determine experience with, and preference for, MiniDraw and location in terms of trust, time, and convenience.

RESULTS: Some of the key findings are summarized. Among the 78 female and 36 male participants, mean age was 49 years. Previous blood collection experience was largely at a doctor’s office (35%) or traditional service center (27%). 62% of participants viewed their last venipuncture experience as a “somewhat” or “very” positive. Following capillary blood collection, 90% of participants expressed a “somewhat” or “very” positive experience with the MiniDraw at an ancillary healthcare setting. In particular, “very satisfied” responses were given for location (81%) and collection time (73%). In a subset of respondents (n=89), those reasons (convenience of pharmacy location and time savings) were most frequent for likelihood of future use.

92% of participants rated the pharmacy blood collection team as “very” or “extremely” trustworthy. Overall, 84% of participants “strongly preferred” (52%), “somewhat preferred” (13%), or had “no preference” (19%) for the MiniDraw, compared to traditional venous blood collection.

CONCLUSIONS: Most participants conveyed a positive experience with MiniDraw, primarily based on location convenience and perceived time savings. Regardless of pharmacies as nontraditional collection sites, the participants expressed a high degree of satisfaction and trust in this blood collection option. This novel service could offer a convenient alternative to individuals for blood testing and to individuals needing to monitor their medical condition more frequently and easily.

A NOVEL, MEDICAL STUDENT LED PROGRAM TO STRENGTHEN HEALTH LITERACY AND MEDICATION ADHERENCE FOR RECENTLY RESETTLED REFUGEES IN PHILADELPHIA Divya Saini¹; Victoria Lord¹; Menaka Dhingra²; Rachael Truchil²

¹Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²Internal Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #3875139)

BACKGROUND: Newly resettled refugees face multiple challenges when initiating medical care in the United States including language barriers and low health-literacy that make adherence to treatment plans difficult. This can lead to medical and psychosocial complications, reduced quality of life, and increasing referral costs (UNHCR, 2019). The Penn Center for Primary Care Refugee Clinic provides initial assessments and medical care for newly resettled refugees in Philadelphia. A patient navigation program was designed to help improve outcomes for this vulnerable population.

METHODS: This patient navigation pilot program will run from December 2022 to May 2023. Medical student volunteers will attend refugee clinic visits to observe and learn the care plan including prescribed medications, tests, and follow-up. Two days after each clinic visit, the student will call the patient with interpreter assistance and use standardized questions to assess if the patient has questions about the visit, were able to pick up prescriptions, and understands the follow-up plan. Students will counsel patients when they can and communicate remaining questions or obstacles to the relevant physicians and resettlement agency to address remaining needs.

The number of patients contacted by medical students will be tracked. Quantitative data will be collected for each call to determine if the patient 1) had questions about the visit, 2) obtained prescribed medications, 3) was taking medications correctly, and 4) understood follow-up plan. At the end of the pilot, interviews will be conducted with clinic physicians, students, the resettlement agency staff, and patients to assess program reach and acceptability. Interviews will be coded thematically and analyzed to assess barriers to adherence and to identify common questions.

RESULTS: To date, two iterations of the pilot have run showcasing successful engagement between students, patients, residents, and the resettlement agency. Two patients received appropriate care that would have otherwise been missed due to the medical student’s call and, notably, without additional work by clinic physicians.

CONCLUSIONS: The findings from this work may apply to clinics serving patient populations that struggle with medical adherence and low health literacy due to social determinants of health, novelty in interfacing with new healthcare systems, or language differences. It creates opportunities for medical students early in training to play a key role in the health care delivery team to provide valuable inter-visit care and improve patient outcomes. This low-cost, high-yield patient navigation program has the potential to enhance the experience and treatment of vulnerable patient populations.

A NOVEL SHORT-TERM STAFFING AND TELEHEALTH PROGRAM WITH IMPLICATIONS FOR PRIMARY CARE WAIT-TIMES IN THE VHA

Amy M. O'Shea¹; Peter J. Kaboli²; Bjarni Haraldsson³; Ariana Shahnazi⁴; Matthew R. Augustine⁵

¹Research, Iowa City VA Healthcare System, Iowa City, IA; ²Internal Medicine, Iowa City VAMC, Iowa City, IA; ³Research, Veterans Health Administration, Washington, DC; ⁴CADRE, Iowa City VA Medical Center, Iowa City, IA; ⁵HSR&D, US Department of Veterans Affairs, Bronx, NY. (Control ID #3855662)

BACKGROUND: The Clinical Resource Hub (CRH) is a Veterans Health Administration (VHA) initiative implemented in October 2019 to fill short-term provider vacancies within primary care (PC) via telemedicine.

One year after the COVID19 pandemic started, VHA clinics experienced a near universal increase in wait- times. Our objective was to determine if CRH modified the wait time increase over this period.

METHODS: Over the 18-month study period (March 2021 - August 2022), 649 PC clinics were included. This start time was chosen as wait-times first normalized in March 2021 after dramatic decline a year prior.

Clinics were the unit of analysis, where CRH user clinics were those with >10 PC CRH visits/month for two consecutive months, yielding 53 CRH user and 596 non-user clinics. Clinics were stratified as small, medium, or large (i.e., 450-2,399, 2,400-9,999, and ≥10,000 unique PC patients). Outcomes included established and new patient wait times (EPWT; NPWT) defined as the average number of days established or new patients wait for a PC appointment in a clinic-month. We estimated wait-time differences at study start and test for CRH modification using linear regression with interaction.

RESULTS: At study start, small and medium CRH user clinics exhibited shorter EPWT compared to non- CRH users of -20.7 days (95% CI -31.3, -10.2; p<0.001) and -8.6 days (95% CI -13.5, -3.7; p=0.001), respectively. Large clinics exhibited no difference in baseline EPWT. EPWT increased over time with no significant difference among CRH and non-CRH user clinics by size (Small: β=-0.03, p=0.96; Medium, β=-0.11, p=0.65; Large; β=-0.33, p=0.42). For NPWT, small CRH user clinics had longer wait-time by 6.8 days (CI 2.33, 11.3, p=0.003), while medium and large clinics exhibited no difference in NPWT at study start (medium: 0.6 days (CI -1.5, 2.7), p=0.59; large: -0.4 days (CI -4.6, 3.7), p=0.84). NPWT did not differ significantly for small CRH users versus non-users over time (β= -0.25, p=0.30), though small non-CRH users modestly increased NPWT (0.28 days/month, p<0.001). For large clinics, NPWT increased at a greater rate among CRH users (CRH: 1.2 days/month (CI 0.9, 1.6) vs. non-CRH users: 0.7 days/month (CI -0.6, 0.8);

β=0.53, p=0.011).

CONCLUSIONS: Clinics using CRH experienced shorter wait-times for established patients; however, CRH services may have prolonged new patient wait-times among large clinics. Further evaluation is needed to determine the factors of a virtual care service like CRH that differentially impact established and new wait- times across clinic sizes as patients are recalled and may desire in-person care.

A QUALITATIVE STUDY OF PRIMARY CARE TIME SCARCITY, CARE QUALITY, AND PHYSICIAN WELL-BEING

Michelle-Linh T. Nguyen¹; Vlad Honcharov¹; Dawna Ballard²; Urmimala Sarkar¹

¹Department of Medicine, University of California San Francisco, San Francisco, CA; ²Communication Studies, The University of Texas at Austin, Austin, TX. (Control ID #3873078)

BACKGROUND: The feeling of not having enough time, or time scarcity, is a well-developed construct in communication science, and has become characteristic of outpatient medical practice. We explored how primary care physicians (PCP) adapt their practice to time scarcity & how this affects their choices and perceptions of care quality, work-related satisfaction, & wellbeing.

METHODS: This study included surveys & in-depth interviews of 25 U.S.-based internal medicine- & family medicine-trained PCPs who had greater than 50% full-time equivalent clinical workload & represented a wide range of clinical experience & practice settings. Validated surveys included demographic/practice characteristics, temporal experience (Organizational Temporality Scale), & wellbeing (Mini-Z Burnout Survey). Interviews explored how physicians adapt their practice to time scarcity during a typical clinic day. We performed a thematic analysis of semi-structured interviews using deductive & inductive approaches.

RESULTS: 14 female & 11 male PCPs participated. Two PCPs owned their own practice, while the rest worked as employees. 9 PCPs practiced in California; the others practiced in Arizona, Colorado, Georgia, Illinois, Montana, New York, North Carolina, Pennsylvania, Texas, & Utah. 18 reported that their workplace accepts Medicaid insurance. 11 have practiced primary care 1-5 years, 5 have practiced 21+ years. All participants expressed that time scarcity affects how they care for their patients. Mismatch between allocated time & work expectations led to feelings of guilt, exhaustion, & burnout. Participants cited sacrifices that affect patients (patient education, clear communication, understanding the patient’s concern) & physicians (personal time, learning, eating lunch, joy in work). Participants described constant tension between providing care that fulfilled their own standards (i.e. not ordering unneeded tests & referrals) with having their work overflow outside of work hours leading to exhaustion and burnout: “I wanted to maintain the quality of what I did, but it became unmanageable & not sustainable.” In an effort to practice sustainably, many physicians sought ways to see fewer patients by increasing non-clinical duties, cutting work hours, or switching to other models of primary care: “I want to make this sustainable… but at this pace, I don’t think I realistically can for my own wellbeing. I probably would cut down [to] two days a week.”

CONCLUSIONS: Most physicians voiced an inability to provide the quality of care they believe to be acceptable due to time scarcity. A mismatch between time allocation and care expectations drives feelings of burnout among PCPs and may contribute to physician shortage. Time scarcity may also be a driver of quality of care, as it leads to unnecessary tests & referrals. In order to address workforce sustainability and global care quality in primary care, health care systems & policymakers should address physician time scarcity.

ARE HOSPITALS IN MARKETS WITH HIGHER SHARES OF MARGINALIZED POPULATIONS LESS LIKELY TO PARTICIPATE IN BUNDLED PAYMENTS?

Aidan P. Crowley¹; Chuxuan Sun^1,4; Qian Huang¹; Deborah S. Cousins¹; Torrey J. Shirk¹; Joshua M. Liao^2,3; Said Ibrahim⁵; Amol S. Navathe^1,3

¹Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²University of Washington Department of Medicine, Seattle, WA; ³Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; ⁴Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ⁵Medicine, Northwell Health, New Hyde Park, NY. (Control ID #3877089)

BACKGROUND: Medicare has expanded alternative payment models (APMs) including voluntary bundled payment programs. While these models have demonstrated generally favorable results on cost and quality, it remains unknown how uneven participation by hospitals may lead to disparities in access to practice redesign innovations for racial/ethnic minorities and patients of low socioeconomic status. Our objective was to examine whether hospitals serving communities with higher proportions of marginalized individuals were less likely to participate in the latest voluntary program, Bundled Payments for Care Improvement Advanced (BPCI-A).

METHODS: We defined communities using Hospital Service Areas (HSAs) representing 3,436 local markets nationwide. Our study population included all Medicare fee-for-service (FFS) patients aged 65 and older from 2010-2012 (pre-BPCI period). Each community’s share of marginalized patients was calculated separately for each of the share of beneficiaries of Black race, Hispanic ethnicity, or dual eligibility for Medicare and Medicaid out of all Medicare FFS-enrolled beneficiaries. Our primary outcome was a dichotomous variable indicating whether a given HSA had at least one hospital that ever participated in BPCI-A from 2018-2022. We used ordinary least squares regression controlling for patient and market factors to evaluate the association between community participation in BPCI-A and the share of each marginalized group. Patient control variables averaged at the market level included gender, age, and comorbidity score. Market control variables included number of Medicare FFS beneficiaries, provider capacity, hospital and skilled nursing facility concentration, Medicare Advantage penetration, metropolitan setting, and concurrent non-BPCI-A APM participation.

RESULTS: Hospitals in HSAs with higher-quartile shares of dual-eligible individuals were less likely to participate in BPCI-A than hospitals in HSAs with the lowest quartile of dual-eligible individuals (Q4: -0.18 percentage points [pp] lower than Q1, p<0.0001; Q3: -0.16pp, p<0.0001; Q2: -0.10pp, p=0.0002). There was no consistent significant relationship between market proportion of Black beneficiaries and hospital likelihood of participating in BPCI-A (Q4: -0.03pp, p=0.38; Q3: 0.06pp, p=0.11; Q2: 0.04pp, p=0.31). Hospitals in HSAs with higher-quartile shares of Hispanic beneficiaries were more likely to participate in BPCI and BPCI-A than those in the lowest quartile (Q4: 0.15pp, p<0.0001; Q3: 0.13pp, p<0.0001; Q2: 0.01pp, p=0.63).

CONCLUSIONS: Hospitals in communities with greater shares of dual-eligible beneficiaries were less likely to participate in BPCI-A. Policymakers should consider approaches to incentivize more socioeconomically uniform participation in voluntary bundled payments to improve equity in access to practice redesign interventions. These approaches may include models focused on hospitals serving more complex populations or mandatory rather than voluntary participation.

ASSOCIATION OF LIMITED ENGLISH PROFICIENCY STATUS WITH PREVENTIVE SERVICE RECEIPT AND PATIENT EXPERIENCE IN THE PRIMARY CARE SETTING AMONG MEDICARE BENEFICIARIES

Pooja Chandrashekar¹; Ishani Ganguli²

¹Harvard Medical School, Boston, MA; ²Department of Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #3875603)

BACKGROUND: While older adults with limited English proficiency (LEP) face barriers to accessing primary care providers (PCPs), it is unclear how LEP status may influence patient experience in the primary care setting among those with a usual provider. Also, patients with LEP may benefit from having someone accompany them to visits (“accompaniment”), but there is little evidence to support this. In this study, we analyzed (1) the association of LEP status with preventive service receipt and patient experience with their usual provider, and (2) whether accompaniment is associated with these outcomes among older adults with LEP.

METHODS: Using 2019 data from the nationally representative Medicare Current Beneficiary Survey, we performed a cross-sectional analysis of community-dwelling Traditional Medicare and Medicare Advantage beneficiaries ≥65-years-old. Those who reported speaking English less than “very well” were “LEP” and all others were “non-LEP.” We used multivariable logistic regression to assess the association of LEP status with receipt of preventive services and with patient experience, adjusting for sex, age, race, ethnicity, income, education, rural location, insurance type, dual eligibility, and health status. Among adults with LEP, we used multivariable logistic regression to compare these outcomes between patients with and without accompaniment.

RESULTS: Between adults with (N=2,534) and without (N=8,690) LEP, there were no differences in preventive service receipt, including blood pressure checked (past year), cholesterol checked (past 5 years), influenza vaccine (last winter), pneumonia vaccine (ever), or shingles vaccine (ever). Compared to adults without LEP, adults with LEP had lower odds of reporting that providers asked about their life (OR: -3.82, 95% CI: -6.06, -1.58), explained things clearly (-4.25, CI: -6.71, -1.78), listened (-3.16, CI: -5.61, -0.72), showed respect (-2.28, CI: -4.67, 0.12), spent enough time with them (-2.59, CI: -5.04, -0.13), or helped them meet health goals (-2.49, CI: -4.65, -0.33).

Among adults with LEP, 871 reported accompaniment and 1,662 did not. Compared to those without accompaniment, those with accompaniment had greater odds of a blood pressure check, but no significant differences in receipt of any other services. Compared to LEP adults without accompaniment, those with accompaniment reported higher odds of providers asking about their life (1.27, CI: 1.03, 1.57), explaining things clearly (1.57, CI: 1.27, 1.95), listening (1.51, CI: 1.20, 1.90), showing respect 1.85, CI: 1.42, 2.41), spending enough time with them (1.35, CI: 1.08, 1.69), talking about health goals (1.70, CI: 1.37, 2.11), and helping them meet goals (1.62, CI: 1.30, 2.01).

CONCLUSIONS: Compared to older adults without LEP, older adults with LEP had similar odds of receiving preventive services but had poorer experiences with their usual providers. Strategies to facilitate accompaniment may improve care for this population.

A SURVEY-BASED ASSESSMENT OF BARRIERS AND FACILITATORS TO PRESCRIBING MEDICATION FOR OPIOID USE DISORDER IN RURAL SETTINGS.

David Chen¹; Sonia Sehgal²; Nicola E. Lanier²; Annika M. Hansen²; Nicholas P. Hansen³; Michael A. Incze¹

¹Internal Medicine, University of Utah Health, Salt Lake City, UT; ²School of Medicine, The University of Utah School of Medicine, Salt Lake City, UT; ³University of California San Francisco School of Medicine, San Francisco, CA. (Control ID #3876369)

BACKGROUND: The effectiveness of medications for opioid use disorder (MOUD) is well-established. Despite increasing rates of opioid overdose, prescribing remains low amongst rural physicians. This study aims to elucidate the reasons behind low rates of MOUD prescribing in rural communities, as well as to identify factors that facilitate the prescription of MOUD, with the intent of finding solutions to address these issues.

METHODS: Physicians from select partnering rural health systems were invited to complete a survey. Demographic information included time spent in a rural practice environment, practice location, types of MOUD prescribed, and the status of their MOUD practice (never a prescriber, former prescriber, current prescriber not accepting new patients, and current prescriber accepting new patients). Participants were asked to rank 6 pre-specified barriers to prescribing MOUD in terms of their significance, and were asked to do the same for 6 pre-specified facilitators. Participants were also able to leave free-text comments identifying additional barriers and facilitators. The mean ranking of each barrier and facilitator was used to determine an aggregate rank list.

RESULTS: 31 physicians located in Utah, Wyoming, and South Dakota participated in our survey. Most participants (68%) worked in a rural setting between 6 to 12 months per year. Most participants (71%) were current prescribers of MOUD accepting new patients, while 23% were never a prescriber. Of those who did prescribe MOUD, all but one (>95%) prescribed buprenorphine-based therapies, 81% prescribed XR naltrexone, and one participant administered methadone (through an Opioid Treatment Program).

The top 3 barriers identified by participants were lack of mental health resources, poor social support for patients, and insufficient time. Concerns about patient population or diversion, buprenorphine training requirements, and concerns about financial reimbursement were ranked as less significant barriers. Participants also commented on lack of community knowledge, frequent visits, few options for specialist referral, and stigma as additional barriers.

The top 3 facilitators identified by participants were extra support staff, positive social support for patients, and access to specialist consultation. Fewer patients, increased reimbursement or extra pay, and improved insurance coverage were ranked as less significant facilitators. Participants also commented on the need for pharmacy support, professional mentorship, and stigma training for staff.

CONCLUSIONS: Our sample of rural MOUD prescribers identified access to mental health resources, specialist consultation, and stong social supports for patients as key ways to support uptake among MOUD for rural clinicians. Academic health centers can play an important role in supporting rural MOUD provision through sustained engagement via telehealth interventions, multidisciplinary educational initiatives, and training local champions.

CAN IMPROVING PATIENTS’ KNOWLEDGE ABOUT CHAPLAINS’ ROLES INCREASE DESIRE FOR ASSISTANCE IN A PRIMARY CARE SETTING?

Patrick Hemming¹; Katherine Henderson²; John P. Oliver²

¹Department of Medicine, Duke University School of Medicine, Durham, NC; ²Chaplain Services, Duke University Health System, Durham, NC. (Control ID #3842499)

BACKGROUND: Patients have limited awareness of health care chaplains’ training and scope of practice, which may influence their openness and desire to engage with a chaplain in the medical context, such as an outpatient clinic.

METHODS: Methods: We designed a quasi-experimental pre-post study of outpatients and family members attending appointments at our internal medicine primary care clinic. We surveyed 174 respondents in Nov 2019 and Sep 2021 regarding their factual knowledge of 10 true-false questions about chaplains, and their desire for chaplain services in eight hypothetical scenarios. To study the effect of providing factual information about chaplains to patients, we conducted a post-survey of 91 respondents in January 2022 of patients who received and read short brochures about chaplain services. We hypothesized that compared with controls, patients who received and read the brochures would have increased awareness about chaplains and higher desire to engage with chaplains. Pre- and post- responses were compared using chi-square statistics, multiple linear regression and multiple logistic regression to examine associations.

RESULTS: Receipt of the brochure was associated with a small increase in patients’ correct understanding of chaplains’ roles and training by an average of 1 of 10 questions (mean of 6.8 post vs. 5.8 pre, p=0.02); however, provision of the brochure did not appear to have a measurable impact on participants’ desire for a chaplain’s help in the eight hypothetical scenarios (mean of 5.5 post vs. 5.1 pre, p=0.41). Correct understanding of one factual question (chaplains’ main role is not administering last rites) was associated with greater desire in the following two scenarios: Desire for having help when grieving a loss (80 % vs 62%, p=0.05) and having a chaplain as a listening ear (83 % vs. 67). Besides the provision of the brochure, correct answers on factual questions were most associated with education level and race. Desire for a chaplain’s service was associated with higher religiosity, female gender, and timing of survey prior to the COVID19 pandemic.

CONCLUSIONS: Provision of factual information about health care chaplains’ role and training can improve patients’ understanding of what a chaplain does; however, the improved knowledge may not be as important in influencing patients’ desire for chaplain assistance as other personal factors.

CHANGES IN HIGH-COST UTILIZATION ASSOCIATED WITH GROWTH OF HOME TELEHEALTH SERVICES FOR DIABETES CARE IN VETERANS HEALTH ADMINISTRATION Ashok Reddy^2,1; Eric Gunnink²; Jorge Rojas Jr.²; Karin Nelson^2,1; Edwin S. Wong²

¹Medicine, University of Washington System, Seattle, WA; ²US Department of Veterans Affairs, Seattle, WA. (Control ID #3873400)

BACKGROUND: Home telehealth (HT) services bridges the gap between office and home management of diabetes, and can avert high-cost utilization such as emergency department (ED) care. In the Veterans Health Administration (VHA), HT services for diabetes care has rapidly expanded. However, little is known about the real-world impact of the expansion of these services on utilization. Our aim is to evaluate the impact of HT services in VHA on high-cost utilization.

METHODS: We applied an innovative cross-temporal difference-in-differences approach using the rapid expansion of HT in VHA over time as a natural experiment. The method uses propensity score methods to identify two groups of patients: 1) Non-users of HT in 2010 and users of HT in 2018 , and 2) Non-users of HT in 2010 and 2018, respectively. Propensity score models estimated HT use as a function of patient and provider characteristics using a gradient boosting algorithm. We then implemented difference-in-differences models using logistic regression to examine the association of HT use on the probability of using three types of high-cost utilization: ED visits, all-cause hospitalization, and hospitalizations for ambulatory care sensitive conditions (ACSCs).

RESULTS: Veterans receiving HT services for diabetes totaled 4,668 in 2010 and 12,073 in 2018. We identified 1,226,482 veterans with diabetes who were non-HT users in 2010 and 1,420,986 in 2018. Veterans in our sample had a mean age of 68 years old (SD = 11 years), were 96.2% male and had an average hemoglobin A1c (HbA1c) of 7.3% (SD = 2.8%). The increase in HT use was associated with a greater probability of receiving an ED visit (6.1% points 95% CI [4.1%, 8.0%]), all-cause hospitalization (3.4% points 95% CI [2.4%, 4.7%]), and ACSC hospitalization (1.32% points 95% CI [0.8%, 1.9%]).

CONCLUSIONS: We found growth of HT-services to support diabetes care was associated with an increase in high-cost utilization. Our work suggests that this increase access to chronic disease care may lead to additional needs for Veterans in the ED or hospital. These results support that HT services likely provide a complement rather than a substitute for diabetes care among Veterans.

CHARACTERIZING PATIENT PERSPECTIVES ON FACTORS IMPACTING BEING ON ACTIVE SURVEILLANCE FOR LOW-RISK PROSTATE CANCER

Shannon Johnson¹; Sarah Hawley^1,3; Aaron J. Rankin¹; Ted A. Skolarus^2,3; Archana Radhakrishnan^1,3

¹Internal Medicine, University of Michigan, Ann Arbor, MI; ²Urology, University of Michigan, Ann Arbor, MI; ³VA Ann Arbor Healthcare System, Ann Arbor, MI. (Control ID #3876471)

BACKGROUND: The number of men with low-risk prostate cancer who are on active surveillance (AS) is rapidly increasing. AS requires routine physical exams, lab tests, imaging and prostate biopsies, however, not all men receive all the recommended components. Reasons for why men do not receive the testing are unclear.

METHODS: Between June 2020-March 2021, we conducted in-depth, semi-structured, virtual interviews with 15 men with low-risk prostate cancer who were on AS as their primary management strategy and their partners. Our interview guide was based on the Theoretical Domains Framework (TDF), an implementation science framework developed to understand determinants of behaviors and to inform the design of interventions. Questions assessed general knowledge of AS, barriers and facilitators to adherence, and preferences for provider roles in AS management. Interviews were recorded, transcribed, and deductively coded into TDF domains and constructs. Three independent coders iteratively developed and used a shared coding framework. Participant recruitment continued until data saturation by group.

RESULTS: Our study included 15 men (on AS between 1-16 years) and 5 partners. Most commonly, patients reported knowledge and social influences as key factors impacting their AS management. Men wanted to know what to expect for their surveillance and be actively involved in treatment decision making. For example, many men reported not having complete discussions with their urologist around pain with biopsies, which impacted their decision about their next biopsy. Clear communication from their urologist and between their urologist and primary care provider was important to achieve this. Additionally, men discussed the importance of peers (e.g., “If you can get people in a support group, it offers a lot of benefits”), both to enhance knowledge and to allow them to discuss “a sensitive topic”.

CONCLUSIONS: Insight into the patient perspective creates opportunities to optimize AS for low-risk prostate cancer. To ensure men receive and maintain on AS, patient-centered interventions focusing on knowledge, enhanced communication among the care teams involved, and augmenting with peer support will be important.

COLORECTAL CANCER SCREENING IMPROVEMENT PROGRAM VIA FECAL IMMUNOCHEMICAL TESTING IN A LARGE VETERANS AFFAIRS HEALTH SYSTEM

Jin Xu^2,1; Jeffrey Kravetz^2,1; Juliette F. Spelman^2,1; Petr Protiva^2,1; Daniel G. Federman^2,1; Kimberley R. Roy²; Vincent E. Lilly²; Danielle Cosentino²; Christopher Ruser^2,1

¹Yale University School of Medicine, New Haven, CT; ²VA Connecticut Healthcare System, West Haven, CT. (Control ID #3872095)

BACKGROUND: Colorectal cancer (CRC) screening rates decreased in the COVID-19 pandemic, with procedural modalities being disproportionally affected. In 2021, the U.S. Preventive Services Task Force lowered the recommended initial CRC screening age from age 50 to 45, adding to the backlog of unscreened patients. In the VA Connecticut Healthcare system, we implemented a program to promote the use of fecal immunochemical testing (FIT) to increase CRC screening rates.

METHODS: The program included the following components: 1) Creation of a team comprising hospital leadership, primary care, nursing, gastroenterology, laboratory, informatics, and group practice management, 2) Staff education, 3) Development of a patient letter template in the electronic medical record (EMR) to introduce CRC, screening, and FIT, linked to a FIT laboratory order, 4) Addition of FIT to the EMR gastroenterology order menu, 5) Development of a data set, divided by each primary care team, or patient- aligned care team (PACT), of average-risk veterans ages 45-52 due for CRC screening. Each PACT was sent an encrypted email with a list of their patients, a patient-facing FIT instruction sheet, and instructions to send each patient a “FIT package,” which included the FIT letter, a FIT kit, and an instruction sheet. Reminder letters were sent three weeks after FIT packages were mailed, and 6) Adding the CRC screening improvement project to the primary care physician performance pay incentive.

RESULTS: The CRC screening improvement program was launched with a clinician education session on 11/24/2021. An all-primary care-staff education session was delivered on 4/5/2022, with instructional emails sent to PACTs on the same day. In the three months preceding the clinician education session, an average of 333 FIT per month were ordered, with numbers increasing in the subsequent four months, peaking in the months following the all-staff educational session. In the three months after the all-staff educational session, an average of 902 FIT per month were ordered, with highest numbers ordered in April and May 2022 - 1126 and 959, respectively.

CONCLUSIONS: Our proactive CRC screening program, centered on mailed FIT outside of the traditional patient visit, substantially increased the utilization of FIT in VA Connecticut.

COMORBID HEALTH AND SOCIAL CONDITIONS AMONG PARENTS OF HOSPITALIZED CHILDREN ENROLLED IN THE COMMUNITYRX-HUNGER RCT

Deborah Burnet¹; Jyotsna S. Jagai¹; Emily Abramsohn¹; Mellissa M. Grana¹; Doriane Miller¹; Victoria Winslow²; Stacy T. Lindau³

¹Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ²OBG, University of Chicago Division of the Biological Sciences, Chicago, IL; ³Ob/Gyn and Geriatics and Palliative Care, University of Chicago, Chicago, IL. (Control ID #3877243)

BACKGROUND: Increasingly, adult and pediatric practices are adopting social care interventions to mitigate health-related social risks (HRSRs) resulting from social and structural inequities. CommunityRx- Hunger (CRxH) is a low intensity, high scale social care intervention, delivered to parents and caregivers of hospitalized children. CommunityRx systematically connects parents to community resources to support self- and social care needs, including food insecurity, the most prevalent HRSR in most care settings. The confluence of parental social and medical comorbidities can hinder care for and recovery of a child with serious medical illness. The objective of this study is to describe the prevalence of HRSRs in relation to chronic illness/conditions and self-efficacy among parents of hospitalized children enrolled in CRxH, a double blind randomized controlled trial.

METHODS: Parents or caregivers (“parents”) of children hospitalized in an urban academic children’s hospital were enrolled between 11/2020-6/2022 (N=640). Self-efficacy for finding community resources was assessed at baseline using a 5-point Likert scale (1=not at all confident to 5=completely confident). One week following discharge, parent comorbidities were assessed using the Charleson Comorbidity Index (CCI). HRSRs (food insecurity, housing instability, transportation issues, utility concerns, and interpersonal violence and safety concerns) were assessed at one week using the Accountable Health Communities (AHC) screening tool. Chi square tests were used to assess bivariate associations and ANOVA was used to assess self-efficacy by medical comorbidities.

RESULTS: Parents for whom complete comorbidity data were available (n=519) predominantly identified as non-Hispanic Black (78%), female (94%) and the parent of the hospitalized child (94%). Nearly half (44%) reported at least one chronic illness/condition, including asthma (n=154, 31%), arthritis (n=62, 12%) and diabetes (n=44, 9%). Among both groups, food insecurity was the most prevalent HRSR (25%), followed by housing instability (21%), utilities and transportation difficulties (20% each) and interpersonal violence (6%). Compared to caregivers without chronic illness/conditions, parents with at least one had significantly higher rates of housing instability (p=0.04) and transportation difficulties (p=0.02), and lower self-efficacy for finding resources compared to parents with no chronic illness/conditions (3.9 vs. 4.1), although this difference was not statistically significant.

CONCLUSIONS: This analysis demonstrated a high rate of morbid conditions among caregivers of hospitalized children. Caregivers with more comorbidities also reported more HRSRs. This finding may help us target screening and services better for hospitalized patients and their families, especially when a technology-assisted, multidisciplinary approach is used.

COMPARISON OF CONTINUITY AND CARE UTILIZATION PATTERNS FOR HOMELESS- EXPERIENCED VETERANS USING TAILORED PRIMARY CARE VERSUS MAINSTREAM CLINICS

Kevin R. Riggs¹; Aerin deRussy²; Audrey Jones⁴; April Hoge³; Sally K. Holmes⁵; Joshua S. Richman⁶; Ann E. Montgomery⁷; Lillian Gelberg⁸; Adam J. Gordon⁴; Stefan Kertesz⁹

¹Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL; ²Research , Birmingham VA Medical Center, Birmingham, AL; ³Health Services Research and Development, US Department of Veterans Affairs, Washington, DC; ⁴Internal Medicine, The University of Utah School of Medicine, Salt Lake City, UT; ⁵VAHS , VA Birmingham, Bourne, MA; ⁶SURGERY, The University of Alabama at Birmingham, Birmingham, AL; ⁷Birmingham VAMC, U.S. Department of Veterans Affairs, Birmingham, AL; ⁸Family Medicine, University of California Los Angeles, Los Angeles, CA; ⁹Medicine, Birmingham VA Medical Center & U. Alabama Birmingham, Homewood, AL. (Control ID #3855664)

BACKGROUND: Continuity is a key aspect of high-quality of primary care (PC). Vulnerable populations, including those with a history of homelessness, often have the most fragmented care despite having even more to gain from higher PC continuity. Some Veterans Administration (VA) clinics have PC clinics tailored for Veterans with homeless experience (VHE), termed Homeless-Patient Aligned Care Teams (H-PACTs). This study compared PC continuity and health care utilization between VHEs in H-PACTs to VHEs in mainstream VA PC clinics. We hypothesized PC continuity would be better in H-PACTs.

METHODS: This was a retrospective cohort study of VHEs (n=5,766) at 26 VAs and participated in a national survey conducted in 2018. Survey data was linked to VA health records data. Analysis was limited to VHEs with >2 PC visits in the 12 months prior to survey (n=3,882). We calculated Usual Provider of Care (UPC) measure, which is the proportion of PC visits with their most frequently seen provider. We defined high PC continuity as UPC >0.75. We also compared mental health visits, other medical and surgical outpatient visits, emergency department (ED) visits, and hospitalizations. Finally, we used multivariable logistic regression models to compare PC continuity adjusting for survey-derived demographics, psychosocial, medical and mental health indicators, and site effects.

RESULTS: Compared to those in mainstream clinics, VHEs in H-PACTs had higher mean UPC (0.86 vs 0.82, p <0.01), and were more likely to have high PC continuity (75% vs 67%, p <0.01). Compared to those in mainstream clinics, VHEs in H-PACTs had more PC visits, fewer other medical/surgical outpatient visits, and were less likely to have an ED visit (Table). After adjustment for potential confounders, care in H-PACTs remained a significant predictor of high PC continuity (OR = 1.9, 95% CI 1.7-2.1).

CONCLUSIONS: H-PACT clinics outperformed mainstream PC clinics on measures of PC continuity, with some reductions in medical/surgical clinic visits and ED use. Overall, the H-PACT model appears to be delivering promising results in access and care continuity, and may serve as a model to improve health care delivery for other vulnerable populations.

COVID-19 CASES, HOSPITALIZATIONS, AND DEATHS AVERTED BY A LARGE METROPOLITAN AREA CONTACT TRACING PROGRAM: JUNE 2020 TO JUNE 2021

Theodore G. Long¹; Cara Feldkamp²; Kathleen Blaney³; Neil Vora³; Jacqueline Bray⁴; Chris Keeley⁵; Laura Neck²; Peter H. Kilmarx⁷; Jay K. Varma⁶

¹Ambulatory Care & Population Health, NYC Health + Hospitals, New York, NY; ²Test and Trace, New York City Health and Hospitals Corporation, New York, NY; ³New York City Department of Health and Mental Hygiene, New York, NY; ⁴New York State Department of Health, Albany, NY; ⁵Ambulatory Care, New York City Health and Hospitals Corporation, New York, NY; ⁶Population Health Sciences, Weill Cornell Medicine, New York, NY; ⁷John E. Fogarty International Center, National Institutes of Health, Bethesda, MD. (Control ID #3877078)

BACKGROUND: Between June 2020 and June 2021 our large, mid-Atlantic area experienced over 749K cases, 54K hospitalizations, and 11K deaths from COVID-19. Starting June 2020, our municipal healthcare agency ran a case investigation and contact tracing (CICT) program to mitigate the spread of COVID-19. Tracers investigated cases, elicited contacts, informed affected persons to isolate/quarantine, and provided supportive services to infected and exposed persons. During this period, our CICT program successfully reached nearly 90% of known COVID-19 cases. Post-intake, tracers monitored cases and contacts for up to 10 days to evaluate symptoms and advise on isolation/quarantine. CICT tracers were locally hired and spoke over 50 languages. Difficult to reach individuals had home visits by specialized tracers. The wildtype virus remained the dominate local strain during this period. Here, we evaluate the impact of the first year of our CICT program on COVID-19 cases, hospitalizations, and deaths averted from June 1, 2020 to June 13, 2021.

METHODS: We used CDC's COVIDTracer Advanced (a susceptible, exposed, infected removed model for case forecasting) to estimate the number of cases averted by CICT. We used CICT data collected during this period for the model inputs. Because some inputs fluctuated, we ran four scenarios where we varied a) the lag between infection and the start of isolation/quarantine, and b) the percentage of people who correctly

followed isolation/quarantine advice. We segmented the study period into two-week windows and fitted error-minimizing curves between observed and model-generated case counts for each window to estimate the combined impact of non-CICT interventions; the remaining cases averted were attributed to CICT. From cases averted, we calculated hospitalizations and deaths averted using proportional relationships in publicly reported data.

RESULTS: Between June 2020 and June 2021, CICT averted an estimated median of 532,445 caes, 38,449 hospitalizations, and 7,498 deaths. Our outputs from COVIDTracer Advanced estimated a 23% reduction in transmission attributable to CICT. Scenarios ranked highest to lowest in cases averted were 2, 1 4, and 3, lag time to isolating had the greatest impact on cases averted, followed by adherence to isolation/quarantine.

CONCLUSIONS: CICT had a substantial impact on reducing transmission of COVID-19 in a dense urban area and should be considered in a similar public health emergency. Importantly, there was a positive relationship between adherence to isolation/quarantine and CICT effectiveness, reinforcing the value of helping cases and contacts separate safely by providing resources such as food and medication delivery, information about paid sick leave, and free hotel stays for cases and contacts. Solutions to reduced lag time to isolation, such as test result processing, should be a focus for future efforts.

COVID-RELATED PRIMARY CARE DISRUPTIONS AMONG HIGH-RISK PATIENTS IN THE VETERANS HEALTH ADMINISTRATION

Linnaea C. Schuttner^1,2; Erin L. Jaske¹; Karin Nelson^1,2; Ashok Reddy^1,2

¹VA Puget Sound Health Care System, Seattle, WA; ²Medicine, University of Washington, Seattle, WA. (Control ID #3872561)

BACKGROUND: During the COVID pandemic, telehealth use rapidly increased in the Veterans Health Administration (VHA). Less is known how this impacted patients at high-risk of adverse outcomes, who may have differing care needs than lower-risk patients. We sought to describe primary care utilization and perceived access for high-risk patients during the COVID pandemic.

METHODS: High-risk Veterans had risk scores predicting hospitalization or mortality >75%/year on 3/10/20 and were included if alive and empaneled in primary care through follow-up. We assessed 3 periods from VHA administrative data (by mode: in-person; virtual (e.g., telephone, video, secure messaging)): baseline (3/11/19-3/10/20), year 1 (Y1, 3/11/20-3/10/21), and year 2 (Y2, 3/11/21-3/10/22) of the pandemic. Perceived access (% reporting “best” in Likert-scale vs. all lower ratings) was from Survey of Healthcare Experiences of Patients (10% outpatient sample, nonresponse weighted); Y2 data not yet available. Descriptives are per-facility means; where indicated, patient-level stratification was by Gagne Comorbidity score (low (< 3) vs. high (> 3)).

RESULTS: At baseline (03/2019-03/2020), 1,311,385 high-risk patients, mostly older (76.6% >65y) men (93.9%), were active in VHA primary care. Per facility, total visits to primary care increased during pandemic year 1 (03/2020-03/2021) and returned to baseline rates by year 2 (03/2021-03/2022, Table). While 18.4% of high-risk patients were existing virtual care users at baseline, sustained increases were seen in years 1 (45.3%) and 2 (31.7%), especially among high-comorbidity patients when stratified by Gagne-comorbidity score. Days to 3^rd-next-available appointment (wait time) improved at year 1, though patients perceived worse access to routine care.

CONCLUSIONS: During the COVID pandemic, high-risk patients, particularly those with high- comorbidity burdens, maintained access to VHA primary care especially via virtual modalities. Among this patient cohort, virtual care users increased over two-fold from baseline to year 1 of the pandemic, with use largely sustained in pandemic year 2. Despite overall higher utilization and some objective improvements in appointment wait times, patients perceived worse access to primary care at year 1.

DELAYED OPPORTUNITIES FOR PATIENT-PROVIDER COMMUNICATION ABOUT MEDICATION OVERUSE HEADACHE: PERSPECTIVES FROM PATIENTS AND NEUROLOGISTS

Allison Pack¹; Stacy Bailey¹; Wei Huang¹; Andrea Zuleta²; rodolfo zuleta¹; Yvonne Curran³; Melissa Herman⁴; Steven M. Kymes⁵

¹General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ²General Internal Medicine, Northwestern University, Evanston, IL; ³Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL; ⁴H Lundbeck A/S, Valby, Hovedstaden, Denmark; ⁵Lundbeck LLC, Deerfield, IL. (Control ID #3876163)

BACKGROUND: Overuse of medications to relieve pain among patients with headache disorders can result in medication overuse headache (MOH), a painful and difficult condition to treat. Limited research has examined patient-provider communication practices or informational needs related to MOH. We conducted a mixed-methods study with providers and patients to further elucidate these topics.

METHODS: This study collected data from both English-speaking adult patients with a chart diagnosis of migraine and practicing neurologists from one academic health center in Chicago, IL. Patients completed a structured, interviewer-administered survey on MOH knowledge and patient-provider communication (Consumer Assessment of Healthcare Providers and Systems). Survey data were analyzed using descriptive statistics and bivariate analyses. Neurologists completed an exploratory, qualitative interview conducted by trained research staff. A modified version of the Rapid Identification of Themes from Audio Recordings (RITA) procedures was used to analyze qualitative data.

RESULTS: A total of 200 patients and 13 neurologists participated. Patients, on average, reported having their first migraine symptoms around age 25 and being diagnosed with migraine at age 30. More than one third of migraine patients (38.6%) reported that they had never heard of ‘medication overuse headache.’ Those who had reported wide variability in when they first learned about the condition; more than one third (38.4%) said they were told about MOH more than 5 years after their migraine diagnosis. Patients who stated that their provider ‘definitely’ explained things in a way that was easy to understand had greater MOH knowledge; this included being more likely to know how often over-the-counter-medications should be taken to avoid MOH. In qualitative interviews, neurologists confirmed a general lack of MOH awareness among patients and highlighted that conversations about MOH are largely prompted by providers when patients report symptoms of constant headaches, frequent medication use, and/or early refill requests. Several noted that patients were often surprised to learn about MOH and found the delay in learning about MOH problematic. Providers believed patients could benefit from additional education on MOH, earlier in their migraine trajectory. Such education would likely occur in primary care, where many patients first seek care for migraine symptoms.

CONCLUSIONS: Findings reveal multiple delayed opportunities to inform patients about MOH: at the first onset of migraine symptoms and at migraine diagnosis. Education and tools to support early, routine patient- provider communication about MOH are needed, not only in neurology, but also in primary care.

DELAYS DESPITE PRIORITY: QUALITATIVE INTERVIEWS OF LIVING KIDNEY DONORS WITH ESRD

Mizna Akbar¹; Lainie F. Ross^2,3

¹Pritzker School of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; ²Pediatrics, University of Chicago Division of the Biological Sciences, Chicago, IL; ³University of Chicago MacLean Center for Clinical Medical Ethics, Chicago, IL. (Control ID #3875303)

BACKGROUND: In 1996, the United Network for Organ Sharing (UNOS) implemented a policy giving former living kidney donors (LKDs) priority status on the waitlist for a deceased donor kidney. Recent literature reports that despite their priority, many former LKDs with end stage renal disease (ESRD) experienced long wait times. The goal of this study is to explore reasons for delays experienced by these LKDs.

METHODS: Semi-structured interviews were conducted of former LKDs, recruited from the University of Chicago Living Donor Project, who reported waiting at least three years after kidney failure before transplantation. Interviews were conducted over the phone and recorded with participants' consent. The researchers reviewed transcripts and developed a code book, with the final code book including 11 codes: donation story, donation risks, health to sickness, listing, delay reasons, living donor considered by LKD, post-transplant reflections, priority points, renal replacement therapy (subcodes: donor on dialysis, dialysis experience, donor receives transplant), support, and multiple institutions. Both reviewers used Atlas.ti to code the transcripts, and discrepancies were reviewed and consensus achieved.

RESULTS: Seven participants, who waited between three and ten years for a transplant, were interviewed. Five (71%) participants were male and ages ranged from 55 to 80. Two participants identified as Black, three as White, one as Black and Native American, and one as Hispanic/Latino. All participants donated to a first- degree relative. Reasons for delay included being highly sensitized, slow transition from non-transplant center to transplant center, and psychosocial factors (lack of social support, former drug use, being perceived as angry or non-compliant). Participants reported feeling more valued as donors than as recipients. While the majority of participants did not express regret at donating to a first degree relative, two did express that others should be very hesitant and careful if they decide to donate a kidney.

CONCLUSIONS: This study has highlighted a unique group of patients’ stories and reminds the transplant community that each individual in need of a kidney transplant experiences system failures in their own way.

That said, many barriers to getting listed and getting a transplant hold regardless of donor status, such as the psychosocial barriers discussed. What makes donors unique is that the transplant community may have increased, or at least accelerated, the donor’s risk of developing kidney failure, which explains at least in part why they are given priority for deceased donor transplantation in the first place. It is clear that greater support and counseling would go a long way to making donor priority a true benefit as it is claimed when described during the donation process. A possible solution would be to provide a navigator or advocate to former LKDs to help them navigate the listing and transplant process.

DEPLOYING SCRUM FOR A HOME HOSPITAL ACCELERATOR: METHODOLOGY AND BEST PRACTICES FOR RAPID HEALTH CARE INNOVATION

Meghna Desai¹; Miriam Tardif-Douglin^3,4; Indigo Miller¹; Stephanie Blitzer¹; David L. Gardner⁵; Teresa Thompson⁵; LaPonda Edmondson^3,4; David Levine^2,1

¹Ariadne Labs, Boston, MA; ²Medicine, Brigham and Women's Hospital, Boston, MA; ³CaroNova, Cary, NC; ⁴North Carolina Healthcare Association, Cary, NC; ⁵Scrum Inc, Cambridge, MA. (Control ID #3876656)

BACKGROUND: The diffusion of innovation in health care is slow. Despite evidence-based care models and interventions, patients wait years to experience such care. We believe the health care community can innovate and deliver innovation faster if it employs a framework for accomplishing work, as has been done in other sectors. Home hospital (HH) is a model that provides hospital-level care in a patient’s home instead of in a traditional hospital with equal or better outcomes. Its uptake has steadily grown during the COVID-19 pandemic, yet barriers to launch remain for health care organizations. The Home Hospital Early Adopters Accelerator (HHEAA) was created to bring together a network of health care organizations to develop tools necessary for HH implementation. The HHEAA utilized the Scrum framework to rapidly produce tools, enable the collaboration of many different specialized skill sets, and bring together individuals who had no experience with one another into efficient teams. Its goal was to use Scrum to develop in 40 weeks 20 knowledge products (KP) critical to supporting the development and implementation of a HH program.

METHODS: We adapted the Scrum framework to fit the HHEAA’s structure. All activities were performed remotely. To measure KP creation metrics we measured level of effort (quantified as “story points” instead of an estimate of time required for each item). Story Points represent the level of complexity and novelty of the tasks within the ensuing Sprint, with more points equating to more work. Velocity represents the Story Points per sprint. A Scrum Master calculates the planned Velocity at the beginning of the Sprint and the actual Velocity at the end of a Sprint. To evaluate the HHEAA we conducted a mixed methods evaluation of HHEAA’s methodology and assessed teams’ productivity and experience using a survey and semi-structured interviews.

RESULTS: 18 health care organizations participated in the HHEAA to produce the expected 20 KPs in 32 working weeks, a 20% reduction in time, yielding an overall productivity of 3.0 points per sprint, compared to a planned productivity of 2.4 points per sprint. Nearly all (97.4%) participants agreed or strongly agreed the Scrum teams worked well together and 96.8% felt the teams produced a high-quality product. Participants said the Scrum team developed products much faster than their respective organizational teams. Participants expressed it was challenging to help participants quickly learn Scrum and to coordinate technology platforms. However, the HHEAA’s ability to rapidly join disparate health care organizations into efficient teams equipped to create KPs for HH program implementation proved effective.

CONCLUSIONS: We demonstrate that applying the Scrum framework to accomplish work in health care is a valuable approach; one missing from most health care efforts, and one that may be transformative for the sector.

DEVELOPMENT AND VALIDATION OF COVID-19 VACCINE MESSAGING MATERIALS FOR LATINX COMMUNITIES

Allison Pack¹; Stacy Bailey¹; Sophia W. Light¹; Andrea Zuleta²; Stephanie Batio¹; Mia W. Cross³; Michael Wolf¹

¹General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ²General Internal Medicine, Northwestern University, Evanston, IL; ³Family Christian Health Center, Harvey, IL. (Control ID #3876083)

BACKGROUND: Lower rates of COVID-19 vaccine acceptance among those at greatest risk of infection exacerbate existing health disparities. Early in the pandemic, Latinx individuals in Chicago, IL had lower rates of vaccine uptake compared to others. We partnered with two federally qualified health centers (FQHCs) to develop and assess language-concordant, low literacy materials promoting COVID-19 vaccine knowledge, acceptance, and uptake among Latinx communities.

METHODS: Building on our prior qualitative work with Latinx adults, we developed draft COVID-19 vaccine Fact Sheets in English and Spanish. Prototypes were iteratively reviewed and refined with input from: 1) two Stakeholder Academic Resource Panels consisting of Latinx adults and FQHC staff, 2) consultation with an external advisory board, and 3) cognitive interviews with Latinx adults. We then evaluated the Fact Sheets in a two-arm randomized experiment. Latinx adults were identified via an electronic health record query at a partner FQHC and/or from social media postings. Enrolled participants were randomized (1:1) to either 1) an attention control patient education material for influenza, or 2) our COVID-19 vaccine Fact Sheets. Virtual interviews were conducted over videoconferencing software with participants in English or Spanish. Participants reviewed their assigned material, completed a 15-item COVID-19 knowledge questionnaire and a measure of health literacy, and provided sociodemographic information. Those randomized to the COVID-19 vaccine Fact Sheet additionally rated their satisfaction with the material.

RESULTS: A total of 81 participants were enrolled. On average, participants were 56 years old. The majority (63%) were female, one-third were born in the U.S., and more than half (56.8%) had low health literacy. Characteristics were similar across study arms. Those randomized to the COVID-19 vaccine Fact Sheet had significantly higher COVID-19 knowledge scores than those randomized to the attention control (Mean score out of 100 (M) = 71.4, Standard Deviation (SD) = 19.2, versus M = 51.6, SD = 11.8; p<0.001). No differences were found by language. Those randomized to the Fact Sheet were also highly satisfied with it. Nearly all (90.2%) rated the appearance as excellent or very good; similar results were reported for its quality (90.3%). On a scale of 1 to 10, participants who viewed the Fact Sheet reported high satisfaction with the information provided (M = 9.6, SD = 0.9), and its readability and understandability (M = 9.6, SD = 0.9).

CONCLUSIONS: Cultural and linguistic tailoring of COVID-19 vaccine materials can result in readable, understandable, and potentially actionable materials. Our publicly available materials were highly satisfying to participants and increased their COVID-19 vaccine knowledge.

DIFFERENCES IN HEALTH CARE UTILIZATION AMONG PATIENTS USING TELEMEDICINE FOR PRIMARY CARE IN THE VETERANS HEALTH ADMINISTRATION

Amy M. O'Shea¹; Bjarni Haraldsson¹; Matthew R. Augustine³; Peter J. Kaboli²; Stephanie L. Shimada⁴

¹Research, Iowa City VA Healthcare System, Iowa City, IA; ²Internal Medicine, Iowa City VAMC, Iowa City, IA; ³HSR&D, US Department of Veterans Affairs, Bronx, NY; ⁴HSR&D, US Department of Veterans Affairs, Bedford, MA. (Control ID #3855614)

BACKGROUND: In the Veterans Health Administration (VA), telemedicine expanded rapidly during the COVID-19 pandemic, offering added telehealth modalities to improve primary care (PC) access. The association of telemedicine use with utilization among PC users is not understood. Our study objective was to evaluate if health care utilization differed across populations using PC telemedicine.

METHODS: The study cohort includes all veterans with any PC visit; October 2018 - September 2020. The exposure is telemedicine (i.e., video and telephone) use, whereby veterans were categorized as using in-person only, telemedicine only, or both. We studied patient characteristics across groups, including demographics, comorbidity, broadband availability, and Area Deprivation Index. Utilization measures included VA urgent care visits, emergency department (ED) visits, and inpatient admissions occurring within 28 days of an index PC visit. We report the overall count and the rate per 1000 veterans compared across groups using two-sample t-test or a test of proportions.

RESULTS: Over the 2-year study period, 3.2 million veterans experienced 15.8 million PC visits. On average, patients using only in-person compared to telemedicine only visits were older [61.5 vs 53.2 years; p<0.001] more likely male [90.8% vs. 87.9%; p<0.001] and rural residing [36.1% vs. 26.3%; p<0.001] with a higher comorbidity score [0.5 vs 0.1; p<0.001]. Those with mixed use were, on average, 61.2 years old, 90.4% male, and 34.7% rural residing with an average 0.6 comorbidity score. No substantial differences were noted compared to in-person only. Patients with mixed use compared to in-person only, on average, had more utilization across all categories: PC visits (4.20 vs. 2.46 visits per patient), urgent care (16.2 vs 7.8 per 1000 patients), ED (120.7 vs 73.7 per 1000 patients), and inpatient admissions (47.1 vs 30.3 per 1000 patients); all p<0.001.

CONCLUSIONS: PC patients who use both telemedicine and in-person visits have substantially higher utilization of services (i.e., ED, urgent care, and inpatient). Further evaluation is needed to determine the factors driving higher PC and acute care utilization among those engaging in telemedicine as adjunct to in- person PC.

DISPARATE TRENDS IN MEDICALLY APPROPRIATE AND LOW-VALUE CARE IN VIRGINIA DURING COVID-19

Michelle S. Rockwelll¹; Sitaram Vangala²; Beth A. Bortz³; Kyle Russell⁴; Jillian Capucao⁴; Marcos Dachary⁵; Chi-Hong Tseng⁸; A. Mark Fendrick⁶; John N. Mafi⁷

¹Family & Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA; ²Medicine, University of California, Los Angeles, Los Angeles, CA; ³N/A, Virginia Center for Health Innovation, Henrico, VA; ⁴Virginia Health Information, Richmond, VA; ⁵MedInsight, Milliman, Seattle, WA; ⁶University of Michigan, Ann Arbor, MI; ⁷Medicine, University of California Los Angeles, Los Angeles, CA; ⁸Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #3877071)

BACKGROUND: The COVID-19 pandemic was associated with dramatic changes in healthcare utilization during Mar-Dec 2020, but the appropriateness and equity of care delivered during this timeframe are not well-understood. Using the Virginia All-Payer Claims Database (APCD), we evaluated trends in the utilization of medically appropriate and low-value care and payer-level variation in care during Mar-Dec 2020.

METHODS: We used the Milliman Medinsight Health Waste Calculator to classify APCD claims for 11 screening, diagnostic, and pre-operative tests delivered during Mar-Dec 2020 as medically appropriate or low-value. Total spending for low-value care was estimated at the claim line (service only) and case rate (service + associated spending) levels. A difference-in-differences model was used to compare changes in the age/sex-adjusted utilization rates between January-February 2020 (pre-pandemic) and each subsequent two- month period in 2020 with parallel rate changes in 2019. Cumulative overall utilization rates were compared using linear models. Results were stratified by payer.

RESULTS: Within the primary cohort (n=1,556,878, aged 61.0 + 24.2 years, 57% female), 22.4% of claims for the 11 tests were low-value, representing total spending range estimates of $16,570,918 (claim line) to $65,305,570 (case rate) in Mar-Dec 2020. Total overall spending for low-value care was 19% lower in 2020 vs 2019. Compared with expected rates, cumulative overall utilization of medically appropriate care was 8% higher than low-value care during Mar-Dec 2020 (p<0.01). Trends in the utilization of medically appropriate and low-value care vs. expected rates were similar during Sept-Oct (med. app.: 91% [90-92%], low-value: 90% [89-91%]) and Nov-Dec 2020 (med. app.: 76% [75-77], low-value: 78% [77-79%]). Cumulative overall

utilization varied significantly by payer (TABLE).

CONCLUSIONS: Findings suggest that the Virginia health system was unsuccessful in the selective preservation of medically appropriate, high-value care over low-value care during the first year of the pandemic. Higher utilization of medically appropriate care by patients insured by commercial vs. all other payers suggests disparate harms of the pandemic to older individuals and those with low-income and/or disabilities.

DISPARITIES IN ACCESS TO POINT-OF-CARE MEDICATION COST INFORMATION AMONG MEDICALLY COMPLEX PATIENTS SEEN IN PRIMARY CARE

Caroline Sloan¹; Sarah Morton-Oswald¹; Clemontina A. Davenport¹; Valerie A. Smith¹; Barrett Bowling²; Jaejin An⁵; Anna Sinaiko³; Matthew Maciejewski⁴

¹Duke University School of Medicine, Durham, NC; ²GRECC, Durham VA, Durham, NC; ³Health Policy & Management, Harvard TH Chan School of Public Health, Boston, MA; ⁴HSR&D, Durham VA Medical Center, Durham, NC; ⁵Kaiser Permanente Southern California, Pasadena, CA. (Control ID #3875974)

BACKGROUND: Patients with multiple chronic conditions (MCCs) often have complex management plans and take numerous medications that can be expensive. Over a third report cutting back on medications due to cost. In January 2021, Medicare began requiring that all Medicare Part D plans make real-time benefit tools (RTBT) available for all enrollees. RTBTs are clinician-facing tools embedded in electronic health records that can display a medication’s out-of-pocket cost at the point-of-prescription. Cost estimates are specific to each patient’s insurance plan, cost-sharing requirements, and preferred pharmacy. RTBTs have the potential to help patients anticipate their medication costs but might also add time and complexity to clinic visits that are already time-pressured. We explored how often primary care providers (PCP) at one large academic institution queried an RTBT during visits with patients with MCCs, and what patient, PCP, and visit characteristics were associated with RTBT queries.

METHODS: We conducted a retrospective cohort study of all primary care visits among patients with MCCs aged >18 years between June 2021 and May 2022. We excluded visits without any medication orders. We described the proportion of 1) PCPs who queried the RTBT at least once; 2) patients whose PCPs queried the RTBT at least once; and 3) visits that included >1 RTBT query. We used a generalized linear mixed model to explore the association between RTBT query and PCP (years’ experience, sex, clinician type), patient (sociodemographics, number of medications and conditions, insurance), and visit characteristics (visit type, calendar time).

RESULTS: Of 555 PCPs in our sample, 18% (n=101) queried the RTBT at least once in the study period for 1.6% of the patients they saw (393/24,067), during 0.7% of visits (428/64,662). RTBT queries increased from 0.4% of visits in June 2021 to 1.2% of visits in May 2022. PCPs with >10 years’ experience had lower odds of querying the RTBT than PCPs with <10 years’ experience (odds ratio [OR] 0.3; 95% confidence interval [CI] 0.2-0.5). PCPs had lower odds of querying the RTBT for patients who were older (OR 0.8 per 10-year increase; 95%CI 0.7-0.8) or had a greater number of chronic conditions (OR 0.9 per additional condition;

95%CI 0.8-0.98). They had higher odds of querying the RTBT for Black vs White patients (OR 1.3; 95%CI 1.01, 1.6). RTBT use did not differ significantly by visit modality (in-person, video, or telephone).

CONCLUSIONS: PCPs requested medication cost estimates during 0.7% of visits with patients with MCCs in 2021-2022. They queried the RTBT differentially by patient age, race, and number of conditions. Future research is needed to understand why RTBT use is so low for patients with MCCs and how the tool can be structured to increase its use. Policy makers and health systems should work to ensure that access to point-of- care medication cost estimates is equitable regardless of race, ethnicity, age, and medical complexity.

DISPARITIES IN TELEHEALTH ACCESS AND USE AMONG PATIENTS IN FEDERALLY QUALIFIED HEALTH CENTERS DURING THE COVID-19 PANDEMIC

Stacy Bailey¹; Allison Pack¹; Paula Rusca²; Wei Huang¹; Guisselle Wismer¹; rodolfo zuleta¹; Josephine Llaneza²

¹General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ²Erie Family Health Center, Chicago, IL. (Control ID #3875848)

BACKGROUND: During the COVID-19 pandemic, many healthcare systems turned to telehealth to maintain access to care. But there were concerns that health equity gaps –already exposed due to the pandemic – would be further exacerbated by a reliance on technology to access healthcare. We sought to assess patient technology needs and experiences utilizing telehealth services during the pandemic among under-resourced patients receiving care in a Federally Qualified Health Center (FQHC).

METHODS: English or Spanish-speaking adults who had ≥1 visit (in person or via telehealth) for themselves or their child within one large FQHC network in Chicago, IL and surrounding areas over the prior 12 months were identified via an electronic health record (EHR) query. Potential participants were contacted via telephone by research coordinators, who administered a structured survey on technology access, use and experiences with telehealth services, and sociodemographic characteristics. Quota sampling was used to ensure representativeness.

RESULTS: A total of 500 adults participated. Most were insured by Medicaid (72.9%) and were of Hispanic ethnicity (73.8%); half spoke Spanish as their primary language. The majority (83%) reported having access to the internet at home, 82.2% had access via their phone, and 49.0% had access elsewhere. Most (59.8%) reported previously having a video telehealth visit with a provider (23.8% by video only, 36.0% by video and phone). Reasons for using telehealth included a desire to be seen as soon as possible (42.2%), possible COVID-19 exposure (14.1%) and preference for telehealth (10.2%). Most reported that telehealth was as good as (52%) or better (10.9%) than in-person visits. The majority (82.8%) reported receiving the care they needed and 86.3% said they would ‘definitely’ or ‘probably’ recommend telehealth to others. Among those who had not had a telehealth visit, 32.3% believed their care required an in-person visit, 27.9% did not want a telehealth visit, 10.5% said they did not know how to access telehealth, and 3.5% cited poor technology access. In bivariate analyses, respondents who were Spanish-speaking, had lower levels of English proficiency, and who preferred receiving care in Spanish were less likely to have had a telehealth visit. Spanish-speaking patients were more likely to have internet connectivity issues and to not have access to someone to help them with technology if needed.

CONCLUSIONS: Findings reveal positive experiences with telehealth services, with most FQHC patients having the access and resources needed to successfully use this platform. Spanish-speaking patients – particularly those with limited English proficiency – had the greatest barriers to health technology and telehealth use. Additional resources will be needed to assist this population in accessing and using telehealth to ensure disparities are not further exacerbated.

EFFECT OF A FINANCIAL INCENTIVE TO ACADEMIC PRIMARY CARE PHYSICIANS ON HYPERTENSION PATIENT PANEL BLOOD PRESSURE CONTROL

Jonathan Li¹; Jennifer L. Cluett¹; Marc L. Cohen³; Timothy Anderson²

¹Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Medicine/General Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ³General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #3876327)

BACKGROUND: Improving blood pressure (BP) control is a national primary care priority. As health systems shift from fee-for-service models to value-based contracts, control of BP has significant implications to the financial health of primary care systems. We hypothesized that providing a modest financial incentive to primary care physicians (PCPs) would lead to improvements in BP control rates.

METHODS: This quality improvement initiative provided financial incentives to PCPs who met certain criteria related to hypertension management: a) participation in hypertension education sessions and uncontrolled patient outreach processes and b) improvement of panel BP control rate by 5% between September-December 2021, or achievement of a BP control rate of at least 75%. Hypertension control was defined as having a BP < 140/90 on the most recent check within the last 12 months. The incentive was proportional to the PCP’s clinical volume, such that a full-time PCP who met both criteria received a bonus of $8,400. We used a time-series analytic framework to compare trends in monthly BP control rates prior to (Aug 2019 to Aug 2021), during the intervention (Sept 2021 to Dec 2021) and after the intervention (Jan 2022 to Nov 2022).

RESULTS: The study includes 54 PCPs (54% female, 30% >=4 weekly clinical sessions) caring for 11,864 patients with hypertension (range 47 – 539 empaneled patients). The practice BP control rate the month prior to the intervention was 66.6% (pre-intervention trend 0.05% increase/month (95% CI, 0.01% to 0.09%). During the intervention, 49 PCPs (90%) completed the education and outreach program and 23 (39%) achieved target BP control goals. At the end of the intervention period, the practice BP control rate improved to 68.3% (1.1% step change; 95% CI, 0.9% - 2.1%), whereas historic trends in the practice saw seasonal declines in BP control rate during winter months. In the post-intervention period, BP control improved at a greater rate than pre-intervention (0.16% increase/month; 95% CI 0.04 to 0.28%). Improvement was sustained through November 2022 (68.8%). In total, 51 (94%) PCPs received financial renumeration (range $450 to $8,400; mean $2,611).

CONCLUSIONS: Providing a modest financial incentive to individual academic PCPs for reaching hypertension control targets was associated with a modest, and sustained, improvement in hypertension control rates. For health systems that participate in value-based ambulatory quality contracts, inclusion of individual physicians in the incentive may be an impactful mechanism to improve population hypertension control rates.

EFFECT OF A PEER COMPARISON AND EDUCATION INTERVENTION ON MEDICAL TEST CONVERSATION QUALITY: A RANDOMIZED CLINICAL TRIAL

Ishani Ganguli¹; Emma D. Chant¹; Kathleen L. Mulligan¹; Stuart Lipsitz¹; Leigh Simmons²; Karen Sepucha²; Robert Rudin³

¹Division of General Medicine and Primary Care, Brigham and Women's Hospital, Chestnut Hill, MA; ²Medicine, Mass General Brigham Inc, Boston, MA; ³RAND, Boston, MA. (Control ID #3876536)

BACKGROUND: Medical test overuse and resulting care cascades represent a common, costly problem driven in part by clinician norms, patient misperceptions, and inadequate patient-clinician communication. One possible solution is priming clinicians and patients to have routine, evidence-based conversations about the role and consequences of medical tests. Earlier, we applied user-centered design to create a scalable, multi-pronged intervention for clinicians and patients intended to normalize and improve medical test conversations during annual visits. In this study, we implemented and tested this intervention.

METHODS: We conducted a randomized trial at an academic medical center. Twenty primary care physicians (PCPs) were matched-pair randomized (based on low-value test rate and gender) with 1:1 allocation ratio to intervention or control groups. For each physician, we enrolled ≥10 of their patients with scheduled in-person annual visits. In the intervention group, physicians received emails that compared their low-value test rates with those of peer PCPs and included point-of-care-accessible guidance on medical testing; patients received educational materials on medical testing (website, video, quiz, handout) via SMS and email before their visit. Control group patients received general visit preparation tips via SMS and email. We administered patient and physician pre- and post-study surveys; among a purposive sample of patients and physicians, we conducted semi-structured post-study interviews. The primary patient outcome was the validated Shared Decision-Making Process Survey (SDMP_4 score). Secondary patient outcomes included medical test knowledge and satisfaction with the conversation. Using multiple imputation to impute missing values, we compared outcomes with robust linear regression models adjusted for patient age, gender, race/ethnicity, and education; standard errors were clustered by matched pair and by physician nested within matched pair.

RESULTS: There were 166 patients in the intervention group and 148 patients in the control group. Intervention group patients had better SDMP_4 scores (2.13 vs 1.96 out of 4, difference(95%CI) 0.16(-0.24, 0.56)) and knowledge scores (2.74 vs 2.55 out of 4, difference(95%CI) 0.20(-0.04, 0.44)) and were more likely to report satisfaction (71.8% vs 66.1%, difference(95%CI) 5.4(-5.8, 16.5)); these differences were not statistically significant. In interviews, patients often noted that the materials confirmed prior assumptions. Some physicians said the peer comparisons led them to reexamine their approach to test conversations.

CONCLUSIONS: In this small randomized trial, a multi-pronged physician- and patient-facing peer comparison and education intervention was insufficient to significantly change the quality of medical test conversations during annuals. Further development and testing of patient- and clinician-facing interventions, as well as broader efforts to change behavior, are needed to improve such conversations and reduce overuse.

EVALUATING FOR BIAS IN A POPULATION HEALTH RISK MODEL: IDENTIFYING THE ASSOCIATION BETWEEN PREDICTED PROBABILITY OF HOSPITAL USE AND ACTUAL HOSPITAL USE ACROSS PATIENTS’ RACE, ZIP CODES, LANGUAGE AND GENDER Reshma Gupta¹; Mayu Sasaki²; Yi Zhang⁴; Georgia McGlynn²; Matthew Crase³; Jeffrey Hoch⁷; Hendry Ton⁵; Lorena Garcia⁸; Gregory A. Maynard¹; Daniel J. Tancredi⁶

¹Department of Internal Medicine, University of California Health or University of California Davis Health, Morgan Hill, CA; ²Population Health & Accountable Care, University of California Davis Health System, Sacramento, CA; ³Population Health and Accountable Care, University of California Davis Department of Internal Medicine, Sacramento, CA; ⁴Center for Healthcare Policy & Research, University of California Davis, Sacramento, CA; ⁵Diversity, Equity and Inclusion, University of California Davis Health System, Sacramento, CA; ⁶Pediatrics, University of California Davis Health System, Sacramento, CA; ⁷Division of Heatlh Policy and Management in the Department of Public Health Sciences, University of California Davis, Davis, CA; ⁸Department of Public Health Sciences, University of California Davis, Davis, CA. (Control ID #3869337)

BACKGROUND: In 2019, Obermeyer et al demonstrated that a widely used algorithm showed significant racial bias and was race-blind in predicting patients’ risk of future hospitalizations. This was due to using data that underrepresented minority populations. Most population health programs across the country use risk models without evaluation to assess if the model presents bias for their local patient populations and local communities. We created an approach to evaluate if there is systematic bias for race, Healthy Places Index (HPI) geocoding, language, and gender in a risk model built using data from an academic medical center in the California-Hawaii region.

METHODS: We asked two questions: 1) Is the predicted probability of emergency department (ED) or hospital use associated with the likelihood of actual use over a 12-month period? and 2) Does the association between predicted probability of ED or hospital use and the actual use over a 12-month period vary systematically by gender, race, language, or Healthy Places Index (HPI) score (i.e., a measure of community health)? We used logistic regression analysis to measure the association of predicted probability of ED or hospital use and actual use over a 12-month period. We controlled for race, HPI, language and gender. We also used each of these variables to create interaction terms with the logit of predicted probability of actual use to see how these terms would impact the observed association with actual use. We report log odds ratios and p-values as measures of success.

RESULTS: We found the predicted probability of use obtained from the risk model is significantly positively associated with actual use, when controlling for gender, race, language or HPI (log ORs 1.23 – 1.27, p-values<0.05). In addition to this finding, when we looked at differences in predicted use and actual use by gender and by language (in separate analyses for gender and language) we did not observe a large difference between groups. We also observed this when seeing the effect by race and found that the model performs similarly for White, American Indian or Alaska Native, Black and Other patients. However, we found the model may be under estimating use for Multi-race and Asian or Native Hawaiian or Other Pacific Islander patients, which were smaller populations. We also observed this similar underestimation for actual use in disadvantaged populations (i.e., people with low HPI). <!--StartFragment -->Similar to high performing national population health risk models, the model had an AUC value of 0.96, 0.81 sensitivity and 0.84 specificity.<!--EndFragment -->

CONCLUSIONS: When using risk prediction models built using datasets that are not representative of the population of interest, health systems should implement evaluation methods investigating potential biases that arise from these underrepresented populations. These findings can be used by health system leaders to build bias mitigation strategies.

EVALUATION OF SICKLE CELL DAY PROGRAM AT URBAN TERTIARY CARE CENTER Romy Portieles Pena¹; Andrea Bundy²; Katherine Sullivan²; Kyle Carey²; Mengqi Zhu²; Rajlakshmi Krishnamurthy²; Valerie G. Press²

¹Biological Sciences Division, University of Chicago Pritzker School of Medicine, Chicago, IL; ²Medicine, University of Chicago, Chicago, IL. (Control ID #3875632)

BACKGROUND: Vaso-occlusive crises (VOC) are a painful hallmark of sickle cell disease (SCD) often requiring hospitalization. Hospitalizations may not be necessary if uncomplicated pain crises are adequately and promptly managed. Current management practices, primarily in emergency departments (ED) pose limitations, such as treatment and reassessment delays and opioid use-related stigma. “Day hospitals” (DH) have arisen as an ambulatory initiative to care for patients with uncomplicated VOCs to reduce ED utilization. DHs are ambulatory clinics that provide acute care treatment (e.g., intravenous medications, fluids) for VOC treatment. DHs have been shown to decrease admissions, length of stay, and 30-day readmission rates for patients treated for VOCs. We evaluated our recently established DH to determine if implementation decreased SCD ED utilization and hospitalizations.

METHODS: Data were obtained from March 2021 until November 2022 for the DH and from January 2020- November 2022 for ED and hospital utilization. These data included demographic data, financial data (insurance, network status), and utilization data (ED re-visits, re-hospitalizations). Chi-squared tests evaluated differences in ED/hospital utilization pre- and post- DH implementation between in network vs out of network cohorts. Run charts visualized DH utilization, ED utilization, and hospitalizations over time. Analyses were performed in Stata.

RESULTS: Data from 137 unique patients, 823 DH visits, 6,913 ED visits, and 2,791 hospitalizations were available for analysis. Most patients seen in the DH identified as Black (96%), female (65%) and were in- network (79%). At baseline (2020) there were on average 58 ED visits (59% in-network, p<0.01) and 45 hospitalizations (63% in network, p=0.4) per month before the DH opened. Post-DH ED revisits were relatively constant and lower than baseline, with an average of 36 ED visits per month over the 20-month analysis period. Of these ED visits 59% were in-network (p<0.01), unchanged from baseline. Hospital admissions post-DH visits were overall lower than baseline, with an average of 23 per month; 79% of which were in-network patients (p=0.7).

CONCLUSIONS: The preliminary results from this evaluation signals that a DH may decrease acute care utilization, as shown by decreased number of ED visits and hospitalizations post DH visit. Subgroup analysis demonstrates a significant baseline difference between in- vs. out-of-network status for ED utilization, which is unchanged post-DH visit, granting further analysis. There is not a significant difference between network status in terms of hospitalization, however, there seems to be a signal suggesting a larger proportion of hospitalizations from patients who are in-network post DH visit, maybe indicating a possible decrease in hospitalizations for patients out-of-network. Further analysis will focus on both rates of reutilization for the DH as well as PCP connections and follow up.

EVALUATION OF THE FUNCTION AND EVOLUTION OF A CARE TRANSITIONS CLINIC “SURGE” PROGRAM

Ashley E. Brown¹; Sarah Kundrat²; Geneatra Green²; Stephanie Chia²; Katherine Sullivan²; Michael Hermsen³; Juhi Gupta³; Thomas Spiegel²; Rajlakshmi Krishnamurthy²; Valerie G. Press²

¹Hospital Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ²The University of Chicago Medicine, Chicago, IL; ³University of Chicago Pritzker School of Medicine, Chicago, IL. (Control ID #3869904)

BACKGROUND: Emergency department (ED) crowding worsens outcomes and increases mortality. Our ED Surge program works collaboratively with our ED to transfer lower acuity patients to an on-site, same- day ambulatory setting within our Care Transitions Clinic (CTC). We aimed to characterize the impact of our program as well as determine which patients may be better served in the ED rather than outpatient care.

METHODS: Eligible ED patients were identified based on acuity and visit reason and then transferred to the CTC. Demographic, visit characteristics, and future ED/hospital visit data were collected. Chi-squared/t-test analysis tested significant group differences and logistic regression modeled predictions for high severity visits (required admission/ED return), high healthcare utilization, and appointment status. Survival analysis with Kaplan-Meier & log-rank test determined significant differences in days to the next ED visit or inpatient admission. Significance was p<0.05, with Bonferroni corrections as appropriate.

RESULTS: From March 2021 to November 2022 there were 569 scheduled visits, 437 completed visits, and 560 unique patients. Most patients were female (60%), Black/African American (92%), not Hispanic/Latino (96%), mean of 36 years and insured by Medicaid (61%). Those with severe appointments were older (p<0.008), otherwise groups were similar. In its second year of operation (starting March 2022), completed to canceled appointments improved (p=0.002) and future ED visits/hospitalizations decreased (ED p<0.001; Inpatient p=0.001). In logistic analysis, patients with high healthcare utilization usually visited with minor trauma (OR 19.67; 95% CI [3.45,112.04]), other infections (OR 5.16; [1.69,15.76] or preventive care (OR 22.95; [2.11,248.74]). Additionally, high severity appointments occurred more with increased age (OR 1.03; 95% CI [1.01,1.06]) or with diagnoses of other infections (OR 3.79 [1.28,11.27]), cardiac issues (OR 7.57 [1.78,32.14]), or lab abnormalities (OR 18.92 [5.95,60.13]). Patients who were female (p=0.02), presenting with eye complaints (p<0.001) or neurologic complaints (p<0.001) were more likely to have a shorter time to the next ED visit. Patients presenting with a severe ED surge visit (p=0.001) were more likely to have a shorter time to the next inpatient admission.

CONCLUSIONS: The ED Surge Program serves a majority of younger, Black, and government-insured patients. In its second year, it continues to reduce patient burden in the ED, with a reduction in both canceled/no-show appointments and future health utilization. The ED Surge program helped offload the ED with diagnoses such as minor trauma, infections, or preventative care in those with high healthcare utilization. Furthermore, patients who are older, female, and carried certain diagnoses seemed to predict the need for the ED rather than outpatient care.

EXPERIENCES WITH WORKPLACE VIOLENCE: A CROSS SECTIONAL SURVEY OF PRIMARY CARE PROVIDERS AND RESIDENTS

Nicholas Tyau¹; Hector R. Perez²

¹General Internal Medicine, Montefiore Medical Center, Bronx, NY; ²Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY. (Control ID #3849949)

BACKGROUND: Workplace violence (WPV) is defined as “incidents where staff is abused, threatened, or assaulted in circumstances related to their work.” Data from the US suggests that up to 10% of victims of WPV are healthcare workers. Moreover, violence against physicians has increased by over two-thirds in the last ten years. Yet, WPV in the US remains poorly characterized amongst primary care physicians.

METHODS: We conducted an electronic cross-sectional survey of primary care providers at Montefiore Medical Center in the Bronx, NY to describe the prevalence and experiences of WPV at our institution. We recruited attending and resident physicians from four outpatient teaching practices from our internal medicine residency program. Attending and resident physicians were emailed a link to an online survey that collected demographic data (age, gender, ethnicity, years of practice), personal exposure to and witnessing WPV. We included participants with non-missing data about having witnessed workplace violence for this analysis. We tabulated data and used chi-square tests to measure associations between feeling unsafe at work and (1) gender and (2) resident vs attending status.

RESULTS: Among the eligible 66 attending physicians and 66 residents, 86 (73%) chose to participate and 85 (64%) completed the survey and constituted our analysis sample. Of the respondents, 54% (n=46) were attending physicians, 58% (n=49) were female, and 55% (n=47) reported being between the ages of 30-40 years old. Among respondents, 55% (n=47) identified as White, 26% (n=22) identified as Asian, and 12% (n=10) identified as other race; additionally, 16% (n=14) identified as Hispanic/Latino. A majority (n=74, 87%) of respondents reported witnessing WPV within the last year. About half (n=35, 47%) of respondents reported feeling unsafe at work at least once per year. Female primary care physicians were significantly more likely (p=0.031) to feel unsafe. There was no significant difference in resident vs attending status chi2 (1, N=74) = 0.08, p=0.64). While 44% (n=37) reported feeling threatened in the past year while at work in the outpatient setting, only a small minority (n=6, 7%) reported experiencing WPV in the past 5 years.

CONCLUSIONS: Our study suggests that a majority of the primary care physicians in our institution witnessed WPV within the last year and a large proportion of physicians felt unsafe at work at least once a year. Women physicians were significantly more likely to feel unsafe. While the number of events experienced by those surveyed was small, the fact that there were so many witnessed events suggests that WPV remains an unreported hazard and further policies should aim to encourage reporting of WPV.

FACTORS ASSOCIATED WITH PRIMARY CARE PROVIDER TURNOVER IN THE VETERANS HEALTH ADMINISTRATION

Leah Marcotte¹; Ashok Reddy²; Seppo Rinne³; Ryan Sterling⁴; Peter J. Kaboli⁵; Edwin S. Wong⁶

¹Medicine, University of Washington, Seattle, WA; ²Medicine, University of Washington System, Seattle, WA; ³Medicine, Boston University, Boston, MA; ⁴Veterans Health Administration, Seattle, WA; ⁵Internal Medicine, Iowa City VAMC, Iowa City, IA; ⁶Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System Seattle Division, Seattle, WA. (Control ID #3876044)

BACKGROUND: Primary care physician (PCP) shortages affect Veterans Health Administration (VA) healthcare nationwide, and this shortage is expected to worsen. As part of a comprehensive effort to ensure adequate primary care workforce, VA is searching for ways to support PCP retention, including by assessing organizational and work characteristics that may contribute to turnover. Our study objective was to quantify the impact of and evaluate mediating factors in the association between workload satisfaction and PCP turnover.

METHODS: We conducted a longitudinal observational study from 2008 to 2016 to quantify the relationship of primary care team workload satisfaction on PCP turnover. Data sources included the VA All Employee Survey (AES), Corporate Data Warehouse, and Personnel Accounting and Integrated Data. The primary explanatory variable, workload satisfaction, was measured at the VA facility-level as the average of AES survey responses from primary care teams (e.g., PCPs, nurses, medical assistants). Workload satisfaction ranged from 1 (very dissatisfied) to 5 (very satisfied). We used a discrete hazard model to estimate the association of workload satisfaction and turnover defined as separation from VA employment in each quarter during the study period. We also examined mediating effects of several other domains of workplace climate derived from AES data: supervisor goal setting, direction, quality, progress evaluation, psychological safety, and appropriate work resources. Models were adjusted for PCP and clinic characteristics.

RESULTS: 7,909 unique PCPs were employed in VA over the 9-year study period. The unadjusted quarterly turnover rate was 1.83% and the mean workload satisfaction score was 3.58 (SD=0.24) on a five-point Likert scale. In adjusted analysis, a one-point increase in workload satisfaction was associated with a 0.73 [95% CI 0.36-1.10] percentage point decrease in the probability of turnover in a calendar quarter. In the mediation analysis, we found workload satisfaction impacted turnover through only one of the workplace climate factors - satisfaction with direction by senior managers.

CONCLUSIONS: Our study findings highlight the key role of achieving satisfaction with primary care workload as one strategy to reduce PCP turnover. Identification of direction of senior managers as an underlying mechanism is an important finding for strategic workforce planning to mitigate PCP turnover.

FAMILY CAREGIVER BURDEN IN A HOME HOSPITAL VERSUS TRADITIONAL HOSPITAL: A SECONDARY ANALYSIS OF A RANDOMIZED CONTROLLED TRIAL

Carson Moss¹; David Levine^2,1

¹Harvard Medical School, Boston, MA; ²Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #3877299)

BACKGROUND: Although there is a growing understanding of the benefits of home hospital (HH), knowledge of the impact on family caregivers remains understudied. Caregiver burden may be a reason to decline HH. In this study, we aimed to identify the burden attributable to caregiving at home compared to the hospital.

METHODS: We performed a retrospective analysis of prospective data collected from a randomized controlled trial. Participants were randomized to either HH or traditional hospitalization. On admission and discharge, family caregivers completed the Zarit Burden Interview-12 (ZBI-12), which ranges 0-48; <10, no burden; 10-20, mild-moderate burden; >20, high burden. Statistical analysis of HH and control groups required non-parametric statistical testing with Wilcoxon signed rank and Mann-Whitney; Fisher’s exact test was used to analyze caregiver demographics between groups.

RESULTS: Overall, 91 patients were enrolled; 42 (46.2%) had a caregiver, of which 33 had complete data. Caregivers were 73% female, 72% children of the patient, and 67% resided with the patient, without demographic differences between groups. Caregivers in HH (n=22) had a median ZBI-12 of 9.5 (IQR=4.75) on admission and 9.5 (IQR=10.75) on discharge compared to the control group (n=11) with a median of 15.0 (IQR=11.5) on admission and 8.0 (IQR=10.5) on discharge (difference, -0.5 vs -2.0; p=0.33). Additionally, there was no significant change in burden within the HH (-0.5, p=0.25) or control (-2.0, p=0.088) groups. Analysis of caregiver covariates revealed no significant difference in burden associated with relation, sex, residence with patient, proxy designation, or next of kin status.

CONCLUSIONS: Caregiver burden is mild-to-moderate upon admission and discharge in both the HH and control groups, with no significant change in burden between both groups. Our study is reassuring against a large difference in caregiver burden effected by HH participation. Furthermore, covariate analysis did not reveal any predisposing or protective factors for burden with respect to caregiver characteristics. These findings suggest that HH programs are a viable alternative for acutely ill patients with caregivers.

FINANCIAL FACTORS THAT INFLUENCED TELEMEDICINE DELIVERY DURING THE COVID-19 PANDEMIC: PATIENT AND PROVIDER PERSPECTIVES

Rahma Mkuu²; Katerina Andreadis³; Kimberly A. Muellers⁴; Jessica S. Ancker⁵; Jenny J. Lin¹

¹Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Health Science, University of Alabama College Store, Tuscaloosa, AL; ³Population Health Sciences, Weill Cornell Medicine, New York, NY; ⁴General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ⁵Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN. (Control ID #3874276)

BACKGROUND: The COVID-19 pandemic necessitated a shift in clinical practice from in-person visits to virtual visits to prevent the spread of infection. Although studies report finances are a barrier to providing telemedicine, no study to date has explored how finances are a barrier to providing and using telemedicine for providers and patients. This study aims to describe reimbursement issues that influenced telemedicine provision and use for patients with chronic conditions and their providers during COVID-19.

METHODS: We recruited adult patients (n=65) and primary care providers (n=21) across four medical centers in three states (New York, North Carolina, and Florida) between March and October 2021. Semi- structured interviews were conducted asking about participants’ experiences with telemedicine during the pandemic. All interviews were audio-recorded and transcribed verbatim. An inductive approach was applied to coding. Transcripts were analyzed for themes relating to financial issues around telemedicine use.

RESULTS: Provider and patient perspectives on financial issues that influenced use of telemedicine differed. Provider concerns were associated with reimbursement while patients were mainly concerned about out-of- pocket costs. Three major themes emerged: (1) telemedicine revealed the burden of providers’ uncompensated ‘invisible’ work, (2) reimbursement will determine sustainability of telemedicine, and (3) telemedicine addresses some cost concerns for patients.

CONCLUSIONS: Policy changes that supported financing of telemedicine catalyzed the rapid expansion of telemedicine to offset reduced in-person patient encounters during the COVID-19 pandemic. Sustainability of telemedicine will likely depend on reimbursement parity and recognition and reimbursement for provider uncompensated services. Given that patients shared that telemedicine reduced their out-of-pocket costs, more research should examine whether telemedicine improves access among underserved populations while maintaining care quality.

GENERAL MEDICAL VISITS CAN DECREASE LONG COVID EMERGENCY VISITS AND OVERALL SUBSPECIALTY HEALTHCARE COSTS ONE YEAR AFTER HOSPITAL DISCHARGE

Jasmine Leahy¹; Rebecca S. Bajracharya¹; Brian L. Altonen³; Samkit Jain³; Tanya Rastogi³; Alfredo Astua²

¹Icahn School of Medicine at Mount Sinai, New York, NY; ²Pulmonary and Critical Care, New York City Health and Hospitals Corporation, New York, NY; ³Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3874874)

BACKGROUND: Though long COVID symptoms are heavily studied, there is a lack of research about how sequelae translate into patient visit behavior and hospital costs. In this study, we used post-discharge healthcare utilization metrics for hospitalized, non-intubated COVID-19 patients to compare how patients sought and received care in the year after hospital discharge.

METHODS: This was a retrospective cohort study of 200 patients in a large public hospital hospitalized between March 2020-February 2022. Number of specialty, general medical (GM), emergency (ED), and missed visits were counted 12 months post-discharge. It was assumed that more than 90% of patients were medicare/medicaid. Appointment costs were derived from Physician’s BlueBook data from the participating hospital, reflecting insurance coverage and physician reimbursement. The following schema was used: 1 GM visit = $164.29, 1 specialty visit = $214.29, and 1 ED visit = $262.55. Appointments incurred costs whether or not the patient attended. Patients were stratified into low and high cost groups. Chi-square tests were run to find correlations between appointment types and confirmed with Linear-by-Linear Association and Fisher’s Exact tests.

RESULTS: Average age was 57 years. There were 71 females and 129 males. One hundred-fifteen patients were Hispanic/Latino. Average BMI was 29. Average length of hospital stay was 8 days. There were 36 patients (18%) with at least one ED visit. 86% (31/36) of ED patients had at least one missed appointment, compared to 58% (95/164) of patients with no ED visits (p=0.002). Patients with a combination of low GM costs and high specialist costs had the highest ED costs and highest average appointments per person.

CONCLUSIONS: Appointments and ED visits increased for hospitalized COVID-19 patients with more specialty and less GM visits. Scheduling numerous specialty visits may exacerbate rates of missed appointments among this group. It is essential and cost-effective that long COVID patients follow-up with GM repeatedly within one year of diagnosis to prevent emergencies and decrease mean annual appointments. Future interventions should reinstate ED-visiting long COVID patients with their internist and identify the needs of patients at risk for Post-COVID emergencies.

HEALTH CARE USE AMONG PATIENTS NEWLY INSURED VIA HOSPITAL-BASED INSURANCE LINKAGE

Ella Eisinger⁴; Angela Chen^4,2; Anna U. Morgan^3,7; M. K. Delgado^5,7; Omar Ramadan^6,7; Elinore Kaufman^1,7

¹Division Of Traumatology, Surgical Critical Care, And Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²University of Pennsylvania Department of Health Care Management, Philadelphia, PA; ³Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ⁴University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ⁵Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ⁶General Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ⁷Leonard Davis Institute of Health Economics, Philadelphia, PA. (Control ID #3870625)

BACKGROUND: Over 60% of the 27 million uninsured individuals in the United States are eligible for public insurance or subsidies. Many health systems assist ED or hospitalized patients with insurance enrollment, in part to facilitate payment for acute care. However, little is known about the impact of these programs. We compared health care utilization and outcomes for patients who obtained insurance retroactively after an acute care encounter to those with prior Medicaid and those who remained uninsured. We hypothesized that newly insured patients would have lower use of preventive services compared to those with pre-established coverage.

METHODS: We identified uninsured patients in an urban academic health system with an ED-to-hospital admission, 1/1/2016-12/31/2021. We compared retroactively insured (RI) patients to patients who presented with preexisting Medicaid (MI) or who remained uninsured (UI). The primary outcome was ≥ one primary care provider (PCP) visit in the 12 months following index admission. Secondary outcomes included PCP listing in the electronic health record, blood pressure (BP), hemoglobin A1c (HbA1c), ED revisits, and hospital-free days (HFDs). Descriptive statistics, univariate analyses, and multivariable regressions were used to evaluate intergroup differences on outcomes of interest.

RESULTS: Of 3,455 presenting uninsured, 2,596 (75%) were enrolled in insurance and 859 (25%) remained uninsured. Unadjusted results are shown in the table. In multivariable analysis adjusted for demographic and clinical characteristics, RI patients had higher odds of 12-month PCP visit vs. MI patients (OR: 1.19, p=0.003) and UI patients had lower odds (OR: 0.78, p=0.037). RI patients with preexisting HTN had the greatest 12-month reductions in systolic BP relative to both MI and UI patients.

CONCLUSIONS: Hospital-based insurance linkage offers a viable route to expanded coverage. RI patients had improved primary care utilization and chronic disease management. Linkage programs are well positioned to address the gap between coverage, care, and health outcomes. Leveraging these programs to engage patients in needed care has the potential to improve health outcomes for vulnerable patients.

HEALTH LITERACY AS AN INDEPENDENT PREDICTOR OF COVID-19 VACCINE ACCEPTANCE IN A DIVERSE SAMPLE OF URBAN ADULTS.

Emily E. Hurstak¹; Francesca Farina³; Michael Paasche-Orlow⁴; Lori Henault²; Melissa Marquez³; James W. Griffith³

¹General Internal Medicine, Boston Medical Center, Boston, MA; ²General Internal Medicine, Boston Medical Center, Boston, MA; ³Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL; ⁴General Internal Medicine, Tufts Medical Center, Boston, MA. (Control ID #3865721)

BACKGROUND: High rates of COVID-19 vaccination are critical to reduce morbidity and mortality, but little is known about modifiable risk factors that influence vaccine confidence and acceptance. We examined the relationship between participant demographics, health literacy, confidence in COVID-19 vaccines, and self-reported vaccine acceptance. We hypothesized that 1) higher vaccine confidence would increase the odds of vaccine acceptance and 2) health literacy would predict vaccine acceptance above and beyond vaccine confidence.

METHODS: We analyzed questionnaire data from English- and Spanish-speaking adults participating in an observational study conducted in Boston and Chicago from November 2020 through March 2021. We collected baseline demographics including age, gender, race, ethnicity, education level, and a performance- based measure of health literacy: the Health Literacy Assessment Using Talking Touchscreen Technology (Health LiTT). We evaluated confidence in the safety and efficacy of the available COVID-19 vaccines using an adapted eight-item Vaccine Confidence Index (aVCI), inspired by the Global Vaccine Confidence Index, measured at three time points. We used a latent growth curve analysis to determine if aVCI scores over time and health literacy (at baseline) predicted vaccine acceptance.

RESULTS: Participants (N = 244) were on average 50 years old, 63% female, 39% non-Hispanic Black, 24% Hispanic, 31% non-Hispanic White, and 4% Asian. Of these, 212 adults (87%) reported at least one COVID-19 vaccination. Individuals who did not report vaccination had lower mean health literacy (50.6 vs 54.3, p = 0.02) and lower mean aVCI scores (1.5 vs. 2.6, p < 0.001). Adjusting for age, gender, race, ethnicity, and education level, a higher mean aVCI score [vaccine confidence β = 1.15, p < 0.001, standardized β = 0.79] and higher health literacy [health literacy β = 0.03, p = 0.03, standardized β = 0.21] predicted vaccine acceptance. Vaccine acceptance did not differ significantly by gender, age, race, ethnicity, or education level.

CONCLUSIONS: A higher vaccine confidence score predicted vaccine acceptance. The aVCI tool may be useful in identifying populations at risk for COVID-19 vaccine hesitancy that would benefit from targeted interventions. In addition, health literacy – but not gender, age, race/ethnicity, or education level - was an independent predictor of vaccine acceptance, even after controlling for vaccine confidence. Thus, health literacy should be addressed in vaccination promotion efforts. Doing so may help ameliorate disparities in vaccination rates.

IDENTIFYING UNNECESSARY HOSPITALIZATIONS USING THE COVID-19 PANDEMIC AS A NATURAL EXPERIMENT: AN INSTRUMENTAL VARIABLE ANALYSIS

Richard K. Leuchter¹; Lucia Chen¹; Sitaram Vangala¹; Chad Villaflores¹; Emmett Keeler³; Catherine Sarkisian^1,2

¹Division of General Internal Medicine & Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²VA Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, CA; ³RAND Corporation, Santa Monica, CA. (Control ID #3857627)

BACKGROUND: It has long been hypothesized that a portion of hospitalizations are unnecessary, possibly arising from medical uncertainty or “defensive medicine”. The threshold to admit patients increased during the Covid-19 pandemic, providing a unique opportunity to evaluate if certain illnesses that were historically treated inpatient could be equally well managed outpatient (i.e., the hospitalizations were unnecessary).

METHODS: In this single-center cohort study, we used EHR data from all adults with an attributed UCLA PCP who were treated for 1 of 8 diagnosis-related groups (DRGs) either 6-months before or after Los Angeles County Covid-19 stay-at-home orders went into effect (3/15/20). An instrumental variable analysis using a 2-stage least squares estimator used admission threshold as the instrument (pre- v. post-pandemic), care setting as the treatment (inpatient v. outpatient), and composite 30-day admission/readmission or mortality as the outcome.

RESULTS: Among 25,547 encounters, the proportion of each DRG managed as outpatients increased by 4-15% during 3/15/20-9/14/20 compared to 9/15/19-3/14/20. Admission threshold served as a strong instrument (F>10) for 6 of 8 DRGs (see Table). Pre- and post-pandemic populations were similar in terms of age (56 years [SD 18] v. 60 [18]), gender (55% female v. 54%), multimorbidity weighted index (2.3 [SD 3.6] v. 2.3 [3.6]) and social vulnerability index (34 [SD 26] v. 34 [26]), arguing against the possibility that the outcome was affected by changes in population characteristics. In the effectiveness analysis, cardiovascular, gastrointestinal (GI), pulmonary, and urinary DRGs demonstrated asymmetric upsides to shifting inpatient to outpatient care (e.g., GI, the 7.3% shift from inpatient to outpatient care was associated with at best a 19% decrease in the composite outcome and at worst a 1% increase in the outcome).

CONCLUSIONS: Even when accounting for unobserved medical and social determinants of health, outpatient management was non-inferior (in some cases superior) to inpatient management for 4 DRGs in terms of avoiding readmission and mortality. This implies 4-11% of past hospitalizations for these conditions have been potentially unnecessary, and suggests specific DRGs that interventions might focus on to reduce unnecessary hospitalizations.

IMPACT OF AN EMBEDDED VTE RISK ASSESSMENT MODEL ON VTE PROPHYLAXIS FOR MEDICAL INPATIENTS

Michael B. Rothberg¹; Aaron C. Hamilton²; Alex Milinovich³; Oleg Lisheba⁴; Bo Hu³

¹Internal Medicine, Cleveland Clinic, Cleveland, OH; ²Hospital Medicine, Cleveland Clinic, Cleveland , OH; ³Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; ⁴Cleveland Clinic, Cleveland, OH. (Control ID #3875153)

BACKGROUND: Venous thromboembolism (VTE) is a common cause of morbidity among hospitalized medical patients. Prophylaxis is recommended for patients at high risk and several risk assessment models (RAM) have been developed to guide prophylaxis. However, none have been tested prospectively as part of the electronic health record (EHR) in a health system. As part of a randomized trial (RCT), we incorporated a RAM into all EHR order sets, but it was often neglected. At the conclusion of the RCT, the RAM remained active and was later converted to a “hard stop” to encourage its use. Physicians could still circumvent the RAM by not using an order set. Our objective was to measure the impact of these changes on prophylaxis, VTE, bleeding and heparin-induced thrombocytopenia (HIT).

METHODS: We conducted an interrupted time series of the embedded RAM at 10 Cleveland Clinic hospitals. Data were extracted from the EHR. We included all adult medical admissions during 3 time periods: the RCT (10/17-1/19), the voluntary period (2/19-8/19), and the mandatory period (8/19-2/20). Patients admitted with VTE, on therapeutic anticoagulation, or at high risk of bleeding (as indicated by their physician) were excluded. Physician estimation of VTE risk (whether or not the RAM was used) was required to meet quality metrics and was recorded in the EHR. Prophylaxis was identified from the medications administered section. VTE, bleeding and HIT were identified using combinations of ICD codes, testing, and treatment. Rates across the 3 time periods were compared using the chi-squared test.

RESULTS: The final dataset consisted of 48,407 patients admitted between October 2017 and January 2020, with 26506 (55%) admitted during the RCT, 10689 (22%) during the voluntary period, and 11212 (23%) during the mandatory period. Patients had a mean age (SD) of 62 (19), 48% were male, and 72% were White; characteristics and predicted VTE risk were similar across all 3 periods. The RAM usage increase from 14% (RCT) to 26% (voluntary period) and 86% (mandatory period), p<0.001. Rates of prophylaxis declined from 66% (RCT) to 55% (voluntary period) and 39% (mandatory period)(p<0.001). Rates of VTE in the same periods were 0.9%, 0.9% and 1.0% (p=0.43). Rates of bleeding and HIT were also unchanged. The RAM identified 26.5% of patients as high risk. Physicians were more likely to assess patients as high risk when they did not use the RAM than when they did (79.4% vs. 42.0%, p<0.001). Patients judged high risk by the physicians alone had a VTE rate of 0.48%, which was lower than the rate for those judged to be high risk by the RAM (2.7%, p<0.001) but higher than the rate for patients judged to be low risk by the RAM (0.28%, p<0.005).

CONCLUSIONS: Mandating use of a VTE RAM embedded in the EHR was associated with a large reduction in patients assessed to be high risk, and a concomitant reduction in prophylaxis use, with no associated increase in VTE.

IMPACT OF REFERRING HIGH-RISK VETERANS TO PRIMARY CARE INTENSIVE CASE MANAGEMENT SERVICES ON HEALTHCARE UTILIZATION AND COSTS

Evelyn T. Chang¹; Alexis Huynh⁶; Jean Yoon²; Donna Zulman³; Melissa D. Klein⁴; Jessica Eng⁹; Susan E. Stockdale⁵; Elvira E. Jimenez⁶; Caroline Yoo⁷; Steven M. Asch⁸

¹General Internal Medicine, VA- Greater Los Angeles, Los Angeles, CA; ²HERC, Palo Alto VA, Menlo Park, CA; ³Medicine, Stanford University, Stanford, CA; ⁴Medicine, Cleveland VA Medical Center, Shaker Hts, OH; ⁵HSR&D Center of Excellence, Greater Los Angeles VA Healthcare System, Sepulveda, CA; ⁶Research, VAGLAHS-Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Los Angeles, CA; ⁷Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ⁸PCPH, Stanford University School of Medicine, Stanford, CA; ⁹University of California San Francisco School of Medicine, San Francisco, CA. (Control ID #3872284)

BACKGROUND: VHA Office of Primary Care piloted an intensive outpatient primary care program by augmenting patient-centered medical homes with Primary care Intensive Management (PIM) for patients at high risk for hospitalization or death. PIM was cost-neutral in the first and second year among patients randomly assigned to PIM, but program participation was low. We evaluated whether a referral model would decrease high-risk patient costs.

METHODS: We conducted a retrospective cohort study using a quasi-experimental design comparing 456 high-risk patients referred to PIM from October 2017 – September 2018 to 1,377 propensity score-matched high-risk patients. Veterans with risk of 90-day hospitalization or death in the top 10^th percentile and recent hospitalization or emergency department (ED) visit were referred to PIM by primary care providers for comprehensive assessments, intensive case management, and care coordination services. We used administrative data extracted from VHA’s Corporate Data Warehouse. Main outcomes included VHA and Community Care outpatient utilization, inpatient admissions, and costs for each patient for 12 months before and 12 months after the index date.

RESULTS: Of the patients referred to PIM, 301 (65.6%) were enrolled. Referred patients were more likely to be older, have medication non-adherence, have chronic medical and behavioral health conditions, and have higher baseline utilization prior to PIM referral than the propensity score-matched high-risk patients. During the 12-month evaluation period after the index date, high-risk patients referred to PIM had significantly more ED visits ([0.27, 1.59]; p<0.05), primary care visits ([1.07, 2.57]; p<0.001), homeless services ([0.14, 1.97]; p<0.05), and home care ([1.28, 1.86]; p<0.001) than propensity-matched high-risk patients; however, overall outpatient costs were similar. High-risk patients referred to PIM had significantly more medical and surgical hospitalizations ([0.10, 0.50]; p<0.05), longer length of stay ([0.56, 4.96]; p<0.05), and higher inpatient costs ([$7,015, $31,922]; p<0.05) than propensity-matched high-risk patients.

CONCLUSIONS: A referral model resulted in increased participation in a Primary Care Intensive Management Program. High-risk patients referred to PIM had higher ED use, inpatient admissions, and inpatient costs than the propensity-matched high-risk patients. Decreasing healthcare costs for high-risk patients through an intensive outpatient primary care program remains a challenge for large integrated healthcare systems. While it may prevent some unnecessary costs, intensive outpatient primary care programs are equally likely to identify unmet needs that result in additional healthcare services and costs.

IMPACT OF SNOWFALL ON MISSED APPOINTMENTS AND UNUTILIZED CAPACITY IN A GENERAL INTERNAL MEDICINE CLINIC

Kelly A. Kieffer^1,2; Jacob Warner³

¹Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH; ²Medicine, Dartmouth College Geisel School of Medicine, Hanover, NH; ³Medicine, University of Vermont Larner College of Medicine, Burlington, VT. (Control ID #3873401)

BACKGROUND: Missed appointments, or no-shows, are associated with worse patient outcomes, increased healthcare expenditures and increased emergency room utilization. No-show rates are higher during winter. We sought to document the degree to which greater snowfall contributes to missed in person appointments in order to inform staffing and utilization of telehealth on anticipated snow days.

METHODS: Using medical record data and historical weather data from the National Oceanic and Atmospheric Administration, attendance outcomes based on daily snowfall in the months of November through April in the years 2015-2022 were evaluated. Outcomes included no-show rate, late cancellations (within 24 hours of appointment), clinic capacity (average daily appointments per month minus appointments that day) and proportion of appointments missed (late cancellations plus no-shows as a proportion of total visits). Unadjusted linear regression models and multivariable linear regression analysis adjusting for patient age and sex, provider type, daily minimum temperature, daily maximum temperature, daily average temperature and modality of visit (in-office or telehealth) examined the association between each outcome and snowfall.

RESULTS: 850 clinic days, consisting of 97,583 visits were analyzed. 38.8% (n=37904) of the sample was male, and average age was 62.6 years. 17.8% (n=17359) of appointments were scheduled with residents, 35.0% (n=34136) with advance practice providers, and 47.2% (n=46088) with attendings. 96.8% (n=94495) were in-office. No-show rates were 6.18% with no snow and increased with higher amounts of snowfall, plateauing at 8.23% for 4 inches. There were 18 late cancellations on average on days with no snow, and increasing numbers of late cancellations with higher amounts of snow plateauing at 45 with 5 inches of snow. Snowfall was more strongly associated with no shows for male patients, younger patients, and patients scheduled with a resident provider. In adjusted linear regression, all four outcomes were significantly impacted by snow (p<0.001). In multivariable analysis with snowfall as the independent variable, no-show rate (beta=0.37, 95% CI (0.21, 0.54), late cancellations (beta=3.16 95% CI (2.63, 3.69), clinic capacity (beta=4.47 95% CI (2.88, 6.06), and appointments missed (beta=4.96 95% CI (4.25, 5.67) were all significant (p<0.001).

CONCLUSIONS: Snowfall is associated with increased no-show rates and unutilized capacity, with the greatest impact on days with 4-5 inches of snow or more. Male patients, younger patients, and patients scheduled with residents may be more likely to no-show related to snowfall. This informs the clinic policy regarding when and for which patients to target rescheduling or transition to telehealth.

IMPLEMENTATION OF THE CLINICAL RESOURCE HUB PROGRAM AND IMPLICATIONS FOR WAIT-TIMES PRIOR TO THE COVID-19 PANDEMIC

Matthew R. Augustine^1,2; Peter J. Kaboli^3,4; Bjarni Haraldsson³; Ariana Shahnazi³; Amy M. O'Shea^3,4

¹Geriatric Research Education and Clinical Center, James J Peters VA Medical Center, New York, NY; ²Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY; ³CADRE, Iowa City VA Medical Center, Iowa City, IA; ⁴Carver College of Medicine, University of Iowa, Iowa City, IA. (Control ID #3869434)

BACKGROUND: In October 2019, the Veteran Affairs (VA) Office of Primary Care (PC) implemented the Clinical Resource Hub (CRH) program. Hubs offer PC primarily via telemedicine to VA PC clinics by filling short term provider vacancies. While the CRH program can relieve vacancies, the effectiveness of CRH implementation on PC wait times is unknown. The study objective was to evaluate PC wait times in VA clinics before and after CRH implementation prior to the COVID-19 pandemic.

METHODS: This retrospective observational cohort study used administrative data to identify VHA PC clinics who used and did not use CRH during the 12-month pre-implementation period (Oct 1, 2019-Sep 30, 2019) and 5-month post-implementation period (Oct 1, 2019-Feb 1, 2020). Data is restricted to the first 5 months of CRH implementation due to the COVID-19 pandemic’s impact on clinic scheduling and care delivery. Clinics were defined as “CRH users” when experiencing >10 PC CRH visits/month for two consecutive months and stratified as small, medium, or large. PC access was measured using new and established patient wait times (number of days a patient can expect to wait for an appointment) and timely care (proportion of patients engaging with VA services within 2 days of a same day or next available appointment request). We performed comparative interrupted time series using linear regression with triple interaction for CRH users, time, and period before and after implementation.

RESULTS: 71 CRH programs with 964 affiliated PC clinics were included. In October 2019, the average established patient wait time (EPWT) for CRH user versus non-user clinics was 46.9 and 52.3 days, respectively (p=0.015). In the pre-implementation period, EPWT increased modestly by 0.57 days / month (p<0.001) at a rate no different across CRH and non-CRH users (β=-0.06, p=0.84). After CRH implementation, CRH users experience ongoing lower EPWT; however, the change over time was no different than non-CRH users (β=-0.23, p=0.85). For new patient wait times (NPWT), clinics using CRH had longer wait times in October 2019 than non-users (22.4 days vs. 19.5 days, p=0.001). In the pre- implementation period, NPWT decreased modestly by 0.19 days per month (p<0.001) at a rate no different across CRH and non-CRH users (β=0.13, p=0.27). In the post-implementation period, NPWT among CRH users remained longer and the decrease in NPWT over time flattened; however, the pre and post changes in NPWT remained similar among CRH and non-CRH clinics (β=-0.21, p=0.63). Stratified analysis across small, medium, and large clinics demonstrated similar findings.

CONCLUSIONS: In a national VA telemedicine program developed to provide gap coverage services for PC clinics, early implementation of this program resulted in no differences in new or established patient wait times. The CRH model offers a modality to provide gap coverage while maintaining access to care. Further investigations of wait-times during the later stages of CRH implementation are still needed.

IMPLEMENTING A TELERETINAL PROGRAM IN PRIMARY CARE CLINICS TO INCREASE DIABETIC RETINOPATHY SCREENING

Michele Rains¹; Kevin Chen²; Hannah B. Jackson³

¹Office of Ambulatory Care, New York City Health and Hospitals Corporation, New York, NY; ²Internal Medicine, Yale New Haven Hospital, New York, NY; ³Office of Ambulatory Care & Population Health, New York City Health and Hospitals Corporation, New York, NY. (Control ID #3868169)

BACKGROUND: Diabetic retinopathy is the leading cause of blindness in the US. NYC Health + Hospitals serves over 62,000 patients with diabetes who require annual screening. Patients may experience barriers to getting screened such as long wait times for eye clinics and coordinating an extra specialist visit. To address these barriers and increase our screening rates for diabetic retinopathy, we implemented a teleretinal screening program in primary care clinics.

METHODS: The teleretinal screening program places a non-mydriatic fundus photo camera in the primary care clinic. A primary care provider (PCP) places the order for screening in the electronic health record (Epic). Then, a trained Patient Care Associate (PCA) takes the photo. Next, a local eye care provider (Ophthalmologist or Optometrist) reads the image within 3-5 days and recommends follow-up in primary care or Ophthalmology, as appropriate. The Ophthalmology clinic follows up with patients needing an appointment and schedules them based on acuity. Finally, the results are then sent back to the ordering provider to close the loop of communication. All PCPs, PCAs, and reading eye care providers are personally trained by the teleretinal screening program manager and must complete the mandatory training before the program is live at that facility. The teleretinal screening program is live at 16 NYC Health + Hospitals sites (11 hospital-based clinics and 5 FQHC sites). There is a comprehensive Epic report that tracks the program metrics on a monthly or ad hoc basis. The metrics include total number of orders placed, number of orders completed, number of patients referred into the eye clinic, number of patients with evidence of diabetic retinopathy, and number of poor-quality photos taken by the PCAs for quality assurance. A report is sent to each facility each month with a live dashboard forthcoming to ensure data transparency and continual quality assurance and improvement.

RESULTS: There have been 31,260 screenings completed in the primary care setting from 2019-2021. Of those 31,260 patients, 13,903 (44%) were referred into the eye clinic for follow up, of which, 7,277 (23%) had evidence of diabetic retinopathy. Screening rates across the system have increased significantly since the initiation of this program. In total, sites that implemented teleretinal screening saw an absolute increase in diabetic retinopathy screening rates of 7% (79.4% in 2021 vs 72.5% in 2018, p<0.01)

CONCLUSIONS: The teleretinal screening program at NYC Health + Hospitals greatly reduces barriers to access for diabetic retinopathy screening. This was seen in our increased screening rates across the system. In addition to increasing access to screening, we can also increase access to treatment for more severe disease by reducing benign screening events from specialist schedules. There is a financial benefit as well; this program satisfies quality benchmarks for value-based payment arrangements and increases billing capabilities of specialist.

IMPLEMENTING INPATIENT SCREENING FOR UNMET SOCIAL NEEDS IN AN ACADEMIC MEDICAL CENTER

Jocelyn A. Carter¹; Adaugo Amobi¹; Brammy Rajakumar²

¹Medicine, Massachusetts General Hospital, Brookline, MA; ²Harvard University, Cambridge, MA. (Control ID #3876941)

BACKGROUND: The social determinants of health (SDOH) are widely recognized as having an important impact on health and mortality with up to 80% of health outcomes shaped by SDOH domains (the conditions in which people are born, grow, work, live, and age). There is strong evidence that addressing unmet social needs can lower healthcare costs and utilization. For these reasons, SDoH screening in primary care settings has been established as important step in addressing unmet needs and clinical outcomes. Emerging evidence is now demonstrating that SDoH screening in the inpatient setting may add value prior to discharge.

METHODS: A structured questionnaire was used to identify unmet social needs for inpatients hospitalized on a single general internal medicine unit within our AMC. Patients eligible for screening were >18 years old, had capacity, and spoke English. Questionnaire domains included food and housing insecurity, transportation needs, inability to pay for medications, find work, obtain educational resources or identify support for childcare. The questionnaire was verbally administered. All responses were documented in a REDCap database. Unmet social needs were shared with the unit team via a SharePoint site. These results were then discussed and integrated into the unit multidisciplinary team meetings held daily. Questionnaire responses were tracked along with process and outcome measures including the timing of social work consultations, integration of unmet social needs within the team discharge summary, and future healthcare utilization (e.g., 30-day readmissions, ED visits, missed PCP and specialty).

RESULTS: Results for 155 inpatients approached (8/2021- 3/2022) revealed the following unmet needs: transportation (21%), employment status (19%), food access (17%), housing (15%), and medication payment ability (14%). Fifty percent of the needs identified on survey were previously unknown to medical teams. Sixty-nine percent of needs were addressed prior to or on hospital discharge and 95% were incorporated into clinical care team planning. Analysis is underway to determine relationships between identified unmet needs and demographics (including insurance, age, race, etc), social work consult placement timing, and clinical outcomes after discharge (30-day readmissions, ED visits, missed PCP and specialty appointments). Final analysis is expected January 2023.

CONCLUSIONS: Screening for social needs is feasible in a high volume, inpatient, academic hospital setting. This pilot enabled healthcare team members to identify and respond to social needs for patients that were otherwise not previously known to the care team. Challenges include staff workflows, EHR integration, and resource response to positive screens. If addressed, the inpatient setting may be established as an underutilized setting for universal social needs screening.

IMPROVING CHRONIC PAIN MANAGEMENT IN OLDER ADULTS: PILOT EVALUATION OF A TOOL FOR PATIENT-REPORTED SYMPTOMS AND TREATMENT PREFERENCES

Ainur Kagarmanova¹; Erin Staab²; Katherine Thompson³; Neda Laiteerapong^3,1; Mim Ari⁴

¹General Internal Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ²Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ³Medicine, University of Chicago, Chicago, IL; ⁴Medicine, University of Chicago, Chicago, IL. (Control ID #3876363)

BACKGROUND: Chronic pain in older adults is complicated to manage due to high rates of multimorbidity and polypharmacy. Patient preferences are important to tailoring chronic pain management. Collecting information on patient-reported symptoms and treatment preferences can be challenging in busy primary care practices.

METHODS: We developed ICOPE (Improving Chicago Older Adult Chronic Pain and Opioid Use through Patient-Centered Clinical Decision Support and Project ECHO®) to improve chronic pain, opioid use, and opioid use disorder (OUD) management in older adults. ICOPE included a pre-visit patient questionnaire on pain and depression symptoms, goals for pain management, treatment preferences, and opioid use, and an order set with clinical decision support and patient resources. Questionnaire could be taken via an online portal before the visit or at check-in. Those eligible were adults ≥65 years with a recent pain score ≥6/10, current opioid prescription, chronic pain and/or OUD diagnosis. ICOPE was piloted in two ambulatory clinics. Study team met regularly to brainstorm ways to improve engagement. We chose a multi-pronged approach to improve questionnaire completion: clinic directors were sent questionnaire completion rates monthly; study team members trained staff and providers to adjust the clinic workflow; clinic staff were given incentives (e.g, branded pens, post-its, and t-shirts) for completion of questionnaires; flyers with provider testimonies were posted throughout the clinic; and providers and staff were emailed project reminders monthly.

RESULTS: In the first 16 months (6/21-10/22) of the ICOPE pilot, 5,871 questionnaires were completed. A third (33%, n=1571) of eligible patients completed at least 1 questionnaire. At 29% (n=1722) of visits, patients stated that they wanted to discuss pain with their provider. Average pain score was 5.01 (SD 2.65). The most frequently reported goals for pain management were to be more physically active (22%, n=1281) and perform more daily tasks (19%, n=1084). The most commonly preferred treatment options were physical therapy (9%, n=506) and patches/creams (7%, n=373). One in ten patients (11%, n=667) preferred a provider choose the treatment plan. Most questionnaires (94%, n=5,492) were completed via the patient portal.

Fidelity to in-clinic questionnaire administration was low. Identified barriers included capacity issues, staff turnover, and workflow changes due to COVID-19. Despite efforts to increase uptake, questionnaire completion rates increased in one of the clinics (6% to 10%) and decreased in the other clinic (17% to 15%) from 6/21 to 10/22.

CONCLUSIONS: ICOPE questionnaires were completed by a third of eligible patients, mostly through an electronic portal. Completion rate did not change appreciably with implementation efforts due to various barriers. Ongoing efforts are needed for successful implementation. A stepped wedge trial in 35 clinics will test the effect of the ICOPE program on quality of care and pain-related outcomes.

INTERNAL MEDICINE (IM) RESIDENT EXPERIENCES IN DISCHARGING PATIENTS TO SKILLED NURSING FACILITIES (SNFS)

Bingyan Shi³; Margaret Fang²; Audrey Lyndon⁵; Andrew Auerbach¹; Rebecca L. Sudore⁴; James D. Harrison¹

¹Division of Hospital Medicine, University of California San Francisco, San Francisco, CA; ²Division of Hospital Medicine, University of California San Francisco, San Francisco, CA; ³Internal Medicine Residency Program, University of California San Francisco, San Francisco, CA; ⁴Division of Geriatrics, University of California San Francisco, San Francisco, CA; ⁵Rory Meyers College of Nursing, New York University, New York, NY. (Control ID #3874860)

BACKGROUND: Internal medicine (IM) residents, as part of their inpatient clinical experiences, often discharge patients to skilled nursing facilities (SNFs). Despite this common practice, residents often do not receive explicit training on this process, nor do they receive education on or undergo clinical experiences at SNFs. This study aims to build on existing research on this topic by exploring IM residents’ attitudes and experiences in discharging patients to SNFs and identify perceived challenges to this common process. METHODS: We conducted a qualitative study using focus groups at a single IM residency, in which residents rotate through three-hospital sites (a tertiary academic center, a county hospital, and a Veterans Affairs medical center). A focus group guide was developed with seven questions exploring residents’ specific experiences and knowledge around discharging patients to SNFs and suggestions for improvement on the process. All sessions were conducted over zoom, audio recorded, professionally transcribed, and analyzed using thematic analysis.

RESULTS: A total of three, hour-long, focus groups were conducted, with a total of ten residents (three post graduate year (PGY)-1, three PGY-2, three PGY-3, and one PGY-4). We found that residents’ prior education and clinical exposures to SNFs were variable: most residents learned about the services SNFs provided indirectly through patients, interdisciplinary team members (case managers, and social workers), or the media. Few residents have stepped foot inside of a SNF, or recall receiving any education or teaching on SNFs. Furthermore, knowledge around the process of discharging patients to SNF was obtained through “learning by doing”.

The most common attitudes elicited from residents about discharging patients to SNF were 1) a sense of urgency 2) a sense of lack of control, for both clinicians and patients 3) uncertainty and concern regarding what occurs when patients are admitted to the SNF. Residents endorse that they try to mitigate the challenges they experience in discharging patients to SNF by focusing on aspects of the discharge that they can control, specifically 1) learning to anticipate discharges 2) ensuring an accurate and up-to-date discharge summary, to highlight priorities and tasks for for SNF clinicians.

CONCLUSIONS: The qualitative study on resident experiences and attitudes towards discharging patients to SNFs highlights the lack of formal education and clinical exposure to the clinical setting of SNFs. The lack of education and knowledge may be contributing residents’ attitudes of uncertainty, lack of control, and concern for the quality of care received by patients. These results suggest that IM residencies should adopt within their formal clinical curriculum and experience rotation or teaching on or at SNFs.

INTERPROFESSIONAL HEALTHCARE WORKERS’ IMPRESSIONS OF BEDSIDE INTERDISCIPLINARY ROUNDS

Katarzyna Mastalerz¹; Sarah R. Jordan²; Susan C. Connors³

¹Hospital Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ³The Evaluation Center, University of Colorado, Denver, CO. (Control ID #3876273)

BACKGROUND: Bedside interdisciplinary rounds (IDR) ask interprofessional healthcare workers (HCW’s) to gather at the patient bedside to make care plans, but little is known about the impact of bedside IDR on this population. In this study, we explored the experiences of interprofessional HCW’s to understand how bedside IDR affect interprofessional work and communication.

METHODS: We conducted a qualitative descriptive study to examine the perspectives and experiences of interprofessional HCW’s during bedside IDR at an academic regional VA medical center. We conducted semi-structured interviews with bedside nurses, pharmacists, and care coordinators between March and June of 2020, until data saturation was reached. We performed thematic analysis to identify key themes.

RESULTS: We interviewed 18 participants and discovered five themes about their experiences with bedside IDR: 1) Strengthened Interprofessional Teamwork, 2) Improved Patient Care, 3) Platform for Inclusive Communication, and 4) Facilitators to and 5) Challenges of Bedside IDR. HCW’s described that bedside IDR strengthened interprofessional teamwork by building relationships, mutual respect, and trust between professions and by defining team members’ roles and expertise. A care coordinator said: “Relationships make communication far easier… because you have the ability to be candid in situations that you may not feel comfortable doing so otherwise.” HCW’s described that bedside IDR created a shared mental model and increased care efficiency; this was fortified by rounds serving as a platform to share information that physicians often miss, such as late-night falls or clarifying mental status. During bedside IDR, everybody “understands what the plan is, what needs to be done, what has been done.” Team members can also “pipe in with the fact that the family is seemingly like they're struggling [so] it is not an afterthought so the doctors can handle that right then and there.” Bedside IDR was seen as a platform for inclusive communication for patients and the interprofessional team. One HCW said: “the value for the patient is to hear exactly what is being said about them, [it’s a way] for the patient to feel part of the team.” Structured inclusion of all interprofessional input, concise and relevant teaching, and keeping rounds “on track” were all named as facilitators to effective bedside IDR. Challenges to bedside IDR were barriers to inclusion of HCW’s, excessive rounds length, use of medical jargon at the bedside, and lack of physician respect for interprofessional input. “There's a handful of the doctors that simply don't call us [for rounds],” a nurse said.

CONCLUSIONS: Interprofessional HCW’s described that bedside IDR improved interprofessional teamwork, patient care, and communication for the healthcare team. The facilitators and challenges HCW’s reported should be strongly considered when designing and implementing bedside IDR.

IS THE SVEAT SCORE SUPERIOR TO THE HEART SCORE IN PREDICTING 30-DAY MAJOR ADVERSE CARDIOVASCULAR EVENTS IN PATIENTS PRESENTING WITH CHEST PAIN IN THE EMERGENCY OR CLINICAL DECISION UNIT? A SYSTEMATIC REVIEW

Bishnu Mohan Singh¹; Hassan Waqar¹; Nisha Singh²; Sonia Mirza³

¹Internal Medicine, Montefiore Wakefield Campus, Bronx, NY; ²Internal Medicine, North East Medical College, Sylhet, Sylhet, Bangladesh; ³Internal Medicine, King Edward Medical University, Lahore, Pakistan. (Control ID #3875564)

BACKGROUND: History, ECG, Age, Risk factors, and Troponin (HEART) score with a cut-off score of ≤ 3 is a widely used assessment tool introduced in 2008 for stratifying patients with chest pain into high and low risk for 30-day major acute cardiovascular events (MACE). The history component of the HEART score is not specific and appears to introduce subjectivity and inter-rater variability, which is one of its limitations. Additionally, it uses traditional risk factors like diabetes, high cholesterol, and hypertension that are usually absent in younger populations. In 2019, a new scoring system known as Symptoms, history of Vascular disease, ECG, Age, and Troponin (SVEAT) score with a cut-off score of ≤ 4 was introduced. The main objective of this review is to compare the performance of the SVEAT score to the HEART score in predicting the occurrence of 30-day MACE in patients presenting with chest pain in the emergency department (ED). METHODS: We conducted the review as per PRISMA 2020 guidelines. We published our research protocol in the research registry with a unique identifying no. reviewregistry1495. We searched electronic databases like PubMed, Google Scholar, PubMed Central, and Cochrane library as per a predefined search strategy. Four reviewers independently screened the articles and assessed the risk of bias in included studies using the modified QUADAS-2 tool. We selected observational cohort studies that assessed the HEART score and SVEAT score in each participant included in the studies and reported the incidence of 30-day MACE as the endpoint of the study. We excluded abstracts and non-English literature.

RESULTS: Our search strategy identified 98 articles. After excluding 69 irrelevant articles, four reviewers did a full-text review of 29 articles and finally included 2 observational cohort studies. In a prospective study by Roongsritong et al 2020 with 321 subjects Area under the receiving-operator characteristic curve (AUC) was higher for the SVEAT score (0.98, 95% CI 0.97 to 0.99) than the HEART score (0.92, 95% CI 0.88 to 0.96). Similarly, in a retrospective study, Antwi-Amoabeng et al 2022 with 330 subjects AUC was significantly higher for the SVEAT score (0.8876, 95% CI 0.82-0.96) than the HEART score (0.7962, 95% CI 0.71-0.88), P=0.03. With an SVEAT score of ≤ 4, 73.8% of patients were identified as low risk in comparison to 45.2% with a HEART score in Roongsritong et al 2020 study (P<0.01). In Antwi-Amoabeng et al 2022 study, the SVEAT score of ≤ 4 had a significant prediction of 30-day MACE (P=0.001) which was not true with the HEART score of ≤ 3 (P=0.32).

CONCLUSIONS: Hence, considering current evidence SVEAT score seems superior to the HEART score in predicting 30-day major adverse cardiovascular events for patients presenting with chest pain. However, single-centered studies with small sample sizes and very few included studies are the limitations of this review. Further studies with greater sample sizes can provide more robust evidence.

IT WASN’T CLEAR: A THEMATIC ANALYSIS OF WHY PATIENTS DID NOT RECEIVE TIMELY FOLLOW UP OF A CONCERNING FINDING IN PRIMARY CARE

Leonor Fernandez¹; Dru Ricci²; Erin Sullivan²; Maelys Amat^1,3; amie Pollack²; Scot B. Sternberg^3,1; Meghan Drielak⁴; Russell Phillips²

¹Medicine, Beth Israel Deaconess Medical Center, Waban, MA; ²Center for Primary Care, Harvard Medical School, Boston, MA; ³Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ⁴None, Boston, MA. (Control ID #3875462)

BACKGROUND: After a primary care visit for concerning symptoms or signs, patients are often referred for follow-up diagnostic tests and consultations. Many such follow-up evaluations are never completed, leading to delayed or missed diagnoses. Understanding patient perspectives is essential to designing effective interventions.

METHODS: We identified two patient groups for semi-structured interviews about follow-up care after a primary care visit to an academic hospital-based clinic or community health center (CHC): 1) Patients with an urgent dermatology order due to a suspicious skin lesion without a follow-up dermatology visit within 90 days, and 2) Patients with a stress test order after a primary care visit with a billed ICD10 diagnosis of chest pain without completion of the stress test within 28 days. We oversampled patients with Medicaid, with resident physicians as PCP, who spoke limited English (Spanish), and who were receiving care at a CHC. Through 30 individual telephone interviews, we explored how patients experienced communication and care processes. Using an inductive and deductive approach, we thematically analyzed patient interviews via NVivo 11.

RESULTS: The major themes that emerged were 1) lack of clarity about the rationale and urgency of a diagnostic evaluation and 2) challenges booking appointments. Patients were often unaware that a referral was delayed. Almost all expressed desire for transparency about the rationale for the referral/test, including a potentially worrisome diagnosis. Many expressed a desire for more details regarding booking logistics, the test experience, and results. A clinician’s attentive explanation of what to expect was experienced as a sign of respect. Some did not know that concern about cancer prompted the dermatology referral, inferred lower urgency, or assumed referral was no longer necessary when symptoms resolved. Some were hesitant or felt unempowered to bring up fears and concerns. Emotions included appreciation of clinicians, frustration, anxiety, and self-blame. Appointment Barriers included: not being contacted for scheduling, call not answered, language barriers, lack of appointment availability, challenging location for referral, forgetting, COVID, no online booking, or “life got in the way.” Some were told to initiate the call, others to expect a call. Some were confused by medical terminology and jargon, e.g., unsure whether a stress test is a cardiology visit. An absence of explicit instructions and limited appointment availability resulted in unclear processes.

CONCLUSIONS: Limited, ambiguous communication about a referral’s rationale and urgency and challenges in booking appointments were key reasons patients did not successfully complete a timely referral. Shared clarity about why a referral is recommended, what a patient should expect, what to do if symptoms change, and who needs to do what by when, may improve loop closure rates and help patients feel respected and empowered.

LANGUAGE CONCORDANT CARE: A QUALITATIVE STUDY EXAMINING IMPLEMENTATION OF PHYSICIAN NON-ENGLISH LANGUAGE PROFICIENCY ASSESSMENT

Maria E. Garcia¹; Mia F. Williams²; Sunita Mutha³; Lisa C. Diamond⁴; Jane Jih⁵; Margaret Handley³; Sarita Pathak⁶; Leah S. Karliner⁷

¹General Internal Medicine, University of California, San Francisco, San Francisco, CA; ²Internal Medicine, University of California San Francisco, San Francisco, CA; ³Medicine, UCSF, San Francisco, CA; ⁴Immigrant Health and Cancer Disparities Service, Memorial Sloan-Kettering Cancer Center, New York, NY; ⁵Medicine, University of California San Francisco, San Francisco, CA; ⁶Emory University School of Public Health, Atlanta, GA; ⁷Medicine, UCSF, San Francisco, CA. (Control ID #3877029)

BACKGROUND: Patient-physician language concordance can increase access to care for patients with language barriers and improve patient health outcomes. However, assessing and tracking physician non- English language skills remains uncommon in most health systems. This is a missed opportunity for health systems to maximize language concordant care. Our objective was to determine barriers and facilitators to participation in non-English language proficiency assessment among primary care physicians.

METHODS: In this qualitative study, we conducted semi-structured interviews with 11 fully and partially bilingual primary care physicians from a large academic health system with a language certification program.

Interviews aimed to identify barriers and facilitators to participation in non-English language assessment. Two researchers independently and iteratively coded transcripts using a thematic analysis approach with constant comparison to identify themes.

RESULTS: Most participants were women (N= 9; 82%). Participants reported proficiency in Cantonese, Mandarin, Russian, and Spanish. All fully bilingual participants (n=5) had passed the oral language assessment (Clinician Cultural and Linguistic Assessment; a commercial language assessment widely used); of the partially bilingual participants (n=6), four did not test, and two did not pass. Three themes emerged as barriers to assessment participation: 1) Beliefs about the consequences of not passing the test, 2) Time constraints and competing demands, and 3) Challenging test format and structure. Four themes emerged as facilitators to increase assessment adoption: 1) Messaging consistent with professional ethos, 2) Organizational culture that incentivizes certification, 3) Personal empowerment about language proficiency, and 4) Individuals championing certification.

CONCLUSIONS: To increase participation in non-English language assessment and thus ensure quality language concordant care, health systems must address the complex barriers to participation physicians experience and leverage potential facilitators. Findings can inform health system interventions to standardize requirements and process, increase transparency, provide resources for preparation and remediation, utilize messaging focused on patient care quality and safety, and incentivize participation.

LEVERAGING TEAM-BASED CARE MODELS TO ADDRESS SOCIAL DETERMINANTS OF HEALTH FROM MULTIDISCIPLINARY PERSPECTIVES

Ifeoma Ikedionwu¹; Anna Volerman²; Lisa Vinci³

¹School of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; ²Medicine and Pediatrics, University of Chicago Division of the Biological Sciences, Chicago, IL; ³Medicine, University of Chicago, Chicago, IL. (Control ID #3875435)

BACKGROUND: Team-based care in primary care clinics is the current model to best address patients’ complex health conditions. This structure also allows for clinical care, behavioral health, and community- based services to collaborate to address the social determinants of health (SDOH) often seen in primary care clinics. However, few studies investigate the various perspectives of team members on the healthcare team when seeking to optimize team-based care models and using said model to address SDOH. Our aims were (1) to identify opportunities for improvement in team-based care delivery and (2) to conceptualize how this team-based care model can best address the social needs of patients.

METHODS: Clinical and non-clinical staff at a large academic primary care clinic in the Mid-West were interviewed. The semi-structured interviews had questions that fell under three key domains: the current team-based care model, an ideal team-based care model, and team-based care in addressing the SDOH. Interviews were anonymized, transcribed, and coded for themes through a third-party HIPAA compliant software.

RESULTS: Eighteen interviews were conducted, which was approximately 21% of the staff. Physicians and staff shared that one of the most important elements of successful team-based care models is increasing staff to match the size of the patient population (67%). Similarly, seeking more full-time practitioners or establishing health-teams based on full-time equivalent hours would improve workflow and patient experience (56%). Another theme that arose from analysis was screening patients for only the social needs that the institution or the institutional community partners would be able to address (56%). Underscoring each interview was the importance of integrating social workers, case managers, and behavioral health professionals as central team members to shift responsibility away from providers, RNs, and MAs to those best equipped to address SDOH (89%).

CONCLUSIONS: As institutions transition to team-based care models and develop approaches to address patients' SDOH, there are key elements needed for success. Our findings suggest that ideal utilization of a team-based care model requires adequate staffing levels and integration of team member work. Furthermore, a sufficient infrastructure to address the social needs of patients once they have been screened is essential if primary care clinics want to treat using the bio-psychosocial model of health. Future studies should continue to investigate secondary and tertiary steps needed after adapting primary care clinics to team-based care models.

MULTIDISCIPLINARY DIABETES MANAGEMENT AND CONTINUOUS GLUCOSE MONITORING IN PRIMARY CARE FOR A VULNERABLE POPULATION: A PILOT STUDY

Britt Marshall¹; Karlene Wortham²; Dylan Stentiford¹; Saria M. Hassan¹

¹Emory University School of Medicine, Atlanta, GA; ²Emory Healthcare, Atlanta, GA. (Control ID #3876124)

BACKGROUND: Significant disparities exist in diabetes management that are in large part due to social determinants of health, poorly controlled mental health problems, and limited access to advanced technologies such as continuous glucose monitoring (CGM). Given the limited capacity of Endocrinology specialists, Primary Care practices have become the front-line for diabetes care and management. Improved models of care within primary care practices are needed to provide equitable, effective, and sustainable diabetes-specific care. Our objective was to assess the effectiveness of an Integrated Multi-Disciplinary Diabetes Clinic in Primary Care (IM-DCP) on diabetes metrics.

METHODS: Primary care patients at an academic center in the southern United States with an HbA1C ≥9% and not followed by an endocrinologist were referred to the IM-DCP. IM-DCP includes an internal medicine resident and attending, registered nurse trained in DM education, dietitian, and behavioral health specialist; social work services are available remotely. At initial visit, patients are screened for depression, anxiety, and food and housing insecurity as well as are assisted with obtaining CGM. Lab values, referrals, and diagnostic tests were obtained from chart review. The primary outcome was the change in average HbA1c using a paired t-test. Secondary outcomes included fidelity to the protocol, proportion of completed referrals (mental health, and social work), and proportion of patients on a sodium-glucose cotransporter-2 inhibitor (SGLT-2-i) or glucagon-like peptide-1 receptor (GLP-1) agonist.

RESULTS: To date 30 clinics have been held over a 13-month period, with 71 unique patients and 129 visits. Average age was 57.4 (SD 11.8) years, and 52% were female. 37% of patients were ordered a continuous glucose monitoring, 66% of patients filled a SGLT-2-i or GLP-1 agonist. 18% referred to behavioral health, and 11% with food/housing insecurity referred to social work. Average HbA1c for patients who met inclusion criteria for IM-DCP and had at least 1 follow-up appointment decreased from 10.8% to 8.1% (p<0.0001). Nearly three quarters of referred patients dropped their HbA1c below 9%.

CONCLUSIONS: An IM-DCP successfully improved diabetes metrics. We believe this is an important model of care in primary care to improve diabetes management and reduce disparities.

PARTNERING TO PROVIDE PATIENT CARE THROUGH THE VA CRH CONTINGENCY STAFFING PROGRAM: LESSONS LEARNED BY SPOKE SITES AND HUB PROVIDERS

Alicia Bergman¹; Danielle Rose¹; Shay Cannedy²; Melissa Medich³; Karin Nelson^6,4; Susan E. Stockdale⁵

¹Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²HSR&D, Veterans Health Administration, North Hills, CA; ³Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, North Hills, CA; ⁴Medicine, University of Washington, Seattle, WA; ⁵HSR&D Center of Excellence, Greater Los Angeles VA Healthcare System, Sepulveda, CA; ⁶General Medicine, US Department of Veterans Affairs, Seattle, WA. (Control ID #3860830)

BACKGROUND: In 2019 the Veterans Health Administration (VA) began national implementation of Clinical Resource Hubs (CRHs) to provide contingency staffing through (mostly) virtual modalities. Using a “hub and spoke” model, regionally-based hubs provide primary care (PC), mental health (MH), and specialty clinicians to VA clinics with staffing gaps or patient access problems. Integrating the virtual CRH providers/staff into clinic-based teams is challenging, given the lack of standardized workflows. We describe key lessons learned by comparing experiences of CRH and spoke site stakeholders and providers.

METHODS: Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured telephone interviews with 25 PC leaders at spoke sites where contingency staffing was provided and 12 CRH providers and staff within 3 VA regions regarding their experiences working as teams to provide PC services. Interviews were recorded, with a rapid analysis identifying key lessons learned.

RESULTS: Challenges shared by both hub and spoke groups centered around a) the adequacy of support staff available for CRH providers, and b) patient appointment scheduling. Spoke sites were expected to provide support staff for virtual CRH providers, but some CRH providers thought the current level of support was insufficient. Spoke site clinic PC leaders wanted the CRH to provide more support staff to accompany CRH providers. Appointment scheduling challenges revolved around complexity and overlapping tasks and roles between the spoke and hub. Some CRH providers/staff emphasized the benefits of designating a single scheduler to handle CRH scheduling or limiting the number of individuals scheduling, and not using a call center. A challenge unique to PC clinic leaders was wanting CRH to deploy providers more quickly. A challenge unique to CRH providers was occasionally experiencing resistance by some clinic staff to provide support. For clinic PC leaders facilitators included having monthly meetings with the CRH, and CRH providers knowing/developing an understanding of local patient issues/context and resources. Facilitators for CRH providers/staff included having a designated telehealth room at clinics, having clinic-based staff trained as back-ups tele-presenters, and having facility leadership provide the CRH with an accurate representation of the level of clinic functioning and workload prior to their deployment.

CONCLUSIONS: Common challenges to CRH and clinic-based providers and staff working together as a team included available support staff to assist the virtual providers and optimal appointment scheduling practices. Facilitators revolved around optimizing communication and telehealth-friendly clinic set-ups. Effectively integrating virtual clinicians into clinic-based teams may require more coordination between clinic and leadership to determine the best protocols for scheduling and other clinic-based care delivery.

PATIENT, CLINICIAN, AND FACILITY CONTRIBUTIONS TO VARIABILITY IN USE OF VA VIRTUAL CARDIOLOGY CARE

Rebecca L. Tisdale¹; Jacqueline M. Ferguson²; Alison L. Greene³; James Van Campen⁴; Todd H. Wagner⁵; Donna Zulman⁶

¹Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA; ²Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA; ³HSRD, VA Palo Alto Health Care System, Palo Alto, CA; ⁴Ci2i, VA, Menlo Park, CA; ⁵Surgery, VA and Stanford, Menlo Park, CA; ⁶Medicine, Stanford University, Stanford, CA. (Control ID #3872239)

BACKGROUND: Virtual cardiology care (care delivered by phone or video) expanded substantially in the Veterans Health Administration (VA) during the COVID-19 pandemic, and ongoing implementation of virtual-based cardiology care models suggests likely continuing use. Prior mixed methods work suggests that individuals, clinicians, and facilities all influence the choice to conduct a visit virtually. However, the relative extent to which individual-, clinician-, and facility-level factors affect virtual cardiology care utilization in this integrated, nation-wide healthcare system is unknown.

METHODS: We analyzed cardiology virtual care utilization during the first two years of the pandemic (3/11/2020-3/10/2022) in a nationwide cohort of Veterans actively using cardiology care (with at least one outpatient cardiology visit prior to COVID-19 [1/1/2019-3/10/2020] and at least two pandemic-era cardiology visits). We constructed multi-level logistic regression models of whether an encounter was conducted virtually and/or via video, with random effects for patient and the Veterans’ main cardiology provider. We included fixed effects for home VA facility for specialty care and for patient sociodemographic and clinical characteristics.

RESULTS: Our analytic cohort comprised 223,809 Veterans with 989,271 encounters and 2,235 unique clinicians. Patients’ average age was 69.1 years and 5% identified as female. 4% of encounters were video- based and 32% were phone-based. Odds that a given visit was conducted virtually were lower if the Veteran was older, male, or of Black race, or had a history of housing instability (age 75 years or older vs 18-49, adjusted odds ratio [AOR] 0.93 [95% confidence interval 0.90,0.97]; female vs male, AOR 1.07 [1.04,1.10]; Black vs White race, AOR 0.96 [0.94,0.97]; housing instability vs none, AOR 0.96 [0.93,0.99]). All these effects were larger when examining odds that a given visit was conducted via video: age 75 years or older vs 18-49, AOR 0.40 (0.37,0.44); female vs male, AOR 1.32 (1.22,1.42); Black vs White race, AOR 0.93 (0.88,0.97); housing instability vs none, AOR 0.84 (0.78,0.91). Odds of an encounter’s being conducted via video were also lower among Veterans living in rural and highly rural areas (AOR for rural, 0.87 [0.83,0.91] and for highly rural, 0.73 [0.65,0.81]). In video-only models, 46% of variation in an encounter’s likelihood of being video-based was found at the patient level, and 17% was found at the clinician level; for virtual models, these figures were 21% and 11%, respectively.

CONCLUSIONS: The largest share of the attributable variability in VA cardiology virtual care utilization in this cohort was explained by the patient, but a large minority was attributable to the clinician. Follow-up work will assess the remaining variability attributable to the facility level. These results suggest that policy solutions intended to change uptake of virtual cardiology care should focus on the patient and clinician levels for maximum impact.

PATIENT REPORTED EXPERIENCE FOLLOWING UP ABNORMAL CANCER SCREENING TEST RESULTS

Steven J. Atlas¹; Katherine Gallagher¹; Sydney McGovern¹; Amy Wint¹; Rebecca E. Smith⁵; Endel J. Orav⁴; Adam Wright²; Timothy E. Burdick³; Li Zhou⁴; Anna N. Tosteson⁵; Jennifer Haas¹

¹Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA; ²Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN; ³Community and Family Medicine, Dartmouth-Hitchcock Health GraniteOne, Lebanon, NH; ⁴Medicine, Brigham and Women's Hospital, Boston, MA; ⁵The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH. (Control ID #3873780)

BACKGROUND: Improving preventive cancer screening has been a focus of population-based interventions, but less attention is paid to systematically ensuring timely follow-up of abnormal screening test results (“abnormal screens”). As part of a randomized trial to improve follow-up of overdue abnormal screens for breast, cervical, colorectal and lung cancer in three large primary care networks (ClinicalTrials.gov NCT03979495), we surveyed patients about their experiences regarding the process of additional workup following an abnormal screen.

METHODS: Patients with an overdue abnormal screen enrolled from 44 primary care practices were surveyed after the primary outcome was assessed at 120 days after enrollment. A randomized sampling strategy stratified patients by network site, cancer type, and completion of follow-up. Because few patients with lung cancer abnormalities were enrolled, not all strata had sufficient numbers to randomly sample. Survey topics included: ease of scheduling follow-up, perceived barriers or concerns about results and follow-up, provider trust and understanding, and satisfaction with communication and care received. Overall response rates and responses stratified by cancer type, and patient-completed follow-up are reported.

RESULTS: Overall, 256 (26.0%) patients completed surveys between April 2021-June 2022. Most patients were female (78.5%), non-Hispanic white (78.1%), did not complete follow-up (51.6%), and had a colon (38.3%), cervical (30.9%), breast (26.2%) or lung (4.7%) abnormality. Few patients reported their workup was delayed because of the Covid-19 pandemic (25.4%) and most said it was somewhat/very easy to schedule the recommended workup (67-91%). Patients reported that they were worried that the test would

find cancer (63.3%), but fewer patients were worried about discomfort or side effects (33.2%) or thought they needed no further workup (16.4%, see Table). Most patients were very satisfied with their overall care (69.9%), but only 50% strongly agreed that they trusted their provider to put their medical needs above all else when making recommendations.

CONCLUSIONS: Patients reported important concerns about following up abnormal cancer screening test results including worry about finding cancer and side effects of testing. Patients who didn’t think they needed further evaluation were less likely to complete follow-up. These findings support the need for improved efforts to address patient concerns about fear of cancer and the need for follow-up procedures across the range of preventive cancer tests.

PATIENTS’ FINANCIAL VALUATION OF TELEMEDICINE VISITS COMPARED TO IN- PERSON VISITS

Koushik Kasanagottu^1,4; Tyler Dunn²; Sean Tackett³; Scott Wright²

¹General Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Johns Hopkins Bayview Medical Center, Baltimore, MD; ³GIM, Johns Hopkins Bayview Medical Center, Baltimore, MD; ⁴Harvard Medical School, Boston, MA. (Control ID #3874921)

BACKGROUND: Telemedicine visits increased significantly during the COVID-19 pandemic across the country driven by the expansion of reimbursement. However, little is known about patients’ perspectives regarding the value they place on telemedicine compared to in-person visits. The objective of this study was to understand the relative value that patients place on telemedicine visits and compare them among younger and older adults.

METHODS: We surveyed patients in our academic primary care practice between March 2020 and March 2021 who had a telemedicine visit and a recent in-person encounter during the study period. The survey specifically asked patients to assess what reimbursement amount for their physician is appropriate for telemedicine visits relative to in-person visits, along with contingent valuation questions to determine the range of acceptable co-payments for patients.

RESULTS: A total of 111/158 (70.3%) of patients responded to the survey. Most respondents were female, 65 years or older, and lived within 5 miles of the clinic. About half of respondents in both age groups thought that total reimbursement for telemedicine should be 50% of in-person visit. There were no significant differences between the responses for both age groups (<65 years vs >65 years, p>0.05). Almost 60% of patients were willing to pay a copay that is the same as for in-person visits, while a smaller percentage (29%) were willing to pay even more for a telehealth visit.

CONCLUSIONS: There were no significant differences in the relative value placed on telemedicine visits between younger and older adults. Patients were willing to pay a comparable copay for telehealth visits which is important as telehealth reimbursement is considered post-pandemic.

PATTERNS IN OUTPATIENT HEALTH CARE UTILIZATION AFTER COVID-19

HOSPITALIZATION BASED ON RACE AND GENDER

Tanya Rastogi¹; Jasmine Leahy¹; Samkit Jain¹; Rebecca S. Bajracharya¹; Brian L. Altonen²; Alfredo Astua³

¹Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Research Administration, New York City Health and Hospitals Corporation, New York, NY; ³Pulmonary and Critical Care, New York City Health and Hospitals Corporation, New York, NY. (Control ID #3876762)

BACKGROUND: The COVID-19 pandemic has affected more than 100 million people in the United States. Long COVID is defined by persistent symptoms two months after infection not explained by an alternative diagnosis and requires a multidisciplinary approach after discharge. We sought to identify referral patterns by general practitioners and trends of subspecialty clinic and emergency department (ED) visits by patient demographics. This information then used to optimize post COVID-19 care and communication between all providers.

METHODS: Retrospective cohort study of 200 non-intubated patients admitted for Covid-19 symptoms between March 2020-February 2022. The study compared the number of general primary care, subspecialty, and ED visits based on demographics such as race and gender, one year after discharge. Additionally, missed appointments were counted towards the total number of visits. Race was categorized as: Hispanic, African American, White, Asian, and other. The total number of visits and mean number of visits per patient were calculated by gender and race then plotted into bar graphs.

RESULTS: Hispanics overall had the highest total general, specialty, ED and no show visits, followed by asian males for general and asian females for specialty and no show visits. Mean number of visits per patient were highest for hispanic females for specialties and no shows, asian males and hispanic females highest for general medicine visits. The latter leading to some of the lowest total ED visits.

CONCLUSIONS: The results suggest that increasing general medicine visits would translate into decreased ED visits and no shows overall. Targeting these populations, specifically hispanic males and females, in the ED and during no show visits respectively with the original concept of a COVID-19 navigator could improve healthcare utilization and prove to be cost effective.

PHYSICIAN PERSPECTIVES ON A BEST PRACTICE ALERT FOR IMPROVING MEDICATION PRESCRIBING IN PATIENTS WITH HEART FAILURE

David T. Zhang, Ramsey K. Kalil, Ozan Unlu, Michael Kim, Sabrina Mangal, Jonathan Elias, Parag Goyal

Department of Medicine, Weill Cornell Medicine, New York, NY. (Control ID #3875390)

BACKGROUND: Mineralocorticoid receptor antagonists (MRAs) are guideline-directed medical therapy (GDMT) for patients with heart failure (HF) and are underutilized disease-modifying agents. Prescribing MRAs instead of potassium tablets to treat hypokalemia in the setting of HF can increase MRA utilization. We sought to examine perspectives of primary care physicians (PCPs) on our newly developed best practice alert (BPA) in the electronic medical record—which appears when clinicians order potassium supplementation for a patient with HF and suggests prescribing an MRA instead.

METHODS: We conducted individual, semi-structured interviews with PCPs to understand the facilitators/barriers of MRA prescription, BPA usage, and our specific BPA until we reached thematic saturation. Two coders independently reviewed interview transcripts and developed codes using directed content analysis. Codes were collapsed into themes and subthemes.

RESULTS: We interviewed 10 participants. We mapped our themes onto the Capability, Opportunity, Motivation, Behavior (COM-B) model, which focuses on influential factors of behavioral intervention. We subsequently created a BPA-specific COM-B framework whereby the appropriateness and the process of ordering medications were embedded within the BPA (Figure 1). The interviews influenced key aspects of the COM-B model including capability, opportunity, motivation, and ultimately behavior.

CONCLUSIONS: We adapted and modified an existing framework of behavioral change to generate a novel framework that can guide future BPAs designed to improve medication prescribing of guideline-concordant therapies like MRAs.

PREVALENCE AND FACILITY-LEVEL VARIATION IN LOW-VALUE PRESCRIBING WITHIN THE VETERANS HEALTH ADMINISTRATION

Thomas R. Radomski^1,3; Elijah Lovelace³; Aimee N. Pickering^1,3; Carolyn T. Thorpe^2,3; Michael J. Fine^3,1; Joseph t. Hanlon³; Walid F. Gellad^1,3

¹Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²School of Pharmacy, University of North Carolina System, Chapel Hill, NC; ³Center for Health Equity Researh and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA. (Control ID #3876518)

BACKGROUND: Although low-value tests and procedures are common and costly within the Veterans Health Administration (VA), there is limited information on the use of low-value medications. Our objective was to use a novel claims-based metric to quantify the frequency and facility-level variation in low-value prescribing (LVP) among older, VA-enrolled Veterans.

METHODS: We conducted a cross-sectional study among a national cohort of Veterans aged ≥65 years who were enrolled in VA and had ≥1 outpatient VA visit in calendary year (CY) 2021. To identify LVP, we applied EVOLV-Rx, a claims-based metric for use in older adults that broadly detects LVP, defined as the inappropriate or prolonged use of unsafe, ineffective, or overly costly medications. This metric comprises the 18 most scientifically valid and clinically useful LVP practices in older adults as per an expert Delphi panel. We applied EVOLV-Rx to VA Corporate Data Warehouse prescription records to identify the outpatient use of 6 LVP practices: 1) gabapentinoids for non-neuropathic pain; 2) prolonged use (>2 months) of proton pump inhibitors (PPIs); 3) antipsychotics in patients with dementia; 4) inappropriate antibiotics for respiratory conditions; 5) unsafe use of benzodiazepines and 6) unsafe use of muscle relaxers. We determined the overall number and percentage of patients subject to each LVP practice in CY2021 and determined the range (10th–90th percentile) of patients subject to each LVP across 139 VA Medical Centers (VAMCs).

RESULTS: Of the 2.8 million Veterans in the overall cohort, the mean age was 76 (6.7), 97% were male, and 74% were non-Hispanic white. Overall, 811,282 (28.9%) Veterans were subject to any of the 6 LVP practices. The most common LVP practice was prolonged use of PPIs, affecting 598,589 (21.3%) Veterans with a VAMC range of 16.1-27.5%. The next most common LVP practice was gabapentinoids for non-neuropathic pain, affecting 237,558 (8.5%) Veterans (VAMC range 6.0-11.4%), followed by potentially unsafe use of skeletal muscle relaxants, affecting 106,035 (3.8%) Veterans (VAMC range of 1.9-6.0%). The remaining LVP practices occurred less frequently with rates and VAMC ranges as follows: potentially unsafe use of benzodiazepines (49,226 (1.8%), 0.9-2.5%), inappropriate antibiotics for respiratory conditions (70,295 (2.5%), 1.3-3.7%), and antipsychotics for patients with dementia (5,897 (0.2%), 0.1-0.3%).

CONCLUSIONS: Among a national cohort of VA-enrolled Veterans aged ≥65 years, low-value prescribing was common, affecting more than 1 in 4 older Veterans with up to 3-fold variation across VAMCs. These findings demonstrate that even within an integrated health system with clinical decision support, such as VA, low-value prescribing is common, and the findings may inform future studies and interventions to further characterize and reduce low-value prescribing among VA-enrolled Veterans both within and outside VA.

PRIMARY CARE, HOSPITAL MEDICINE, AND SPECIALTY CAREER CHOICE AMONGST INTERNAL MEDICINE RESIDENTS, 2019-21

Neha S. Paralkar²; Nancy A. LaVine²; Saoirse Ryan¹; Rosemarie L. Conigliaro²; Jason Ehrlich²; Aisha Khan²; Lauren Block².

¹Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; ²medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY. (Control ID #3834883)

BACKGROUND: The importance of primary care to population health is well documented. However, there continue to be troubling projections of impending primary care provider shortages. The Association of American Medical Colleges projects a shortfall of 48,000 primary care physicians by 2032. West and colleagues reported on the career plans of graduating categorical Internal Medicine (IM) residents completing the IM In-Training Examination (IM-ITE) in 2004 and found that only 25% planned to enter General Internal Medicine (GIM). West’s 2011 IM-ITE analysis showed a further decrease in GIM plans to 19.9%. We examined IM-ITE data from 2019-2021 to assess current trends in GIM career choice.

METHODS: Respondents included categorical and primary care IM residents who participated in a voluntary survey as part of the IM-ITE from 2019-2021. A de-identified limited dataset on demographic factors, program type, medical school location, post-graduate year and career plans was provided by the American College of Physicians. Residents indicated their intended career path by selecting GIM, hospital medicine (HM), a subspecialty career, or other. Respondents who did not answer the question on career choice, those in a med-peds program, and those who did not want their data used were excluded. Survey data was analyzed descriptively in Excel. Stata 17 was used to perform univariate and multivariate analysis of the odds of GIM career plan by program type, gender, calendar year, and medical school location.

RESULTS: 62,562 residents, including 19,795 PGY3s, contributed career choice data. Among PGY3s, 2,203 (11.1%) reported GIM as their career plan, compared with 4,222 (21.3%) who reported HM. 12,568 PGY3s (63.5%) planned to enter a subspecialty. 31.8% of those in primary care programs planned GIM careers compared to 9.5% from categorical programs. In the cohort of residents completing the survey in both 2019 and 2021, 309 (6.8%) changed their minds during residency towards GIM, and 236 (5.2%) changed away from GIM. In the same cohort, 642 (14.1%) changed their minds towards HM and 192 residents (4.2%) changed away from HM.

CONCLUSIONS: The percentage of graduating categorical residents planning GIM careers as of 2019-21 has decreased by 44% compared to ten years prior despite an increase in primary care tracks and incentives such as loan forgiveness; while HM has gained popularity. Analysis revealed shifts both toward and away from GIM, indicating the potential for interventions during graduate medical education (GME) to inspire residents to remain upon or change towards a GIM course. The IM-ITE data, along with the projected primary care provider shortages, suggest that changes are needed in GME design, physician reimbursement, and ambulatory health system structure to facilitate primary care careers.

PRIMARY CARE PERSPECTIVES COMPARING THE VA’S NATIONAL CONTINGENCY STAFFING PROGRAM TO OTHER ALTERNATIVES FOR COVERING STAFFING SHORTAGES Alicia Bergman¹; Danielle Rose¹; Shay Cannedy²; Melissa Medich³; Karin Nelson^6,4; Susan E. Stockdale⁵

¹Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²HSR&D, Veterans Health Administration, North Hills, CA; ³Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, North Hills, CA; ⁴Medicine, University of Washington, Seattle, WA; ⁵HSR&D Center of Excellence, Greater Los Angeles VA Healthcare System, Sepulveda, CA; ⁶General Medicine, US Department of Veterans Affairs, Seattle, WA. (Control ID #3860754)

BACKGROUND: The Veterans Health Administration (VA) began implementation of a national contingency staffing program (Clinical Resource Hubs [CRHs]) in 2019. Using a “hub and spoke” model, regionally-based hubs provide mostly virtual primary care (PC), mental health (MH), and specialty clinicians to VA clinics with staffing gaps or patient access problems. We describe the benefits and disadvantages of using CRH from the perspectives of hub, spoke providers and staff, and PC leaders.

METHODS: We conducted semi-structured telephone interviews with 25 PC leaders receiving CRH provider coverage, 16 CRH providers and staff, and 27 clinic-based primary care staff within 3 VA regions. Interviews were recorded, with a rapid analysis identifying perceived advantages and disadvantages to using CRH.

RESULTS: Across all roles, the most frequently mentioned advantages of using CRH providers compared to referring patients to non-VA community providers were getting patients in for appointments more quickly, better care coordination, higher quality care, patient convenience, and accommodating Veterans’ preferences to stay within VA system. PC leads and facility chiefs emphasized the financial advantage of using CRH providers. When comparing CRH to use of locum providers or other contracted gap providers, both PC leaders and clinic staff said CRH offered better provider availability to medically underserved areas, and they perceived CRH providers as better quality with greater knowledge of VA, which translated to quicker hiring and onboarding processes. For PC clinic staff, the perceived advantages of using CRH compared to locums included CRH providers sometimes bringing support staff with them (whereas locums do not), CRH providing an MD provider versus an NP, and CRH providers staying longer. CRH providers highlighted the education that they provide to spoke sites as a key advantage. Not many interviewees identified disadvantages of using CRH providers as compared to other gap coverage mechanisms. The few mentioned disadvantages included reports that some patients do not want virtual care, patients sometimes get frustrated when CRH uses centralized call centers instead of PC clinic staff for patient appointment scheduling, the need for extra administrative tasks, telehealth equipment malfunctions, PC clinic staff not knowing which CRH provider will be sent on any given day, and PC leaders not having control over when CRH providers get time off.

CONCLUSIONS: All roles reported more advantages than disadvantages of using CRH. Advantages revolved around perceiving the CRH as facilitating better access, care coordination and quality of care for patients. Disadvantages centered on logistical, workflow, and patient preference considerations. Future research should include gathering patient experiences directly. Policy and practice implications include raising awareness of these CRH benefits among VA administrators and clinic leadership, as well as those outside VA considering implementation of similar programs.

PRIMARY CARE VISIT CADENCE AND HOSPITALIZATIONS IN HIGH-RISK PATIENTS

Adam Matsil³; Daniel Shenfeld⁴; Clive Fields³; Aaron Yao^1,2; Jen Clair^3,1

¹Research Institute, VillageMD, Chicago, IL; ²University of Virginia, Charlottesville, VA; ³VillageMD, Chicago, IL; ⁴Manganese Solutions, Boston, MA. (Control ID #3873881)

BACKGROUND: Few quantitative studies have evaluated the impact of regular primary care visits on healthcare outcomes. This study investigated whether quarterly primary care visits are associated with reduced hospitalizations in high-risk patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD).

METHODS: This retrospective study used medical records and claims for 1,342 CHF and/or COPD patients in a quality improvement program and 4,981 other patients at 14 clinics from July 2019 to June 2021. CHF and COPD patients were encouraged to receive quarterly primary care visits in a quality improvement program (Q90). Other patients were not invited to the program (non-Q90). We created four patient groups based on their annual number of quarterly primary care visits and whether they were in the Q90 program. We compared their hospitalizations during the base and following years, adjusting for patient characteristics and risks.

RESULTS: A total of 6,323 patients (56.7% female; mean [SD] age, 74.0 [8.6] years; 69.2% White) were included. Q90 and non-Q90 patients had average HCC scores of 1.98 and 0.99 during the base year. For both the Q90 and non-Q90 populations, higher visit frequency at the base year was associated with higher HCC scores and elevated baseline admission-per-thousand (ADK). Compliant Q90 patients at the base year (n=881) had comparable ADK in two years (199 [95% CI: 174-227] vs. 196 [95% CI: 171-223], p =.88), and non-compliant Q90 patients (n=461) had elevated ADK in the second year (62 [95% CI: 44-88] vs. 117 [95% CI: 90-149], p < .05). ADK also increased across all HCC quartiles among the non-compliant Q90 patients.

In contrast, year-over-year ADK declined or was flat among the compliant population for the bottom three HCC quartiles. Adjusted difference-in-difference analyses confirmed the suggestive evidence of reduced ADK in baseline compliant Q90 patients (coefficient= -0.63, [95% CI: -1.22 ~ -0.05]; p = .033). A similar coefficient of -0.56 (p<0.01) was found in non-Q90 patients.

CONCLUSIONS: Visit cadence is a core part of value-based primary care models. Quarterly primary care visit was associated with a significant reduction in hospitalizations among high-risk patients.

PROVIDER AND PATIENT EXPERIENCES OF DELAYS IN PRIMARY CARE DURING THE EARLY COVID-19 PANDEMIC

Kimberly A. Muellers^1,3; Katerina Andreadis²; Jessica S. Ancker⁴; Carol Horowitz⁵; Rainu Kaushal⁶; Jenny J. Lin⁷

¹General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Population Health Sciences, Weill Cornell Medicine, New York, NY; ³Psychology, Pace University, New York, NY; ⁴Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN; ⁵General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ⁶Department of Population Health Sciences, Weill Cornell Medicine, New York, NY; ⁷Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3852019)

BACKGROUND: The necessary suspension of non-acute services by healthcare systems early in the COVID-19 pandemic was predicted to cause delays in routine care in the United States, with potentially serious consequences for chronic disease management. However, limited work has examined provider or patient perspectives about care delays and their implications for long-term health. This study explores primary care provider (PCP) and patient experiences with healthcare delays during the COVID-19 pandemic.

METHODS: PCPs and patients were recruited from four large healthcare systems in three states. Participants underwent semi-structured interviews asking about their experiences with primary care and telemedicine. Data was analyzed using interpretive description.

RESULTS: Twenty-one PCPs and 65 patients participated in interviews. Four main topics were identified: (1) types of care delayed; (2) causes for delays; (3) miscommunication contributing to delays; and (4) patient solutions to unmet care needs.

CONCLUSIONS: Both patients and providers reported delays in preventive and routine care early in the pandemic, driven by healthcare system changes as well as patient concerns about infection risk. Primary care practices should develop plans for continuity of care during crises and communicate these plans clearly to patients in order to promote chronic disease maintenance during future systemic healthcare disruptions.

PROVIDER PERCEPTIONS ON SCREENING FOR FOOD INSECURITY IN PRIMARY CARE PRACTICE

Gianna Aliberti, Carter Baughman, Son Quyen H. Dinh, Elizabeth Targan, Kelly Graham, Katherine Wrenn, Ruth-Alma N. Turkson-Ocran

Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #3874789)

BACKGROUND: Dietary and lifestyle modification represent the foundation of chronic disease management for cardiovascular risk states. However, food insecurity (FI), defined as lack of access to affordable, nutritious food, is a significant obstacle to implementing such measures for many patients. Despite the high prevalence and availability of screening tools, many primary care providers (PCPs) do not screen for or address FI. This is particularly important as more states adopt requirements for uniform social determinants of health screening, including for FI.

METHODS: A web-based questionnaire was emailed via REDCap to all PCPs in a large, academic primary care practice in Boston, MA. All PCPs were sent the link once weekly over a 3-week period. The survey consisted of 13 multiple choice/rating scale questions as well as 5 open-ended questions that assessed the following constructs: (1) knowledge of FI and available resources, (2) comfort with counseling patients with FI, (3) individual screening practices, (4) barriers to screening, and (5) perceived usefulness of food prescription programs.

RESULTS: Of 239 PCPs approached, 101 responded (43.3%), with 60 (59.4%) being residents, 36 (35.6%) being faculty, and 3 (3%) being nurse practitioners. More than 75% of respondents were in practice for <10 years and aged <40 years, 60% were female, and >70% identified as non-Hispanic Whites. 95% of respondents were familiar with the term ‘food insecurity’ and 91.1% felt that screening for FI is valuable in primary care, but only 7.9% felt that they were aware of available screening tools for FI. Only 3% of respondents reported screening patients annually for FI, primarily due to lack of time and knowledge about available resources or interventions. Preference for specific practices for the screening protocol were mixed, however, the majority felt that all patients should be screened annually rather than as needed or targeted based on a specific risk factor or condition. PCPs also reported a need for screening to integrate into the practice workflow outside of the PCP encounter, clarity on which patients should be screened, and privacy/stigma concerns.

CONCLUSIONS: There is no one-size-fits all approach to implementing screening for FI in primary care despite the importance of addressing food and nutrition as part of disease modification and for meeting state screening requirements. Many PCPs agreed that screening for FI is valuable but felt they did not have enough time to screen and were unaware of available resources to offer.

PUBLIC HEALTHCARE QUALITY SCORES REMAIN INSUFFICIENT FOR CALIFORNIA HEALTH INSURANCE EXCHANGE DECISION-MAKING

Esther Y. Hsiang¹; Laura Derry¹; Michael Girouard¹; Kristie Hsu¹; Riana B. Jumamil¹; Johnny Blanchard¹; Kavon Javherian¹; Sarah E. Durney²; Sonam Dilwali³; Namrata Patel-Sanchez²; Stephanie chen¹; Tyrone Johnson¹; Amy Pugh⁷; Omar Viramontes¹; Theodore Peng⁵; Cary Kraft⁶; Sarah Lumsden⁴; Edgar Pierluissi⁵

¹Internal Medicine, University of California San Francisco School of Medicine, San Francisco, CA; ²Pediatrics, University of California San Francisco, San Francisco, CA; ³Neurology, University of California San Francisco, San Francisco, CA; ⁴Anesthesia, University of California San Francisco, San Francisco, CA; ⁵Internal Medicine, University of California San Francisco, San Francisco, CA; ⁶Gastroenterology, University of California San Francisco, San Francisco, CA; ⁷Internal Medicine, UCSF Medical Center, San Francisco, CA. (Control ID #3875547)

BACKGROUND: Reports on healthcare quality metrics have been publicly available for over 20 years. However, health insurance exchanges face challenges with leveraging these reports to inform which health plans should be allowed on the exchange based on objective quality. In collaboration with Covered California, the UCSF Health Systems and Leadership (HSL) Pathway sought to understand and visualize how public quality data might be used to inform decision-making about California's health plan offerings on the exchange.

METHODS: We performed a landscape analysis of healthcare quality data at the health plan, hospital, and provider group levels and identified strengths and limitations of each data source. We then created a data visualization tool in which health plan quality data in an example Covered California region can be directly compared using these metrics.

RESULTS: We found major gaps in healthcare quality data: [1] composite measures are difficult to interpret (e.g., not intuitive what a “five-star” health plan or hospital means; not able to assess granular strengths or weaknesses in composite scoring system), [2] redundant or missing data are problematic (e.g., smaller practices often excluded from receiving quality scores; some hospitals elect not to share certain metrics), [3] accessible provider group-level data are sparse relative to hospital-level data despite a greater number of provider groups than hospitals, and [4] accessible provider group-level data are difficult to compare directly due to lack of unique identifiers for each provider group. We then developed a prototype interactive dashboard with a “heat map” visualization of aggregated health plan and hospital level quality metrics for Covered California.

CONCLUSIONS: Given the vast number of measures available in the healthcare quality landscape, composite scores are necessary. However, the current five-star rating systems limit meaningful conclusions about health plan quality. Future directions for health insurance exchanges aiming to incorporate quality measures into decision-making include considering a heat map visualization of quality metrics, considering creation of a weighted composite quality score based on hospital or provider group size, working with stakeholders to obtain missing data, and leveraging more complete provider group-level quality data.

QUALITATIVE ANALYSIS OF AN AUTOMATED TEXT MESSAGE-BASED POST-DISCHARGE PROGRAM

Aiden H. Ahn¹; Katherine Honig²; Anna U. Morgan³; Robert E. Burke⁴; Judith Long²; Nancy P. Mcglaughlin⁵; David A. Asch⁶; Eric Bressman⁷

¹University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ³Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ⁴Medicine, Philadelphia VAMC, VA Medical Center Corporal Michael J Crescenz, Philadelphia, PA, US, hospital, Philadelphia, PA; ⁵Primary Care Service Line, Penn Medicine, Philadelphia, PA; ⁶Medicine, University of Pennsylvania, Philadelphila, PA; ⁷Internal Medicine, University of Pennsylvania Department of Medicine, Philadelphia, PA. (Control ID #3872229)

BACKGROUND: To support patients after hospital discharge, we developed and implemented a 30-day automated text-messaging intervention. The program was piloted in a single practice in Philadelphia, and was associated with a significant reduction in 30 day readmission and utilization of acute care resources.

However, we wanted to understand the timing and nature of patient needs following discharge that were addressed through the intervention.

METHODS: Escalations were defined as instances in which a patient would report they needed help via text, followed by a categorization of their needs. Each escalation was reviewed in the EHR to determine: (1) days from hospital discharge to initial escalation, (2) reason(s) for escalation, and (3) outcome(s) of escalation.

The reasons and outcomes were then categorized according to the Ideal Transition of Care framework, which was modified to fit the patient needs data from our analysis. Escalations were often complex, and multiple needs may have been addressed; therefore escalations could be assigned to more than one category.

RESULTS: The study data set included 199 unique escalations reflecting 235 categories. Escalations were most frequent 0-5 days after discharge (30.1%), with 77.0% of escalations occurring within the first 15 days after discharge (Image 1). The three most frequent categorizations were: Monitoring and Managing Symptoms After Discharge (26.8%); Outpatient Follow-Up (20.4%); and Medication Needs and Reconciliation (15.7%).

CONCLUSIONS: This analysis demonstrates that patients utilize the texting program appropriately, expressing similar needs as reported in comparable call-based programs. Three quarters of needs arose within the first two weeks of the 30 day program. The needs identified were relevant to primary care practice and generally fell within nursing scope of practice. This program can serve as a model for health systems looking to support safer transitions, and the findings of this analysis can inform future iterations of this approach.

RAPID PRODUCTION OF KNOWLEDGE PRODUCTS FOR HOME HOSPITAL CARE: OUTCOMES OF A SCRUM ACCELERATOR

Meghna Desai¹; Stephanie Blitzer¹; Miriam Tardif-Douglin^3,4; Indigo Miller¹; Bruce Leff⁶; LaPonda Edmondson^3,4; Carme Hernandez^7,5; David Levine^1,2

¹Ariadne Labs, Boston, MA; ²Medicine, Brigham and Women's Hospital, Boston, MA; ³CaroNova, Cary, NC; ⁴North Carolina Healthcare Association, Cary, NC; ⁵Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA; ⁶John Hopkins University School of Medicine, Baltimore, MD; ⁷University of Barcelona, IDIBAPS, CIBERES, Barcelona, Spain. (Control ID #3876710)

BACKGROUND: In November of 2020, the Centers for Medicare and Medicaid Services issued the Acute Hospital Care at Home waiver in response to over-taxed hospital capacity created by the COVID-19 pandemic. For the first time, the waiver created a nationwide regulatory and payment pathway for hospitals to deploy home hospital; however, launching a home hospital program without a depth of expertise and implementation tools is challenging. To meet this challenge, we launched the Home Hospital Early Adopters Accelerator (HHEAA) to facilitate 18 health organizations collaborating in the development of critical home hospital knowledge products (KPs) - tools. It was the first of its kind in the national space of acute hospital care at home. 18 health care organizations collaborated using the Scrum framework to develop 20 comprehensive KPs that support the startup and implementation of home hospital programs.

METHODS: We used the Scrum framework to collaborate in the rapid creation of 20 KPs. To evaluate participant experience creating the KPs as well as their experience implementing the KPs we conducted a mixed methods evaluation. We used a Developers and stakeholder feedback survey to evaluate participant’s thoughts on the process of creation and the KPs themselves. Then we conducted semi structured interviews at the end of the HHEAA to gain further insight into their experience and gather feedback on the KPs overall. Three months after the HHEAA ended we conducted a KP implementation survey to understand what KP implementation looked like at each site.

RESULTS: 20 knowledge products were created during the HHEAA in less time than expected (32 working weeks instead of 40). These included clinical protocols, regulatory tools and guides, clinical and administrative workflows, pharmacy workflow, market scans, and patient/caregiver facing tools and guides. Most Developer’s (68.59%) and stakeholders (51.79%) strongly agreed that the KPs created during the HHEAA were useful. Developers either strongly agreed (53.85%) or agreed (37.82%) that implementation of the knowledge products at their site would improve patient care. Qualitative results show that most participants said that the content of the KPs were comprehensive and that they were high quality products. This was a result of the collaboration between individuals who were experts in the knowledge product content area, peer review process, real time testing of knowledge products, and feedback from subject matter experts.

CONCLUSIONS: Use of Scrum enabled rapid construction of high quality and highly-rated KPs for home hospital care among newly formed healthcare teams. To our knowledge, this represents one of the first trials of a Scrum-enabled accelerator in healthcare. Given its ability to generate products useful to healthcare and delivered a positive Developer experience, we argue that the organization of healthcare teams should strongly consider use of this methodology.

REFERRALS FOR PRIMARY CARE IN THE VETERANS HEALTH ADMINISTRATION (VHA): COMPARISON OF INTER- AND INTRA-SYSTEM WAIT TIMES

Peter J. Kaboli^1,3; Amy M. O'Shea^1,3; Bjarni Haraldsson¹; Ariana Shahnazi¹; Matthew R. Augustine^2,4

¹CADRE, Iowa City VA Medical Center, Iowa City, IA; ²US Department of Veterans Affairs, Bronx, NY;³Carver College of Medicine, University of Iowa, Iowa City, IA; ⁴Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY. (Control ID #3869417)

BACKGROUND: Access to primary care is a critical component of overall health. Under the 2018 Mission Act, veterans may qualify for VHA-funded care in potentially more accessible non-VHA settings (i.e., “community care”) when they meet drive or appointment wait time criteria. A veteran meeting these criteria is presented with the choice to pursue their care at a VHA facility or through community care. The goal of this work was to describe patient characteristics and wait times between these two groups.

METHODS: This observational cohort study used VHA administrative data to identify primary care visits delivered within VHA facilities or non-VHA community medical centers from October 2017 through September 2021. Non-VHA community care referrals classified as 1) scheduled, 2) completed 3) discontinued or 4) cancelled were included. We compare the percent of patients receiving referral primary care within VHA versus the community by residential rurality. In addition, we calculated and compared the time to having a referral approved, scheduled, and completed using the t-test based on the location of care (i.e., within VHA or community).

RESULTS: During the 3-year study period, 738,061 unique primary care patients received nearly 1 million referrals for non-VHA PC. Ultimately, 114,810 (15.5%) patients received community care, while the remaining 623,251 (84.5%) received care at another VHA facility. Patients who received care from a VHA facility were more likely to live in an urban area than patients who sought care in the community (71.5% vs 39.2%; p<0.001). Overall, wait times for VHA-provided care compared to community care referrals took fewer days to be approved (Mean of 1.5 vs 2.9 days), scheduled (Mean of 9.0 vs 31.1 days), and completed (Mean of 26.5 vs 43.0 days); all p<0.001.

CONCLUSIONS: Among primary care referrals, wait times vary substantially between those that remain within the VHA system and those obtained within the community. Referrals for primary care outside the VHA system took longer, suggesting community care referrals are administratively less efficient with particular barriers to scheduling appointments outside the VHA. The choice to obtain care in the community should be carefully considered by both providers and patients, especially for rural populations who are more likely to choose care in the community. Further work should consider how referral wait times vary within regional clinical networks in VHA and the potential impact of the COVID-19 pandemic on the use of the referral system.

SCREENING FOR HIV: MISSED OPPORTUNITIES IN THE DIAGNOSIS OF PERSONS LIVING WITH HIV

Kristi Seemiller¹; Elizabeth Cuevas²; Stuart Fisk¹; Bruce Ling¹

¹Medicine, Allegheny Health Network, Pittsburgh, PA; ²Internal Medicine, Allegheny Health Network, Pittsburgh, PA. (Control ID #3876904)

BACKGROUND: While HIV has become a manageable chronic illness, screening rates remain low. Prior work shows patients with HIV make multiple visits to healthcare settings without screening in the years before diagnosis, though this work is older and may be dated. We provide a more current assessment of missed opportunities to screen for HIV in an era where CDC guidelines for routine HIV screening should be more widely adopted.

METHODS: In 2016, we implemented routine HIV and HCV screening within our healthcare network. Patients presenting to the Emergency Department (ED) or a primary care (PC) clinic were assessed for eligibility (13-64 years of age, not previously diagnosed with HIV, and not screened within the past 12 months). A Best Practice Advisory in the electronic medical record (EMR) triggered the clinical staff to screen eligible patients for HIV. We performed a retrospective chart review of patients diagnosed with HIV at these sites. Prior visits in PC, Gastroenterology (GI), Ob-Gyn, and the ED at one and three years before the patients’ HIV diagnosis were recorded. These settings were felt to be the most applicable for HIV screening. In addition, contacts with any health care provider within the health care system were identified. Data was collected on patient characteristics (age, race, and gender), date of diagnosis, and prior clinical visits. Data are presented as means for continuous variables and were compared using a t-test or Mann-Whitney U test as applicable.

RESULTS: Forty-five patients were newly diagnosed as HIV positive with no prior HIV screening during the evaluation period (2016-2021). The mean number of visits within one year of diagnosis per patient to a provider in Ob-Gyn, GI, PC, or the ED was 1.51. Of note, there were five patients (11.1%) who had greater than five visits with one of those types of providers (range 6-9 visits per patient) in the one-year pre- diagnosis. The mean number of visits to all providers (which included other types beyond those above) in the one-year period was 2.27. For 38 patients, medical records were available in the three years preceding HIV diagnosis. These patients had a mean number of 3.63 visits per patient to Ob-Gyn, GI, PC, or the ED. The mean number of visits to all providers (which included other types) in the three-year period was 5.32. Nine patients (23.7%) had over 5 visits to Ob-Gyn, GI, PC, or the ED during this time period (range of 6-19 visits per patient). There were no statistically significant differences in the number of visits according to race, age, and gender for both the one year and three-year periods prior to the diagnosis of HIV.

CONCLUSIONS: We found a high number of missed opportunities in which HIV screening did not occur prior to the diagnosis of HIV but could have. Delays in the diagnosis and curative treatment of HIV allow for the further transmission of disease to others and poorer prognosis to the patient. Further system level interventions are needed to correct this deficiency in clinical practice.

TELEHEALTH IN NATIVE COMMUNITIES: A SCOPING REVIEW OF BARRIERS, FACILITATORS, AND CONTEXTUAL FACTORS FOR EXPANDING RURAL HEALTHCARE THROUGH TECHNOLOGY

McKinsey M. Pillsbury²; Kaia Barth²; Peter Emanuel²; Tabitha Carroway²; Josephine Tan¹; Jennifer Mandal²

¹School of Medicine, University of California, San Francisco, San Francisco, CA; ²Department of Medicine, University of California San Francisco, San Francisco, CA. (Control ID #3874748)

BACKGROUND: Indigenous communities in the United States face significant barriers to equitable healthcare access, as distance, transport costs, limited infrastructure, and inefficient referral systems compound existing health disparities. Telehealth has been proposed as a method to deliver high-quality, cost- effective, and timely care to these communities.

Telehealth modalities have rapidly expanded over the past twenty years. These include direct patient-to- provider virtual visits, provider-to-provider teleconsultation, and tele-mentoring projects, which build capacity for subspecialty care among rural primary care providers. There is a need for more data examining how these modalities can be used in indigenous communities, including their cultural appropriateness, adaptability to local infrastructure, and impact on health outcomes and equity.

METHODS: We conducted a scoping review of telehealth interventions in American Indian and Alaska Native communities. Our search included three databases (PubMed, Embase, Web of Science); results were analyzed by three independent reviewers based on pre-determined inclusion criteria. Our analysis framework categorized studies in three domains: 1) disease category (e.g. mental health, infectious disease), 2) intervention point on the care cascade (e.g. screening/diagnosis, maintenance of remission), and 3) delivery model (provider-to-patient, provider-to-provider, tele-mentoring).

RESULTS: We identified 271 studies in our initial search. Of these, 77 were selected for full-text review and 42 met final inclusion criteria.

A majority of studies describe telehealth applied to chronic disease management. The most common intervention points involve screening/diagnosis of conditions and maintenance of remission, rather than initial treatment and management of disease decompensation.

Common barriers identified include availability of technology and glitches, acceptability by patients and providers, perceived appropriateness for this population.

Common facilitators identified include increasing patient and provider familiarity with telehealth, use of telemedicine as an adjunct to (but not replacement for) in-person visits, and engaging community resources and local ‘telehealth champions’ to adapt programs to each context.

CONCLUSIONS: There is a lack of high-quality data investigating this topic; much of the published literature describes existing telehealth programs and lacks health outcomes or system-level metrics (e.g. cost- effectiveness). We also expect that many telehealth programs in this population are not represented in the peer-reviewed literature.

As the field evolves, we should recognize that telemedicine encompasses a variety of interventions that may have specific advantages and disadvantages for implementation in Native communities. This scoping review of the literature highlights variable applications of telemedicine in this population and proposes a framework for comparing patient-provider, provider-provider, and tele-mentoring encounter types.

THE IMPACT OF THE COVID-19 PANDEMIC ON HOSPITAL LENGTH OF STAY BY DISCHARGE DISPOSITION

Alexandra M. Mapp²; Mia Papas²; LeRoi S. Hicks^1,2

¹Department of Medicine, Christiana Care Health System, Newark, DE; ²Institute for Research on Equity and Community Health (iREACH), Christiana Care Health Services Inc, Wilmington, DE. (Control ID #3876699)

BACKGROUND: The impact of COVID-19 was felt across all aspects of our healthcare system. Significant burdens on staffing and bed-capacity as well as shortages of post-acute care facilities exacerbated existing challenges resulting in increasing hospital length of stay (LOS). We sought to examine the differential impact of the post-acute care environment on LOS by discharge disposition prior to and during the COVID-19 pandemic. We examined LOS over time by discharge disposition within our local health care system (ChristianaCare) compared to geographical areas in the United States with varying access to post-acute care facilities.

METHODS: We conducted a retrospective study utilizing data from Vizient’s Clinical Resource Database for two time periods: Pre-COVID (October 2018 to January 2020) and COVID (February 2020 to December 2021), by month. Comparisons were made among our health care system and those within Vizient Group A. Group A hospitals were categorized into three groups (small, medium, or large) according to level of access to post-acute care facilities by using CMS Medicare Post-Acute Care provider summary data. SNF providers, by state, were aggregated and ranked based on total number of providers. LOS for three selected discharge dispositions (home, home with home health, or skilled nursing facility) for all cause admissions were compiled and compared among ChristianaCare and Small, Medium and Large Group A hospitals. Descriptive statistics and Mann-Whitney U tests were used to examine LOS by discharge disposition across the 4 groups. Difference-in-difference (DiD) analyses were also conducted to examine differences across the groups over time; LOS was log transformed. All analyses were conducted in SPSS version 25.

RESULTS: Median LOS for ChristianaCare patients significantly increased from pre-COVID to COVID for all discharge dispositions: home (70%; p<0.001), home with home health (16%; p<0.001), and SNF (19%; p<0.001).

DiD analysis comparing mean LOS changes overtime for ChristianaCare and Small, Medium, and Large Group A hospitals showed significant differences for patients discharged home (p=0.005, p<0.001, and p<0.001, respectively). Similar effects were found for patients discharged home with home health (p=0.001, p=0.003, and p=0.002, respectively) and those discharged to a SNF (p=0.009, p=0.007, and p=0.001, respectively).

CONCLUSIONS: Access to post-acute care facilities such as skilled nursing facilities (SNFs) differentially impacted length of stay during the COVID-19 pandemic. Higher increases in LOS within our local community may be a result of limited capacity for both home health care and SNFs. These findings highlight the dependence of hospital LOS on discharge disposition across multiple contexts. Streamlining discharge pathways and planning as well as strengthening community access to post-acute care facilities may help alleviate overwhelmed resources, reduce discharge delays, and decrease hospital LOS.

THE IMPACT OF VIRTUAL DIABETES GROUP VISITS ON STAFF AND PROVIDER WELLBEING AND JOB SATISFACTION

Rohan Moghe¹; Mengqi Zhu²; Erin Staab²; Daisy S. Nuñez⁴; Sana Basheer¹; Wen Wan³; Amanda Campbell⁵; Michael T. Quinn⁶; Cynthia Schaefer⁷; Arshiya A. Baig⁸

¹Pritzker School of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; ²Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ³Section of General Internal Medicine, University of Chicago, Chicago, IL; ⁴Section of General Internal Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ⁵Executive Director at Midwest Clinicians' Network, Inc., Lansing, MI; ⁶Medicine, University of Chicago, Chicago, IL; ⁷Research , MidWest Clinicians Network, Evansville, IN; ⁸Department of Medicine, University of Chicago Andy Minn Oncology Lab, University of Chicago Division of the Biological Sciences, Chicago, IL, US, academic/biosci, Chicago, IL. (Control ID #3872723)

BACKGROUND: Burnout in medicine has been linked to a variety of adverse effects on providers and staff, including increased medical errors, the deterioration of interpersonal and interprofessional relationships, and higher rates of turnover. In community health centers (CHCs), where longitudinal patient-provider relationships are paramount, identifying and addressing causes of burnout is especially relevant. Group visits (GVs) are a model of care where a team of providers and staff see patients with similar conditions as a group, providing individual medical care alongside group education and support. Benefits of GVs for patients have been previously described, but the impact of GVs on CHC staff and provider wellness has not been assessed.

METHODS: As part of a larger cluster randomized trial assessing the impact of diabetes GVs on patient outcomes, we trained two cohorts of providers and staff in 13 Midwestern CHCs to implement in-person (N=37) and virtual GVs (N=30). Semi-structured interviews and surveys (pre and post-implementation) of staff and providers were conducted in both cohorts. Survey questions included measures of morale, burnout, and the perceived benefits and burdens of GVs. Changes in survey measures were assessed via a Generalized Linear Mixed Model test adjusted for within-site association. Thematic analysis was conducted from interview transcripts.

RESULTS: Interviews were conducted with participants from both the in-person cohort (N=15) and the virtual cohort (N=19). Survey data were collected from a total of 67 respondents from the in-person (N=37) and virtual (N=30) cohorts. The majority of respondents were female (84%) and Non-Hispanic White (85%). Quantitative measures of burnout (0 to 1, 1=burnout) and morale (1 to 5, 5=excellent) did not significantly change from pre- to post-implementation: 0.42 ± 0.50 to 0.48 ± 0.51, p=0.3 and 3.19 ± 0.85 to 2.96 ± 1.18, p=0.64, respectively. Interview responses showed that GVs improved professional and personal relationships with colleagues (“It has made our professional relationships stronger and I feel more comfortable talking about other things, as well.”), strengthened connections with patients (“We were able to help patients on a deeper level and provide more detail and one-on-one care.”), and were individually rewarding (“Morale has increased. They’re contributing and doing something positive for the patients.”). When asked about in-person vs. virtual GVs, most respondents noted that they preferred in-person care but appreciated the flexibility virtual care afforded.

CONCLUSIONS: While our study was not designed to address staff and provider burnout or well-being directly, there is evidence that implementation of a new model of care can impact key areas of burnout, including relationships, job attachment, and feelings of meaningful contribution in the workplace. Future clinic-based implementation studies may consider measuring staff and provider well-being and burnout as a part of the evaluation.

THE ORGANIZATION OF ACADEMIC GENERAL INTERNAL MEDICINE PRACTICE AT THE TOP PRIMARY CARE MEDICAL SCHOOLS

Lisa Rotenstein¹; Jeanette Wong²; Stacie Schmidt³; Nancy A. LaVine⁴; Julie Oyler⁵; Urmimala Sarkar²

¹Medicine, Brigham and Women's Hospital, Boston, MA; ²Medicine, UCSF, San Francisco, CA; ³General Medicine, Emory University, Atlanta, GA; ⁴General Internal Medicine, Northwell Health, New Hyde Park, NY; ⁵Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #3876325)

BACKGROUND: Academic general internal medicine physicians, who may balance patient care and teaching with other responsibilities, often spend only part of their time in primary care practice. While prior studies have explored staffing infrastructure for primary care practices, little is known about the range of academic primary care practice models and supports available for academic general internists.

METHODS: This was a survey study disseminated to clinical leaders at the hospitals affiliated with each of the top 22 primary care medical schools, as identified by the 2023 US News and World Report Rankings. We first contacted General Internal Medicine Division Chiefs affiliated with each of these medical schools and asked them to identify which leader could best provide insight into their organization’s structure of academic primary care delivery. We subsequently sent a survey to the leaders identified, with two reminders sent. The survey queried participants about the characteristics of the clinical site(s) they oversee, panel and productivity expectations, coverage expectations, and staffing and support models.

RESULTS: We received 19 unique responses, representing 14/22 (63.6%) of medical schools surveyed. Of the clinical sites represented by survey respondents, 16/19 (84.2%) were in an urban area. The clinical enterprises represented ranged from 7 to 200 PCPs. Medical residents practiced at 17/19 (89.5%) of the sites, with a range of 7 to 160 residents. At 12/19 (63.2%) of sites, three quarters or more of faculty also had non- clinical roles. Panel size, half-day direct care session, precepting session, and relative value unit per full FTE expectations varied widely among sites.

While occasional clinical coverage for other physicians (cross-coverage) was an expectation at all practices, there was significant variation in organization, expectations, and associated supports. Patterns of staff support for key general internal medicine workflows, including addressing or triaging patient portal messages and completion of prescription refill requests, prior authorizations, durable medical equipment requests, and urgent forms, also varied widely by site.

CONCLUSIONS: There is significant variation in expectations and support for academic general internal medicine practice. Given the increased demands of primary care and the important role of academic general internists in training the next generation of primary care physicians, it is crucial to optimize how primary care is delivered in academic settings. The variation we have identified can be leveraged to inform areas of improvement for the experience of modern primary care delivery.

TURNOVER, BURNOUT, AND TURNOVER INTENT AMONG VA PCPS FROM 2017 TO 2021

Eric A. Apaydin¹; Caroline Yoo¹; Susan E. Stockdale¹; Nicholas Jackson²; Elizabeth M. Yano¹; Karin Nelson³; David C. Mohr⁴; Danielle Rose¹

¹Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ³Seattle-Denver Center of Innovation, VA Puget Sound Health Care System Seattle Division, Seattle, WA; ⁴Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, MA. (Control ID #3869239)

BACKGROUND: Burnout among primary care providers (PCPs) has been well documented in recent studies, but less is known about the downstream effect of burnout on turnover (i.e., separation from employment). There is also relatively little research on the effect of the COVID-19 pandemic on primary care burnout. We investigate both topics by examining how individual-level turnover among VA PCPs from fiscal year (FY) 2017 to 2021 was associated with facility-level burnout, turnover intent, workload, and COVID-19 burden.

METHODS: In this longitudinal, multi-level study, we identified a cohort of 6444 PCPs nationally in 129 facilities using data from the VA Primary Care Management Module in the first quarter of FY 2017, and tracked them on a quarterly basis through the fourth quarter of FY 2021. We obtained quarterly individual- level turnover and demographic data from the VA Personnel and Accounting Integrated Data (PAID) payroll system, and linked it to quarterly or annual facility-level data on burnout, turnover intent, workload (panel overcapacity), COVID-19 burden (tests per 1000 patients), and facility complexity from the VA All Employee Surveys, the VA Corporate Data Warehouse, and the VA COVID Shared Data Resource. We performed logistic regression to estimate the impact of facility-level burnout (model 1) and facility-level turnover intent (model 2) on individual PCP turnover, controlling for individual demographics, facility-level workload and COVID-19 burden, and individual-level demographics, using generalized estimating equation models, adjusting for clustering at the facility level.

RESULTS: From 2017-2021, turnover among VA PCPs ranged from 6.3% to 8.4% annually (mean [M]: 7.0%; standard deviation [SD]: 0.9%), and burnout ranged from 42.6 to 52.3% (M: 47.2%, SD: 12.9%). Separation from employment was higher among employees at facilities with the highest burnout rates (OR=1.15; 95% CI=1.02 to 1.29). PCPs in facilities with the highest turnover intent rates were also more likely to actually separate (OR=1.23; 95% CI=1.08 to 1.40). In the model assessing the impact of burnout on turnover, high facility-level COVID burden (OR=1.40; 95% CI=1.09 to 1.81), low or medium facility complexity (OR=1.34; 95% CI=1.13 to 1.59), PCP age of 55-64 (OR=1.64; 95% CI=1.46 to 1.84) or over 65 (OR=5.59; 95% CI=5.02 to 6.22) were also associated with higher turnover. The probability of turnover did not differ significantly by year, except in 2020 (OR=0.70; 95% CI=0.55 to 0.88). Results were similar in the turnover intent model.

CONCLUSIONS: This is the first study to show a relationship between PCP burnout and turnover using a national sample. This is also the first study to show the differential effects of COVID-19 burden and the pandemic period on turnover in primary care. Future research should focus on reducing burnout in primary care. Reducing employee burnout may prevent costly turnover, even during disruptive external events like the COVID-19 pandemic.

UNDERSTANDING HEALTHCARE STAFF PERSPECTIVES ON ADDRESSING PATIENTS' MEDICATION ADHERENCE IN PRIMARY CARE SETTINGS

Tiffany R. Martinez²; Anna Y. Kharmats^2,4; Hayley Belli²; Devin Mann^1,3; Antoinette Schoenthaler^2,5; Saul B. Blecker^2,6

¹Population Health, NYU Langone Health, New York, NY; ²Population Health, New York University Grossman School of Medicine, New York, NY; ³Medical Center Information Techn, NYU Langone Health, New York, NY; ⁴Office of Disease Prevention, National Institutes of Health, Bethesda, MD; ⁵Institute for Excellence in Health Equity, NYU Langone Health, New York, NY; ⁶Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #3874089)

BACKGROUND: Medication adherence is a common cause for uncontrolled hypertension but is often missed in clinical care. Various healthcare staff interact with patients during routine visits and may have the opportunity to discuss medication adherence. The purpose of this study is to determine facilitators and barriers that impact the ways in which Medical Assistants (MAs), Registered Nurses (RNs), and Primary Care Physicians (PCPs) perceive their clinical role in addressing patients’ adherence to antihypertensive medications.

METHODS: We performed a qualitative study with MAs, RNs, and PCPs in primary care practices in a large healthcare network. We used semi-structured interviews informed by the Consolidated Framework for Implementation Research (CFIR) to understand perspectives on addressing patients’ barriers to adherence to antihypertensive medications. Interviews were conducted virtually, audio-recorded, and transcribed. Coding was performed in Deedose, using a combination of deductive coding based on CFIR and inductive coding of themes. We iteratively coded five transcripts until agreement was reached on a final codebook. Then all transcripts were coded by at least two members of the research team who had greater than 95% agreement; all differences were discussed with the full research team on coding. Themes and representative quotes were identified.

RESULTS: We conducted 12 interviews with 15 healthcare staff (5 MAs, 5 RNs, and 5 PCPs). MAs, RNs, and PCPs all reported facilitators and barriers to addressing patients’ medication adherence in their current roles. Although MAs were responsible for medication reconciliation and patients regularly disclose barriers to medication adherence during the rooming process, MAs felt that providing counseling related to medication adherence was beyond their scope of practice (Table). RNs were believed to be more well-suited to provide counseling on patients’ medication adherence barriers due to their training and skillset, however providing counseling did not fit in their existing clinic workflow. While PCPs also reported having limited time during clinical encounters, PCPs viewed counseling as their responsibility and expressed concerns with delegating the task to other healthcare staff because of the importance of building and maintaining relationships with patients.

CONCLUSIONS: Our findings highlight the barriers that can hinder healthcare staff from addressing patients’ adherence to antihypertensive medication, despite having the chance to discuss this issue in their current roles. A more coordinated approach among staff may be effective in addressing medication adherence in primary care settings.

UNDERSTANDING THE CHALLENGES OF PEOPLE LIVING WITH HOUSELESSNESS AND DIABETES MELLITUS: PERSPECTIVES AND INSIGHTS FROM HEALTH CARE PROVIDERS WORKING IN A MOBILE CLINIC SERVING HOUSELESS ON OAHU, HAWAII

Sean Choi¹; Camlyn Masuda¹; Sarah Stotz²; Marjorie Mau³

¹Pharmacy Practice, University of Hawai'i at Hilo The Daniel K Inouye College of Pharmacy, Hilo, HI; ²Community and Behavioral Health, University of Colorado - Anschutz Medical Campus, Aurora, CO; ³School of Medicine, University of Hawai'i System, Honolulu, HI. (Control ID #3873398)

BACKGROUND: Hawaii has one of the highest percentages of houselessness per capita in the USA. Houseless individuals have higher rates of chronic illnesses, such as type 2 diabetes (T2D), as well as T2D related hospitalizations as compared to non-houseless individuals. The ability to manage T2D in houseless individuals is not well understood by existing health care systems. Improvements in the quality of health care services requires a better understanding of the challenges providers face. To gain a deeper understanding we conducted a qualitative study with staff and volunteers from the mobile clinic known as the Homeless Outreach and Medical Education (HOME) Project.

METHODS: Semi-structured focus group interviews were conducted with physicians, medical students and volunteers who provide care to houseless individuals seen at the HOME Project. All focus groups were conducted remotely using audio-video technology. Researchers employed a thematic qualitative analysis approach which included coding transcribed interviews, categorizing the codes, and reorganizing the categories into thematic representations by comparing data across transcriptions to identify similarities and differences.

RESULTS: The study included 14 participants: 6 volunteers, 6 medical students and 2 physicians (11% of all clinic staff). The two major themes included challenges to managing T2D and pre-T2D and opportunities to improve care for those with T2D or pre-T2D.

The major challenge that clinic staff reported to managing T2D in houseless individuals is that it is a low priority when food and safe shelter are uncertain. Another challenge is the lack of continuity of care as patients may not have the proper means of transportation.

Several opportunities to improve care were discussed. One overarching sub-theme was the need for improving education to medical students and patients with context-appropriate material. Having accessible documents with information on living with T2D in the context of houselessness available to clinic personnel was recommended. The creation of a T2D Education Program where members educate clinic staff on T2D was another suggestion.

Other opportunities included adding registered dieticians or nutritionists to the existing interdisciplinary team of providers and forming partnerships with grocery stores to provide incentives for healthy food options. Another idea was creating buddy systems where an individual, such as a friend, would be paired with a patient to remind them to take their medications and attend appointments.

CONCLUSIONS: Although this study focused on a mobile medical clinic dedicated to caring for the houseless population in Hawai‘i, the data from this qualitative study provides a starting point for changes to the services of any medical facility providing care for houseless individuals who have T2D or pre-T2D.

UNPACKING THE COMPONENTS OF AN EFFECTIVE MULTICOMPONENT POST-SEPSIS PROGRAM

Natalie Reed, Nirja Sutaria, Megan Donaldson, Claire Morley, Peter Samuel, Anika Noorali, Stephanie Taylor, Marc Kowalkowski

Internal Medicine, Carolinas Medical Center, Charlotte, NC. (Control ID #3874073)

BACKGROUND: A multicomponent sepsis transition and recovery (STAR) program reduced post-sepsis readmission and mortality at 30 days but the specific types of care delivered by this multicomponent program is unknown. The objective of this study was to “unpack” the complex STAR interventions into discrete care activities to facilitate dissemination of the program.

METHODS: We conducted a secondary analysis of patients enrolled in the IMPACTS randomized clinical trial, in which patients received post-sepsis support provided by nurse navigators for 90 days. Six internal medicine physicians reviewed STAR navigator notes in study patients’ medical records and classified care activities based on pre-established definitions using a structured data collection form. Assessments were double reviewed and disagreements were resolved by discussion. We report frequency of intervention delivery using proportions and we evaluated the association between receiving at least one STAR intervention category and the composite of mortality or readmission at 30 days using a multivariable logistic regression model.

RESULTS: From the IMPACTS trial, 317 patients were randomized to receive the STAR intervention and discharged alive without hospice care. We identified 9 distinct categories of care provided by the STAR navigators. 228 (72%) received ≥1 intervention component and 91 (29%) received ≥4 different components. Nine (3%) refused participation, 17 (5%) had no care needs that required specific intervention, and 63 (20%) were unable to be reached post discharge. “Care coordination” was the most common intervention delivered (174, 55%), followed by “health behavior counseling” (dietary, smoking cessation, exercise or mobility; 104, 33%), “emotional listening” (95, 30%), “symptom management” (89, 28%), “medication management” (87, 27%), “chronic disease management” (87, 27%), and “addressing social determinants of health” (73 (23%). There were no differences in median age, comorbidity burden, or organ dysfunction at trial enrollment between groups who did versus did not receive any STAR program interventions. Adjusting for age, comorbidity index, and admission Sequential Organ Failure Assessment score, patients who received ≥1 STAR intervention had lower odds of combined readmission or mortality at 30 days, compared to those who did not receive any (19% vs 34%; OR=0.44, 0.25-0.78).

CONCLUSIONS: We characterized a multicomponent sepsis transition program into distinct care activities and identified the most common components. Many patients received 4 or more components indicating the complexity of the intervention. Receiving at least one intervention was associated with lower risk of 30-day readmission or mortality.

UTILITY OF THE CKD REPORT CARD: USING PATIENT EDUCATION TOOLS TO IMPROVE UNDERSTANDING

Jillian E. Bowman¹; Lindsay J. Zasadzinski³; Milda R. Saunders²

¹Pritzker School of Medicine, The University of Chicago Medicine, Chicago, IL; ²Hospital Medicine, University of Chicago Medical Center, Chicago, IL; ³Biological Sciences Division, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #3875298)

BACKGROUND: Prior work has demonstrated the need for a chronic kidney disease (CKD) education tool to both increase patient knowledge and improve patient self-management. We developed and tested the efficacy of a patient-driven educational intervention, the CKD Report Card, designed to facilitate patient- centered communication and enhance patient understanding of lifestyle changes needed to manage disease progression. We also examined whether the effect CKD Report Card varied by patients’ baseline health literacy. We hypothesize that patients with low health literacy will have less knowledge of their kidney disease as compared to patients with greater health literacy. Further, we hypothesize that patients who use the CKD Report Card will have a greater increase in kidney disease knowledge as compared to patients who did not use the CKD Report Card, and the benefits will be greater for patients with low health literacy.

METHODS: Adult patients were enrolled at a nephrology clinic in an urban academic medical center in the Midwest over 8 weeks. Patients were block randomized by clinic day to either the intervention or usual care. The intervention group was provided the CKD Report Card, a 2-sided investigator-developed education tool, prior to the clinic visit. Patient knowledge was assessed before and after the clinic visit using a 30-item investigator-developed CKD Knowledge Tool, modified from the Kidney Disease Knowledge Survey (KiKS). We also collected demographic information and baseline health literacy using the three question Brief Health Literacy Screen. We used paired t-tests and multivariable regression to characterize the relationship between knowledge gain and intervention status while controlling for several other co-variates.

RESULTS: Of the 91 patients, the mean was 66.2 years old (SD = 11.62), 64.8% of our sample identified as Black, and 41.8% identified as male. Additionally, 41.8% of patients (n = 38) received the CKD Report Card to use during their nephrology visit. Overall pre-visit knowledge was 57.60%; 55.75% for control and 60.16% for the intervention (p = 0.28). Patients in the intervention group experienced a statistically significant knowledge gain (difference = 19.24, p = 0.000) as measured by the CKD Knowledge Tool. The effectiveness of the CKD Report Card did not differ by patient’s baseline health literacy score.

CONCLUSIONS: A simple patient intervention significantly increased CKD knowledge gain during a clinic visit, regardless of patients' baseline health literacy status.

VACCINE ADVOCACY BY MEDICAL AND DENTAL STUDENTS: DOES PERSONAL VACCINATION STATUS PLAY A ROLE?

Arati Kelekar¹; Nelia Afonso²; Victoria Lucia³; Ana Karina Mascarenhas⁴

¹Internal Medicine, Oakland University William Beaumont School of Medicine, Rochester, MI; ²Foundational Medical Sciences, Oakland University William Beaumont School of Medicine, Sterling Heights, MI; ³Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI; ⁴Texas Tech University Health Sciences Center El Paso, El Paso, TX. (Control ID #3847351)

BACKGROUND: The Advisory Committee on Immunization Practices (ACIP) recommends that all health care personnel (HCP) receive an annual influenza vaccination to protect themselves and their patients. The importance of HCP recommendation of vaccines in patient decisions have been well documented. Several states in the US allow dentists to administer vaccines, including influenza to increase access for patients. Our objective was to determine the acceptance of influenza vaccination amongst medical students (MS) and dental students (DS) and the impact of vaccination status on opinions regarding role in promoting influenza vaccination and counseling patients.

METHODS: An anonymous survey was completed by students from 1 medical and 4 dental schools in the US. The survey assessed knowledge about influenza, personal influenza vaccine status in 2020-21 and confidence in vaccine counseling. Survey used was an existing tool previously published by the investigators involving attitudes, opinions and behaviors about vaccination and included 5-point Likert scale and dichotomous (yes/no) items.

RESULTS: A total of 221 MS and 232 DS completed the survey. 99.1% of MS and 71.3% of DS had received the influenza vaccination. In bivariate analyses comparing opinions between those who took the influenza vaccine and those who did not, statistically significant differences were seen in all 10 questions related to opinions regarding role as advocates for influenza vaccination and counseling vaccine-hesitant patients (Table). Vaccinated students were two to twenty times more likely to agree with the statements noted in the table.Vaccinated students indicated they were more likely to provide flu vaccines in their future practices (OR 6.49).

CONCLUSIONS: The higher rate of influenza vaccination among MS was likely due to institutional requirements. However, irrespective of institutional mandates, vaccination status had a positive impact on opinions regarding recommendations for vaccination, counseling vaccine hesitant patients and counteracting vaccine misinformation. This is an important factor for increasing vaccination coverage in the patients they serve. In addition to teaching vaccine hesitancy counseling skills, healthcare educational institutions should promote vaccination amongst their students as an interventional strategy to shape HCPs’ attitude towards influenza vaccination and vaccine advocacy.

VA PRIMARY CARE FRONTLINE PERSPECTIVES ON PATIENT EXPERIENCES OF VIRTUAL CARE PROVIDED BY A NATIONAL CONTINGENCY STAFFING PROGRAM

Alicia Bergman¹; Danielle Rose¹; Shay Cannedy²; Melissa Medich³; Karin Nelson^6,4; Susan E. Stockdale⁵

¹Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²HSR&D, Veterans Health Administration, North Hills, CA; ³Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, North Hills, CA; ⁴Medicine, University of Washington, Seattle, WA; ⁵HSR&D Center of Excellence, Greater Los Angeles VA Healthcare System, Sepulveda, CA; ⁶General Medicine, US Department of Veterans Affairs, Seattle, WA. (Control ID #3860803)

BACKGROUND: The Veterans Health Administration (VA) implemented a national contingency staffing program (Clinical Resource Hubs [CRHs]) in 2019. Using a “hub and spoke” model, regionally-based hubs provide (mostly virtual) primary care (PC), mental health (MH), and specialty clinicians to VA clinics with temporary or short-term staffing shortages, in order to ensure Veterans have timely access to care. We describe CRH providers/staff and PC clinic-based providers/staff perspectives on patient preferences and experiences with receiving virtual care from CRH providers.

METHODS: We conducted semi-structured telephone interviews with 16 CRH providers and staff, and 27 primary care staff within 3 VA administrative regions regarding their experiences with the CRH. Interviews were recorded and transcribed. We conducted rapid analysis describing clinicians’ perspectives on what patients think about receiving care virtually through the CRH.

RESULTS: Most interviewees perceived patients to be generally satisfied with the CRH virtual care received. Initial patient reluctance about virtual care/telehealth reportedly turned into satisfaction and positive perceptions once they tried it. Challenges reportedly faced by patients included not always answering their phone calls when CRH calls originated from numbers associated with other states or geographical areas where CRH providers, schedulers, etc. are located; perceptions that virtual care would be substandard; and connectivity issues, especially in rural areas. There were also concerns that older Veterans experienced loss of social engagement when not spending in-person time at the VA. CRH providers/staff emphasized that patients, particularly those hard of hearing, appreciated having the ability to turn up the volume on their headset and appreciated the high-quality images captured by telehealth equipment. Other reported advantages included patients’ ability to call CRH providers directly and reduced need for patients to travel for appointments. Clinic-based staff reported that computer-savvy patients (or family members) facilitated virtual visits. Clinic-based staff reported that the congeniality of remote CRH providers played an important role in patient acceptance of virtual care. Interviewees reported that younger patients (age 18-60) tended to be more open to virtual care than older patients. CRH providers explained that they often successfully converted patients to use virtual visits by asking them to try it at least one time.

CONCLUSIONS: According to interviewees, patients are often initially skeptical about virtual care for various reasons but are generally satisfied once they agree to try it at least once and realize the benefits, including high quality of care. Practical implications for the mentioned challenges include adjustments to logistics in care processes or creating campaigns for patient education about virtual care. Future research will benefit from direct qualitative investigations into patient experiences.

WHAT PERSPECTIVES DO U.S. HOSPITALISTS WHO HAD CLINICAL TRAINING IN JAPAN HAVE TOWARD INTRODUCTION OF HOSPITALIST SERVICES FOR THE WORK STYLE REFORM IN JAPAN? A QUALITATIVE INTERVIEW STUDY.

Michito Sadohara, Kunihiko Matsui

General and family medicine, Kumamoto Daigaku Byoin, Kumamoto, Kumamoto, Japan. (Control ID #3874853)

BACKGROUND: Hospitalists, born in the United States in 1996, mainly engage in in-patient care on a shiftwork basis and are known to contribute by improving quality of care, patient outcomes, patient satisfaction, and educational impacts, and by reducing management costs. Japan has provided high-quality and easily accessible medical care at a relatively low cost with few doctors, but its sustainability is threatened due to the rapidly advancing super-aging population. The Japanese Work Style Reform Act was enacted in

2018 and the work-hour limit regulations for doctors will apply from 2024. Japanese doctors and their facilities must prepare for this by effectively streamlining their work. This study aims to explore the possible effectiveness of introducing hospitalist services in Japan to deal with the work-style reforms.

METHODS: Semi-structured interviews were conducted, in Japanese, with U.S. hospitalists who had clinical training in Japan, working in the U.S. The interviews were recorded, and the data were transcribed verbatim and analyzed by the Steps for Coding and Theorization (SCAT) framework.

RESULTS: Four themes were delivered toward introduction of hospitalist services in Japan: difficulty due to differences in healthcare service delivery and insurance systems, breaking traditional work styles, concrete advice, and assessment of demands and needs for implementation. The U.S. hospitalists are working in conditions with “fair and appropriate number of patients” for “sufficient number” of hospitalists, and “diversity in working styles.” They were satisfied with the “clear on/off” with “complete sign off and hand over after shifts.” They thought the yielded “hourly wages” were sufficient. Concrete suggestions included “out-of-hospital use of electronic charts” and “off-site orders.” They recognized well about the advantages and disadvantages of two countries such as “cost and efficiency of health care systems and services,” “access and continuity,” “standardization and quality/disparity,” “education,” and “professionalism.” The introduction in Japan would depend on demands and needs and require some cultural changes. The issues to be addressed were “labor contracts,” “securing essential personnel,” “consolidation of resources of doctors and facilities,” “ratio of generalists to specialists,” “task-shifting,” and changing some traditional work styles in Japan, such as “working overtime as a virtue.”

CONCLUSIONS: Hospitalists with clinical training from Japan working in the U.S., recognizing the differences between the two countries, they had concrete suggestions regarding the introduction of hospitalist services in Japan; they observed many issues to solve, depending on the demands and needs in Japan.

X-EXPRESS: EVALUATING THE EFFECTS OF BUPRENORPHINE TRAINING ON HOSPITALIST PRESCRIBING PATTERNS AND ATTITUDES

Marco Barber Grossi¹; Jeffrey A. Wilhite²; Ann R. Garment³; Mat Kladney⁴

¹Internal Medicine, NYU Langone Health, New York, NY; ²Medicine, New York University Grossman School of Medicine, New York, NY; ³Department of Medicine, New York University School of Medicine, New York, NY; ⁴Internal Medicine, Bellevue Hospital Center, New York, NY. (Control ID #3875121)

BACKGROUND: Treatment of opioid use disorder (OUD) has primarily been managed by outpatient providers, namely psychiatrists and primary care doctors. Patients with OUD are frequently hospitalized, with each hospitalization representing an opportunity to intervene. Hospitalists are well positioned to initiate or continue OUD treatment with buprenorphine. The removal of required training for X-waiver recipients by the Drug Enforcement Agency offered an opportunity to expand buprenorphine prescribing by hospitalists. METHODS: A one-hour training session was developed for hospitalists to learn best practices for prescribing buprenorphine for patients with OUD. The number of buprenorphine prescriptions written on discharge by hospitalists versus addiction medicine consult services were compared for the 12-month periods before and after the training. Training participants were surveyed about their experience and comfort with prescribing buprenorphine.

RESULTS: Twenty-six hospitalists received the one-hour training and completed pre- and post-training surveys. Of these, 10 had already received X-waivers. Five-point Likert scale surveys (strongly disagree to strongly agree) showed statistically significant gains for the following buprenorphine prescribing practices: new prescriptions (+2.04), prescribing on discharge (+2.20), continuing prescriptions (+1.40), prescribing for acute pain (+1.52), discontinuing prescriptions (+1.64), and teaching trainees about buprenorphine (+1.80), (p <0.001 for all). Hospitalists who had not previously received X-waivers showed the greatest positive change in attitudes towards buprenorphine prescribing in all areas (apart from prescribing buprenorphine for acute pain).

Approximately 5,000 patients were discharged from hospitalist teams each year during the study period with 60 patients receiving buprenorphine prescriptions on discharge during the year prior to the training and 76 patients after the training (Table). Addiction medicine consult services accounted for the majority of buprenorphine prescriptions during the years both before and after the study period (p = 0.028).

CONCLUSIONS: After receiving a one-hour training on prescribing buprenorphine for management of OUD, surveyed hospitalists expressed greater confidence prescribing buprenorphine and teaching trainees about buprenorphine, particularly among those who had not previously received X-waivers. However, hospitalist teams continued to rely on addiction medicine services to prescribe buprenorphine on discharge for patients with OUD. Future research should assess other hospitalist behaviors around the care of patients with OUD, such as engagement with addiction medicine consults or approaches to teaching trainees about the management of OUD.

“HOW” VERSUS “WHY” MESSAGING TO INCREASE UPTAKE OF BOOSTER VACCINATION AGAINST COVID-19: RESULTS OF A PRAGMATIC TRIAL

Nancy Haff⁵; Niteesh K. Choudhry⁵; Gauri Bhatkhande⁵; Punam Keller¹; Ted Robertson³; Rebecca Oran²; Kaitlin Hanken⁵; Katherine L. Crum⁵; Theresa Oduol⁵; Daniel M. Horn⁴; Julie Lauffenburger⁵

¹Tuck School of Business, Dartmouth College, Hanover, NH; ²Nudge Unit and Behavioral Insights, Blue Cross Blue Shield of Massachusetts, Boston, MA; ³ideas42, New York, NY; ⁴Medicine, Massachusetts General Hospital, Boston, MA; ⁵Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. (Control ID #3874096)

BACKGROUND: Vaccination is key to protect against illness and death from COVID-19; despite this, uptake of booster vaccinations has been modest. Messages designed using behavioral science principles increase the uptake of other vaccinations and might help increase booster acceptance. In this study, messages were designed using principles from Construal Level Theory and emphasized either how or why to get a vaccine, as different framing could affect decision making.

METHODS: In this 3-arm pragmatic randomized trial, we tested the effects of pre-visit patient messages with “how” and “why” framing delivered through the electronic health record (EHR)-linked patient portal versus no message (usual care), on the receipt of booster vaccinations. Eligible patients: 1) were age 18 years or older, 2) had received a primary vaccine series but not yet a first booster dose, 3) had an upcoming in- person primary care visit in one of 3 clinics, and 4) were portal users. Weekdays were randomized such that by study completion a balanced number within each clinic were expected by arm. Each day, eligible patients were identified using an EHR report and were sent a message in their preferred language (or no message) through the portal 2-3 days before their visit. The primary outcome was receipt of a COVID-19 vaccination after the message was sent through the day of the target visit; the secondary outcome was receipt of a

COVID-19 vaccination within 6 weeks. Outcomes were collected from the EHR, supplemented by a vaccine registry drawing from a statewide database. Generalized estimating equations were used to evaluate outcomes, adjusting for clustering and, in secondary analyses, for patient characteristics.

RESULTS: In total, 3,665 patients were randomized: 1249 to “how” arm, 1199 to “why” arm, and 1217 to usual care (UC). The mean age was 53.5 years, 59% were female, 34.8% were non-white and 26.6% were of Hispanic ethnicity. The primary outcome occurred among 11.7% of patients in the “how” arm, 13.7% in the “why” arm, and 13.6% in the UC arm. No differences in vaccination rates between arms were observed (Table). Adjusted and secondary outcome vaccination rates were also not significantly different with one exception; the “why” arm outperformed the “how” arm for vaccination at 6 weeks (Table).

CONCLUSIONS: There was no difference in rates of COVID-19 booster vaccination among patients sent different pre-visit messages designed to encourage vaccination. Many factors could have contributed to these findings, including the message content, messenger, timing, targeted vaccination event, and extensive outside influences on vaccination behavior that were present at the time.

Scientific Abstract - Health Policy

ACROSS PHYSICIAN SPECIALTIES, SERVING FEWER BLACK PATIENTS IS ASSOCIATED WITH HIGHER COMPENSATION

Christopher Cai¹; Danny McCormick²; Stephanie Woolhandler⁴; David Himmelstein⁴; Elizabeth Schrier⁵; David Bor²; Emily L. Lupez²; Adam Gaffney³; Samuel Dickman⁶

¹Internal Medicine, Brigham and Women's Hospital, Boston, MA; ²Internal Medicine, Cambridge Health Alliance, Cambridge, MA; ³Pulmonary and Critical Care, Cambridge Health Alliance, Cambridge, MA; ⁴City University of New York, New York, NY; ⁵University of California San Francisco School of Medicine, San Francisco, CA; ⁶Planned Parenthood of Montana Inc, Billings, MT. (Control ID #3868995)

BACKGROUND: More Non-Hispanic White (henceforth, “White”) than Non-Hispanic Black (“Black”) patients have private insurance, which generally pays physicians higher fees than what Medicaid or uninsurance pays. This may disincentivize service to Black patients. We quantify the association between the shares of White and Black patients served and average annual physician compensation across specialties.

METHODS: We pooled nationally representative data on adult outpatient visits from the 2014-2019 Medical Expenditure Panel Survey (MEPS). For each specialty, we calculated adjusted visit rate ratios (ARR) for White and Black respondents, using negative binominal regressions adjusted for age and sex (ratios > 1 indicate that visits to physicians in that specialty were disproportionately White). Annual physician compensation was obtained from the 2019 MedScape Compensation Report. We assessed the association between the White:Black ARR and annual physician specialty compensation using linear regression.

RESULTS: Our sample included 195,810 respondents who made 145,030 outpatient visits to 22 specialties. The White:Black visit ARR was significantly > 1 for 16 specialties, non-significantly different from 1 for 5 specialties and <1 for Nephrology. Higher White:Black visit ARR for the specialty was positively correlated with higher annual compensation (standardized beta coefficient= 0.50; P<0.001), i.e. a 10% increase in the White:Black visit ARR was associated with a $6,117 increase in annual compensation. Controlling for patients’ insurance attenuated, but did not eliminate, the association between visit ARR and annual compensation (standardized beta coefficient=0.36; P<0.001).

CONCLUSIONS: Physicians in specialties serving more White patients receive, on average, higher annual compensation. This partly reflects racial disparities in insurance coverage, a form of structural racism. Equalizing insurance would partially address disparities: reforms to address racism in referral rates and income inequities are also needed.

ASSOCIATION BETWEEN CHANGES IN PRICES AND OUT-OF-POCKET COSTS FOR BRAND- NAME CLINICIAN-ADMINISTERED DRUGS

Hussain S. Lalani^1,2; Massimilano Russo^3,2; Rishi Desai^3,2; Aaron S. Kesselheim^1,2; Benjamin N. Rome^1,2

¹Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA; ²Harvard Medical School, Boston, MA; ³Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #3874134)

BACKGROUND: Clinician-administered drugs (e.g., injections and infusions) represent a rising share of prescription drug spending in the US. Increases in drug prices have been associated with higher patient out- of-pocket costs for pharmacy-administered drugs, thereby leading to poor patient outcomes. However, the relationship between prices and patient costs for clinician-administered drugs is unknown.

METHODS: Using a national commercial claims database (Merative Marketscan), we conducted a repeated cross-sectional study among privately insured adults who received one of 52 high-priced brand-name clinician-administered drugs from 2009 to 2018. We calculated the annual percent change in manufacture list prices (from commercial databases) and post-rebate average sales prices (i.e., net prices, from Medicare). We used two-part generalized linear regression models with variance clustered by drug to assess the relationship between prices and two primary outcomes: 1) annual percent change of individuals with non-zero out-of- pocket costs and 2) annual percent change in median non-zero out-of-pocket costs. We conducted analyses among all patients and stratified by insurance plan type (high deductible health plan vs. other) and place of service (hospital outpatient vs clinic). All prices and costs were adjusted for inflation and reported in 2018 US Dollars.

RESULTS: Of the 52 clinician-administered drugs, 27 (52%) were antineoplastic, 7 (13%) were hematologic, and 6 (12%) were immunomodulators. The 310 annual drug-year cohorts included 1.2 million patients, among whom 62% were female and the median age was 53 years (interquartile range [IQR], 44-69). List and net drug prices increased by a median of 4.4% (IQR, 1.1%-6.0%) and 3.3% (IQR, -0.3%-5.5%) per year, respectively. The share of individuals with non-zero out-of-pocket costs increased from a median of 35% (IQR, 31%-43%) in 2009 to 48% (IQR, 40%-51%) in 2018, and median non-zero annual out-of-pocket costs increased by 9.6% (IQR, 4.1%-15.4%) per year. There was no association between changes in the list or net drug prices and out-of-pocket costs.

CONCLUSIONS: From 2009 to 2018, prices for brand-name clinician-administered drugs increased faster than inflation. There was a substantial increase in out-of-pocket costs among privately insured patients using these drugs, which could decrease medication adherence, negatively impact patient outcomes, and increase disparities in access to care. There was no observed relationship between changes in prices and out-of-pocket costs for individual drugs, which might reflect the complexity of medical insurance benefit design. Policymakers should act to reduce the financial burden posed by clinician-administered drugs to improve affordability and access to these therapies.

ASSOCIATION BETWEEN RECEIPT OF PHARMACEUTICAL MARKETING PAYMENTS FOR NOVEL CARDIOVASCULAR MEDICATIONS AND SOCIOECONOMIC STATUS OF PHYSICIANS’ PATIENT POPULATION

Benjamin Y. Liu¹; Timothy Anderson²

¹Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Medicine/General Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #3876555)

BACKGROUND: Individuals with lower socioeconomic status (SES) are more likely to have worse health outcomes and less likely to be prescribed guideline-based cardiovascular medications. One driver of prescribing is pharmaceutical industry marketing, which has been associated with increased use of medications, including novel cardiovascular drug classes. Thus, to determine whether marketing may drive disparities in medication use, we examined the relationship between receipt of industry payments for cardiovascular medications and SES of physicians’ patients.

METHODS: We linked the 2019 Centers for Medicare & Medicaid Services (CMS) Open Payment database and 2019 CMS Part D Prescriber database to obtain information on receipt of industry payments, prescription volume, and characteristics of prescribers and prescriber patient populations. We limited our study to specialties which regularly prescribe cardiovascular medications: primary care physicians (PCPs), cardiologists, endocrinologists, and nephrologists. We examined two markers of SES: the proportion of physicians’ panel who were dually eligible for Medicare and Medicaid, and the county-level Social Deprivation Index. Our outcome of interest was receipt of industry payment for novel cardiovascular medications. We used a multivariable logistic regression model to determine whether receipt of industry payments was associated with SES of a physician’s panel.

RESULTS: We examined 172,988 physicians comprised of 81% PCPs, 13% cardiologists, 4% nephrologists, and 3% endocrinologists who had at least 10 cardiovascular drug beneficiaries in 2019. Overall, 40% of physicians received industry payments for novel cardiovascular medications (PCSK-9 inhibitors, ARNIs, SGLT-2s, and GLP-1s). Physicians with greater than 75% dual eligible patients were much less likely to receive industry payments than physicians with fewer than 25% dual eligible patients (24% vs 45%, p<.001). In multivariable analyses, physicians with > 75% dual eligible patients were significantly less likely to have received a marketing payment (OR: 0.62; CI, 0.59 - 0.66). Conversely, physicians in counties with the highest social depravity index scores were more likely to receive payments, although this effect was smaller (OR: 1.002, 95% CI, 1.002 - 1.003). Compared to PCPs, cardiologists (95% CI, 2.44 - 2.60) and endocrinologists (95% CI, 3.02 - 3.42) were more likely to receive industry payments.

CONCLUSIONS: In this national retrospective study, we found physicians caring for a larger proportion of patients dual-eligible for Medicaid and Medicare were less likely to receive industry payments for novel cardiovascular drugs. Difference in receipt of industry marketing payments may be one factor driving disparities in the uptake of novel cardiovascular medications, although whether these differences are due to industry targeting or differences in physician acceptance of payments is not known and requires further study to ensure pharmacoequity.

CHANGES IN SITE OF DEATH AMONG MEDICARE BENEFICIARIES DURING THE COVID-19

PANDEMIC

Jessica J. Zhang¹; Hiroshi Gotanda²; Debra Saliba³; Haiyong Xu⁴; Yusuke Tsugawa^4,5

¹Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; ³Medicine -Geriatrics, UCLA Borun Center, VA GRECC, RAND, Los Angeles, CA; ⁴Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁵Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA. (Control ID #3874650)

BACKGROUND: Understanding how the coronavirus disease 2019 (COVID-19) pandemic affected end-of- life care would inform healthcare system resiliency in future public health emergencies. We evaluated the changes in site of death during the COVID-19 pandemic among Medicare beneficiaries (who did not have COVID-19).

METHODS: We used a 20% sample of Medicare fee-for-service beneficiaries aged 66 years and older who died from 2016 through 2020, and excluded beneficiaries who died in acute care hospitals with a diagnosis of COVID-19. Using a quasi-experimental difference-in-differences (DID) method, we estimated net changes in site of death during the pandemic period (March–December 2020) from the pre-pandemic period (January– February 2020), using data on the same months in prior years (2016-2019) as the control. Site of death was categorized as: (1) home or community (e.g., assisted living facility); (2) acute care hospital; (3) nursing home; or (4) inpatient while receiving hospice benefits. We also investigated whether the site of death varied by medical conditions of beneficiaries: cancer, chronic obstructive pulmonary disease (COPD), and dementia.

RESULTS: We included 1,133,273 beneficiaries who died without a hospital diagnosis of COVID-19 during the study period. We found that the proportion of Medicare beneficiaries who died at home or in the community setting increased (DID estimate, +3.1 percentage points [pp]; 95% CI, +2.6 to +3.6 pp; P<0.001), beneficiaries who died (without COVID-19 diagnosis) in an acute care hospital decreased (-0.8 pp; 95% CI, -1.2 to -0.4 pp; P<0.001), and beneficiaries who died in inpatient hospice decreased (-2.1 pp; 95% CI, -2.4 to -1.7 pp; P<0.001) during the COVID-19 pandemic. We found no evidence that the proportion of deaths in nursing homes changed during the pandemic. We observed similar trends across beneficiaries with cancer, COPD, or dementia, with the largest observed changes among those with cancer.

CONCLUSIONS: Using national data on Medicare beneficiaries, we found that site of death shifted from acute care hospitals and inpatient hospice to home during the COVID-19 pandemic, with no change in nursing home deaths.

COVID-19 TRANSMISSION AMONG PARTICIPANTS OF THE ISOLATION HOTEL PROGRAM, JULY 1, 2020 - JUNE 30 2021, IN A LARGE METROPOLITAN AREA OF THE MID-ATLANTIC REGION.

Sarah Klem²; Owen Stevenson³; Kate Whittemore⁴; Shigeru Odani⁵; Steffen Foerster⁶; Theodore G. Long¹; Amanda Johnson⁷

¹Ambulatory Care & Population Health, NYC Health + Hospitals, New York, NY; ²NYC Test & Treat, New York City Health and Hospitals Corporation, New York, NY; ³Test & Treat Corps, New York City Health and Hospitals Corporation, New York, NY; ⁴Center for Pandemic Prevention and Response, Weill Cornell Medicine, New York, NY; ⁵Statistics, Baruch College Zicklin School of Business, New York, NY; ⁶Division of Disease Control, Bureau of Division Management and Systems Coordination, New York City Department of Health and Mental Hygiene, New York, NY; ⁷Division of General Internal Medicine & Clinical Innovation, NYU Langone Health, New York, NY. (Control ID #3877000)

BACKGROUND: In spring 2020, a large metropolitan area in the Mid-Atlantic launched a program to provide free hotel stays for COVID-19 cases and their contacts who needd a safe place to separate from others where they lived. The program was hypothesized to reduce onward transmission to household contacts, particularly among those living in large or crowded homes.

METHODS: Using data from the metropolitan area's extensive contact tracing program, we examined whether the household contacts of caes that stayed in the COVID-19 isolation hotels were less likely to become a case and whether any factors made the program more or less effective at reducing transmission. We conducted a logistic regression model with 22 covariates, including demographic information about the contact and their index case, characteristics of their census tract, and proxies for vaccination. Three variables were found to have effect mesasure modification with whether the contact's index case was hoteled and were included as interactions: the availability of the vaccination, age of the contact, and the perdent of their census tract living in overcrowded housing.

RESULTS: From July 1, 2020 - June 30 2021, 477,779 metropolitan area cases were identified along with 245,795 household contacts, meeting the inclusion criteria of the study. 10,805 cases were identified as hotel guests, who provided 8,235 qualifying household contacts. Of those hotel contacts, 2,522 (31%) converted to cases. Contacts of cases who did not stay in hotels converted at a rate of 36%.

The regression model found that contacts of cases that used hte isolatio hotels were associated with a 28% reduction in the odds of becoming COVID-19 cases (95% CI 21% - 34%), with the odds further reduced by 7% for every 21 years the contact aged (95% CI 2 - 21%). After vaccines were introduced, the program reduced the likelihood of converting to a case to 8%. Additionally, an 8% increase in the percentage of their census tract living in crowded housing was associated with an 11% increase in the odds of contacts of hoteled cases becoming cases.

CONCLUSIONS: COVID-19 isolation hotels were found to be effective in reducing onward COVID-19 transmission within households, particularly for older contact. This protective effect was found to be present but was reduced in census tracts with higher household crowding and areawide after vaccinations were introduced. This is a promising result demonstrating the efficacy of a unique program that was not widely adopted across the United States. Such programs can be useful tools in combating transmission of COVID-19 and, potentially, other infectious diseases with high household transmission.

DAYS SPENT AT HOME AND PATIENT WELL-BEING AMONG FRAIL OLDER ADULTS

Hiroshi Gotanda¹; Nabeel Qureshi^1,2; Teryl K. Nuckols¹; Yusuke Tsugawa^3,4

¹Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; ²Pardee RAND Graduate School, Santa Monica, CA; ³Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁴Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA. (Control ID #3874680)

BACKGROUND: Days spent at home (DAH) has been gaining increasing attention as a meaningful outcome measure. This study examined the association between DAH and patient-centered outcomes among frail older adults.

METHODS: We included frail older adults from the 2016-2018 Health and Retirement Study, defined as those with three or more out of five self-reported symptoms (wasting, weakness, slowness, fatigue or exhaustion, and falls). DAH was calculated by subtracting the total number of days spent in hospitals and nursing homes from 730 days and categorized into five groups: 730 days (all days at home), 729 to 723 days (1 week away from home), 722 to 716 days (2 weeks away from home), 715 to 702 days (3 weeks away from home), and less than 701 days (4+ weeks away from home). Outcomes were life satisfaction, psychological well-being, and a decline in activities of daily living (ADL). We fit multivariable linear regression models to examine the association between DAH and each outcome adjusting for individual characteristics.

RESULTS: Our study included 1,740 frail individuals. The mean DAH among study participants was 723.0 days (SD 21.6 days) and 54.8% had 730 days of DAH. We found no evidence that DAH was associated with life satisfaction (p-for-trend=0.57) or psychological well-being (p-for-trend=0.32) among frail older adults. However, we found that a one-week increase in DAH was associated with a lower probability of experiencing a decline in ADL by 6.5 percentage points (p<0.001).

CONCLUSIONS: We found that DAH was not associated with patient well-being measures among frail older adults while more DAH was associated with a lower decline in ADL.

DISPARITIES IN MYOCARDIAL INFARCTION BY SEX ACROSS 6 HIGH-INCOME COUNTRIES

Hannah Lu¹; Peter Cram^1,2; Bruce E. Landon³

¹School of Medicine, The University of Texas Medical Branch at Galveston School of Medicine, Galveston, TX; ²Health Management Policy and Evaluation, University of Toronto, Toronto, ON, Canada; ³Health Care Policy, Harvard Medical School, Boston, MA. (Control ID #3849094)

BACKGROUND: Acute myocardial infarction (AMI) is a leading cause of morbidity and mortality in high- income countries. Previous studies from a small number of countries including the US and Canada have observed sex-based disparities in AMI treatment and outcomes with women less likely to receive interventional procedures and experiencing higher mortality. However, it is unclear whether sex disparities for AMI are widely prevalent internationally. We investigated the epidemiology and care of women and men hospitalized with ST elevation and non-ST elevation MI (STEMI and NSTEMI) in six diverse countries with different culture and healthcare systems.

METHODS: We identified adults age > 66 years hospitalized with a primary diagnosis of STEMI or NSTEMI between 2011 and 2018 in the US, Canada, England, Netherlands, Taiwan, and Israel using administrative data. In each country, we compared women and men with respect to age-standardized hospitalization rates, rates of cardiac catheterization, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery within 90-days of hospitalization, and 30-day mortality. Analyses were conducted separately for the STEMI and NSTEMI cohorts.

RESULTS: Our study included 390,637 patients hospitalized with STEMI and 1,117,568 patients hospitalized with NSTEMI across our six countries. Hospitalization rates for STEMI and NSTEMI decreased between 2011-2018 in all countries. Between 2011 and 2018 the ratio of the hospitalization rate in men relative to women for both STEMI and NSTEMI (rate in men/rate in women) increased in all countries (e.g., US STEMI ratio 1.58:1 in 2011, 1.73:1 in 2018: Israel NSTEMI ratio 1.71:1 in 2011, 2.11:1 in 2018). Rates of cardiac catheterization, PCI, and CABG were lower for women than men for STEMI (Figure 1) throughout all countries and years (e.g., US cardiac catheterization in 2018 88.6% for women vs 91.5% for men; Israel PCI in 2018 76.7% for women, 84.8% men) with similar findings for NSTEMI. Adjusted 30-day mortality for STEMI in 2018 was higher for women in four countries (US, Canada, Netherlands, and Taiwan). For NSTEMI, there was no clear pattern of mortality differences in women versus men.

CONCLUSIONS: We observed a larger decline in STEMI and NSTEMI hospitalizations for women than men between 2011 and 2018, resulting in both conditions becoming increasingly associated with males and less with females. Women were less likely to receive cardiac interventions or revascularization across all six countries for STEMI with this gap in interventional treatments widening over time in some countries. Women also had higher mortality after hospitalization with STEMI. Sex disparities appear to transcend borders, raising questions about underlying causes and potential remedies.

ELIGIBLE BUT NOT ENROLLED – MEDICAID PARTICIPATION RATES AND THE EFFECTS OF AUTOMATED RENEWALS

Daniel B. Nelson¹; Phillip Singer²; Vicki Fung³

¹Population Medicine, Harvard Medical School, Boston, MA; ²Political Science, University of Utah, Salt Lake City, UT; ³Mongan Institute, Massachusetts General Hospital, Boston, MA. (Control ID #3874908)

BACKGROUND: Maintaining coverage among those eligible for Medicaid has health consequences. Temporary losses of Medicaid (“churning”) are common and are associated with gaps in coverage, care fragmentation, medication nonadherence and poor health outcomes. Medicaid eligibility renewal has historically required enrollees to submit verification of their income and other personal information at least annually. After the Affordable Care Act (ACA), states were required to use existing databases to facilitate automated Medicaid renewals to reduce beneficiaries’ administrative burdens and prevent churning. States varied in the timing of when they implemented this mechanism and the proportion of applications they automatically processed. This study examined state variation in Medicaid participation rates among nondisabled adults and whether adoption of automated renewals was associated with increases in participation.

METHODS: We used American Community Survey (ACS) data to estimate Medicaid participation among nondisabled adults ages 19-64 with incomes less than 138% of the federal poverty level (FPL) based on household composition and annual income, 2015-2019. Participation rates were defined as the proportion of the estimated Medicaid-eligible population who reported Medicaid coverage. Using a difference-in- differences analysis, we also assessed whether implementation of automated renewals was associated with changes in Medicaid participation. among a subset of states selected based on the timing of program implementation: control states (KY, MN, ND, OH) implemented automated renewals in 2014; treatment states (IA, IL, WI) delayed implementation until 2017. We estimated linear probability models, controlling for individual sociodemographic (e.g., age-sex, race/ethnicity, education, receipt of other public assistance) and state-level characteristics that could influence Medicaid participation (e.g., Medicaid managed care penetration).

RESULTS: Adult participation in Medicaid varied widely across the US during the study period, with a maximum and minimum of 85.6% and 31.7% in Massachusetts and Texas, respectively. National mean participation was 70.0%: 71.6% in expansion states and 55.7% in non-expansion states. Among a subset of states, adoption of automated renewals in 2017 was not associated with relative increases in participation rates (-1.3 percentage points [-4.3, 1.6], p=0.31).

CONCLUSIONS: Following the ACA, there are persistent and wide differences in the Medicaid participation rates across states. We did not find changes in Medicaid participation associated with the automated renewal process. Future work should explore the causes of the wide variation in participation in the post-ACA era and potential barriers to implementing automated renewals.

ESTIMATED ANNUAL SPENDING ON LECANEMAB IN THE U.S. MEDICARE PROGRAM Julia C. Arbanas¹; Cheryl Damberg²; Mei Leng¹; Nina Harawa¹; Catherine Sarkisian¹; Bruce E. Landon³; John N. Mafi^1,2

¹Medicine – GIM & HSR, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²RAND Corporation, Santa Monica, CA; ³Health Care Policy, Harvard Medical School, Boston, MA. (Control ID #3876333)

BACKGROUND: Lecanemab, a dementia drug with a small but statistically significant clinical benefit, has been granted FDA Priority Review, setting the stage for widespread use. Lecanemab’s projected high cost could markedly impact Medicare's budget through direct drug costs and indirect costs from increased cognitive screenings, PET scans for amyloid plaque, and other ancillary services. To assess lecanemab's potential impact on Medicare, we performed a cost analysis using a nationally representative sample of Medicare beneficiaries with mild cognitive impairment (MCI) or mild dementia.

METHODS: We used cross-sectional data from the nationally representative 2018 Health and Retirement Study (HRS) to provide a national estimate of potential lecanemab patients. We included those aged ≥65 years with Traditional Medicare (TM) or Medicare Advantage (MA) and used validated cognitive measures to estimate the prevalence of MCI or mild dementia. We assumed a lower bound cognitive screening rate of 27% based on the literature and an upper bound screening rate of 35%, a 30% anticipated relative increase. Using prior studies and expert input, we assumed 35% of those screening positive would undergo formal neurocognitive testing; 50% of those undergoing formal neurocognitive testing would receive a PET scan, and 37% (lower bound) and 68% (upper bound) of those receiving a PET scan would test positive for amyloid plaque. We applied clinical trial age and comorbidity restrictions. To quantify costs, we used the 25^th and 75^th percentiles of the announced annual price range and calculated ancillary costs, like MRIs and neurology visits to monitor amyloid-related imaging abnormalities using trial data and Medicare's fee schedule. We multiplied annualized per-person costs assuming TM's 80% coverage rule and 6.9% attrition due to drug discontinuation. We accounted for survey clustering and adjusted results by survey weights for national representativeness and response rate.

RESULTS: Among 7,588 HRS participants representing 44 million TM or MA beneficiaries, 16.2% had MCI or mild dementia. Total annualized per-beneficiary drug costs ranged from $15,838-$29,016. If 85,687 (lower bound) eligible patients received lecanemab, Medicare would spend $1.4 billion annually (95% CI, $1.3-1.5 billion). Applying the upper bound estimate (204,724 patients) would cost Medicare $5.5 billion annually (95% CI, $5.0-5.5 billion). Annual per-beneficiary coinsurance estimates ranged from $4,326-$6,961. Ancillary health services increased spending estimates by 28%. If cognitive screening rates rose to 35%, additional screenings alone would add $483 million annually.

CONCLUSIONS: Lecanemab’s use would add an estimated $1.4-$5.5 billion to annual Medicare spending. Policymakers should consider the impact of the broad use of anti-amyloid drugs with modest clinical benefit on federal and beneficiary spending. Pharmaceutical companies’ marketing strategies to increase screening to find wider markets may raise these spending estimates.

EVALUATION OF A MASSACHUSETTS OPIOID PRESCRIBING LIMIT LAW AMONG POST- OPERATIVE ORTHOPEDIC PATIENTS

Bryant Shuey¹; Fang Zhang²; Edward Rosen¹; Nicolas K. Trad³; J F. Wharam⁴; Hefei Wen⁵

¹Department of Population Medicine, Harvard Medical School Department of Population Medicine, Boston, MA;²Population Medicine, Harvard Medical School, Boston, MA; ³Harvard Medical School, Roxbury Crossing, MA; ⁴Duke University, Durham, NC; ⁵Department of Population Medicine, Harvard Medical School, Boston, MA. (Control ID #3874051)

BACKGROUND: Postoperative prescribing following orthopedic surgery accounts for nearly 8% of opioids prescribed in the United States. Opioid overdose deaths related to overprescribing prompted a wave of state policies that set limits on the duration of opioid prescriptions. Massachusetts was the first state, implementing a 7-day limit in March 2016. Internists often care for patients prescribed opioids following orthopedic surgery and should be aware of how state laws affect opioid prescribing across different specialties and patient populations.

METHODS: We used a repeated cross-sectional interrupted time series design with a comparison series using commercial claims data from May 2015 to June 2017 to evaluate the impact of the March 2016 Massachusetts law on post-operative opioid prescribing among patients undergoing orthopedic surgery. Our denominator included adults aged 18 and older from Massachusetts (intervention) and New Hampshire (control) undergoing elective orthopedic procedures during the 10 pre- and 14 post-policy months. Primary outcomes included the initial fill’s days’ supply and the probability of receiving an initial fill greater than 7-days duration. Secondary outcomes included the probability of opioid initiation (to assess for a chilling effect), and daily and total morphine milliequivalents in the post-operative period (to assess for a gaming effect). We fit generalized estimating equations to estimate the effect of the policy on outcome level and trend changes among the intervention relative to the control group, adjusting for patient characteristics. We estimated absolute differences in outcomes among intervention group members compared to the counterfactual in the post-policy period.

RESULTS: Our final analytic sample included 7,883 Massachusetts and 1,967 New Hampshire adults. Seventy-two percent of our sample filled an opioid within the 7-day post-operative period. Following the policy, we observed an immediate 6.4% absolute reduction (95% confidence interval -10.6, -2.1%) in initial fills greater than 7-days in the intervention group. We observed a 1.0 percentage point per month reduction (95% confidence interval -1.6, -0.3) in the pre-post trend of monthly fills greater than 7-days in the intervention group. By the end of the study period, the intervention group experienced an absolute reduction in initial fills greater than 7-days duration of 19.7% (95% confidence interval -31.5, -8.0%). We observed no significant post-policy changes in level or trend among other outcomes.

CONCLUSIONS: We found a substantial reduction in initial opioid prescriptions greater than 7-days duration among Massachusetts patients undergoing elective orthopedic procedures who were exposed to the Massachusetts opioid prescribing limit policy. The Massachusetts opioid prescribing law appears to have partially met its intended aim of reducing longer duration initial opioid prescriptions and we did not observe gaming or chilling effects.

EXPERIENCES OF UNDOCUMENTED IMMIGRANTS WITH HEMATOLOGIC MALIGNANCIES WHO CANNOT ACCESS HEMATOPOIETIC STEM CELL TRANSPLANT Apoorva Ram, Haley Simpson, Manisha Dubey, Katherine Feldman, Lilia Cervantes

Internal Medicine, University of Colorado, Denver, CO. (Control ID #3874943)

BACKGROUND: Undocumented immigrants often rely exclusively on Emergency Medicaid or Federally Qualified Health Centers for their healthcare, due to lack of access to other health insurance options. While these provide essential care, undocumented immigrants with cancer often experience delays in diagnosis and receive substandard care because of limitations in coverage. For many hematologic malignancies, hematopoietic stem cell transplant (HSCT) is often the only curative treatment; however, this is not accessible to undocumented, uninsured immigrants in much of the United States, including Colorado. Undocumented immigrants who are diagnosed with cancer, specifically hematologic malignancies, often experience inaccessibility to the most effective cancer treatments including HSCT, leading to higher rates of relapse and decreased survival. The study objective was to describe the experiences of undocumented immigrants living with hematologic cancers who cannot access HSCT.

METHODS: This qualitative study was conducted using semi-structured interviews of uninsured, undocumented immigrants who were diagnosed with a hematologic malignancy that was medically appropriate for stem cell transplant in Colorado from February 2021 to October 2022 Interviews were audio- recorded and transcribed. The analysis of the data is based in grounded theory and descriptive analysis, based on Charmaz’s constructivist approach. Main outcomes were themes and subthemes.

RESULTS: Seven people between the ages 21 and 56 were interviewed. Six of the seven participants spoke Spanish as their preferred language. We identified four themes, as follows. 1) Immigration and socioeconomic status as magnifiers of the challenges faced while enduring cancer. 2) “Animo”, “Agradecimiento”, and Internalized Acceptance of Sub-Standard Care. 3) Perceptions of the Healthcare System. 4) Socio-Emotional Experience of Cancer Care. A quote which exemplifies part of our first theme came from a 35 year old man with Hodgkin Lymphoma who was ineligible for HSCT. He said “Si yo tuviera dinero, vivo, pero si no tengo dinero, muero. Es duro cuando uno ve que la vida humana se reduce a eso” (translated to English: “If I had money, I would live, but if I don’t have money, I would die. It’s hard when you see human life reduced to this”).

CONCLUSIONS: Some states have taken action to expand coverage for this gap in cancer care, but the vast majority have not. This study provides valuable insight into the experiences of undocumented immigrants who lack access to curative therapy for cancer. This work may inform interventions on both an individual and policy level to improve access to care for undocumented immigrants with cancer.

FINANCIAL INCENTIVES AND THE LIKELIHOOD OF SEEING MEDICAID PATIENTS: A NATIONAL SURVEY OF PHYSICIANS

Jubi Y. Lin^1,2; Joseph H. Joo^1,2; Lingmei Zhou^1,2; Joshua M. Liao^1,2

¹Medicine, University of Washington School of Medicine, Seattle, WA; ²Value & Systems Science Lab, Seattle, WA. (Control ID #3874586)

BACKGROUND: There is continued interest in improving US health care via payment reform. One reform goal is to address inequity in access to care, a particularly important consideration for Medicaid beneficiaries. As physicians play critical roles in determining access, it is crucial to understand their perspectives about proposed payment reforms.

METHODS: Web-based survey of American College of Physician member physicians in the US. The survey assessed whether physicians saw Medicaid patients; contributing factors to that decision; and how providing primary care physicians with financial incentives for reducing overall costs and achieving minimum quality thresholds (defined as new financial incentives) would affect the likelihood of seeing Medicaid patients in the future. Major factors were those that contributed some or a lot to decisions not to see Medicaid patients.

RESULTS: Of 730 physicians, 45% responded. Fewer than half reported quality or cost incentives (44%) or both (27%) in their practices. Most reported that Medicaid reimbursement rates inadequately adjust for patients’ clinical (81%), social (89%), and behavioral (88%) risk factors.

Few (6%) did not report seeing Medicaid patients. Of those, half (56%) indicated low reimbursement rates as a contributing factor, while few indicated clinical (6%) or social (11%) complexity as factors. Over one-third (39%) reported that the likelihood of seeing these patients in the future would increase under new financial incentives. These perspectives varied by respondents’ views about Medicaid reimbursement and patient complexity. Physicians who reported (a) low reimbursement rates, (b) clinical complexity, and (c) social complexity as major contributors to not seeing Medicaid patients were more likely to report increased likelihood of doing so in the future under new financial incentives.

Among the 94% of respondents who saw Medicaid patients, over one-third (35%) reported that new financial incentives would increase the likelihood of Medicaid patients being seen in their practices. This view was less prevalent among physicians who (a) agreed that Medicaid reimbursement inadequately adjusted for patients’ behavioral, clinical, and social risk factors, and (b) did not face quality and cost incentives in their practices.

CONCLUSIONS: Most physicians in our sample reported that Medicaid reimbursement rates inadequately adjusted for patients’ behavioral, clinical, and social risk factors. Over one-third reported that new financial incentives would increase their likelihood of seeing Medicaid patients in the future. These perspectives varied by several physician views and characteristics.

GET OUT THE VACCINE (GOTVAX): IMPACT ON CANVASSERS OF AN INNOVATIVE, EQUITY FOCUSED APPROACH TO DELIVERING COVID-19 VACCINATION

Lisa Mansfield³; Stefanie D. Vassar¹; Arleen F. Brown²; Natalie Robles¹; Savanna L. Carson⁴; Dale Slaughter¹; Gloria Kim⁵; Alana G. Troutt⁶; Keith C. Norris²

¹Division of Internal Medicine & Health Service Research, UCLA, Los Angeles, CA; ²Medicine, University of California Los Angeles, Los Angeles, CA; ³Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles, Los Angeles, CA; ⁴Department of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA; ⁵Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA; ⁶Government Operations Agency, State of California, Sacramento, CA. (Control ID #3877111)

BACKGROUND: Get Out the Vaccine (GOTVax) is a door-to-door canvassing program in California that contracted with community-based organizations (CBOs) to hire canvassers with lived experience to register local residents for COVID-19 vaccination. The program identified zip codes in Southern and Central California that had high COVID-19 morbidity, hospitalization, and mortality; were in the lowest quartile of the Healthy Places Index; and had not been reached by previous State-led initiatives. We identified 34 CBOs that served residents in these zip codes and contracted with each to hire up to 25 unemployed and underemployed residents as canvassers. This study evaluates the impact of participation in GOTVax on canvasser confidence in providing COVID-19 and vaccine information and answering questions about the vaccine.

METHODS: Canvassing events were collected using technology that tracked the number of contacts made for each canvasser, including canvasser interaction date, time, and location and canvassing outcomes, including vaccine registration status.

Eligible canvassers were employed for the GOTVax campaign between April 2021 and December 2021 and were surveyed online or by phone in English or Spanish between December 2021 and March 2022. The survey included questions on canvassers their confidence in providing information and answering questions about COVID-19 and the vaccine before and after participating in the GOTVax program.

Multilevel models, clustering for CBO, were used to assess change in confidence answering questions about COVID-19 and confidence in providing vaccine information to the community. Models were adjusted for canvasser demographics, region of California and CBO characteristics.

RESULTS: GOTVax had over 1.1 million interactions. Of the residents not previously vaccinated, 12.6% signed up for a vaccination or booster. Of the 942 canvassers identified as eligible, 496 participated in the survey (52.6% response rate). Mean age was 31 years, 65% were female, 76% Latino, 11% Black, 6.6% Asian, 2.7% American Indian, 1.0% Pacific Islander, and 3.0% multi-race.

Canvassers who reported being fairly or completely confident in providing information about COVID-19 vaccines increased from 46.5% before GOTVax to 89.3% afterward. For answering questions about COVID-19 vaccines, confidence increased from 40.5% to 87.3%. In multivariate models, female and older canvassers were more likely to have increased confidence in providing information and in answering questions (all p<0.01).

CONCLUSIONS: Individuals with lived experience who canvassed for GOTVax were effective in engaging residents of vulnerable communities and had substantial increases in self-reported confidence in providing information and answering questions about COVID-19 vaccines. Trusted CBOs and community residents are an important source of tailored outreach and engagement in high-risk communities during public health emergencies.

HEALTH CARE USE, COVERAGE, AND ACCESS FOR INDIVIDUALS AT HIGH RISK OF UNDIAGNOSED DIABETES AT MEDICARE ELIGIBILITY: EVIDENCE FROM THE CALIFORNIA HEALTH INTERVIEW SURVEY 2013-2018

Felippe O. Marcondes¹; Sungchul Park²; Arturo V. Bustamante³

¹Division of General Internal Medicine, Massachusetts General Hospital, Roxbury , MA; ²Korea University, Seoul, Korea (the Republic of); ³University of California Los Angeles, Los Angeles, CA. (Control ID #3875890)

BACKGROUND: In the US, one in five individuals has undiagnosed diabetes. Undiagnosed diabetes can be defined as meeting laboratory criteria for either type 1 or type 2 diabetes yet lacking awareness of having diabetes or not reporting it. Gaining Medicare eligibility at age 65 may lead to proper diagnosis and management of undiagnosed diabetes. This study aims to examine the impact of Medicare eligibility onset on measures of health care use, coverage, and access among individuals at high risk for undiagnosed diabetes.

METHODS: We used 2013-2018 data from the California Health Interview Survey (CHIS), representative of the non-institutionalized population of California. We identified individuals at high risk for undiagnosed diabetes by a modified version of the American Diabetes Association Diabetes Risk test, a validated tool to

assess diabetes risk based on age, sex, history of gestational diabetes, history of hypertension, physical activity, and weight/height combinations. In our modified score (range 0-9), those with a score greater than or equal to 4 were considered to have a high risk for undiagnosed diabetes. We used a regression discontinuity design to assess the impact of gaining Medicare eligibility on health care use, insurance coverage, and health access. We restricted our final population to adults 56-74 without self-reported diabetes at high risk for diabetes. We excluded individuals 65 years of age. Our primary outcome was having a preventive care visit in the past year. Secondary outcomes were having a doctor’s visit in the past year, health care coverage (insurance, Medicare), and health care access measures. We used linear probability models with clustered standard errors to estimate the adjusted percentage point change in the outcome at the point of gaining Medicare eligibility.

RESULTS: Among 30,357 individuals 56-74 years at high risk for diabetes, becoming Medicare-eligible led to an increase of 7.3 percentage points (pp.) (95 % CI 3.1, 11.4, p=0.002) in having a preventive care visit in the past year. There was a significant increase in having a doctor’s visit (4.7 pp., 95% CI 2.4, 7.1, p=0.001) and a decrease in delaying or not getting needed medical care (-5.3 pp., 95% CI -7.6, -2.9, p<0.001). Non- Hispanic White individuals had a 5.9 percentage point increase in having a preventive visit in the past year (95 CI% 3.6, 8.2, p<0.001). There was no significant increase in preventive visits for Hispanic individuals and individuals with lower education (high school or less).

CONCLUSIONS: Medicare eligibility increased preventive medical visits for individuals at high risk for undiagnosed diabetes. However, the benefit of Medicare eligibility may not be even across the population. Efforts to screen and diagnose Medicare-eligible individuals at high risk for diabetes should be focused on particularly vulnerable groups such as Hispanic and lower-education individuals.

IMPACT OF STATE-LEVEL ABORTION HOSTILITY ON MIFEPRISTONE UPTAKE AMONG AN EMPLOYER-INSURED POPULATION, 2010-2020

Karim Sariahmed¹; Paul J. Christine³; Mallika Sabharwal¹; Jiayi Wang¹; Christine Prifti⁴;Marc LaRochelle²

¹General Internal Medicine, Boston Medical Center, Boston, MA; ²General Internal Medicine, Boston University School of Medicine, Boston, MA; ³Internal Medicine, Boston Medical Center, Boston, MA; ⁴Medicine, Boston Medical Center, Boston, MA. (Control ID #3875851)

BACKGROUND: Mifepristone - in combination with misoprostol - is a safe and effective medication for early abortion. It accounts for an increasing number of abortions in the US. Hundreds of new state-level abortion restrictions were implemented between 2010 and 2020, but their impact on uptake of mifepristone is unknown.

METHODS: We conducted a state-level repeated cross-sectional study to estimate the effect of abortion hostility on mifepristone claims from 2010 to 2020. We used MarketScan commercial insurance claims data for employer-sponsored plans. We created a cohort of reproductive-aged female enrollees aged 15-49 in each year. We created an annual state-level abortion hostility index adapted from the Guttmacher Institute and other sources. The resultant index is a 13 point score based on presence of policies which either reduce or protect access to abortion. The outcome was mifepristone for abortion identified using HCPCs codes S0190 and S0199. We used a linear mixed effects model with mifepristone claims as the outcome, predictors of baseline abortion hostility score and change in hostility score from baseline, and potential cofounders of urbanicity and age group.

RESULTS: In 2010, the median baseline abortion hostility index was 2 (IQR -1 to 3). 21 states had no change in score over the 10-year study period. For the other 29 states the median change in hostility index was 1 (IQR -1 to 2). The median rate of mifepristone claims ranged from 33.5 to 61.6 claims per 100,000 reproductive-aged female enrollees from 2010 to 2020.

A one unit increase in baseline hostility index was associated with a change of -17.0 in the rate of mifepristone claims (95% CI: -24.1 to -9.8). A one unit increase in the change in hostility index over follow- up was associated with change of -2.8 in the rate of mifepristone claims (95% CI: -8.8 to 3.1). After adjusting for urbanicity and age group, baseline hostility index and change in hostility index were associated with changes of -16.1 (95% CI: -23.2 to -9.0) and -7.4 (95% CI: -13.4 to -1.4) in the rate of mifepristone claims, respectively.

CONCLUSIONS: Higher baseline levels of state abortion hostility and greater increases in state abortion hostility from 2010 to 2020 were associated with fewer mifepristone claims per 1000 female MarketScan enrollees age 15-49. The strong association between baseline hostility and mifepristone use indicates important structural determinants of mifepristone access that predated the new restrictions on abortion enacted between 2010 and 2020. Intervention is needed at multiple levels to improve access.

IMPACT OF THE ESRD TREATMENT CHOICES (ETC) MODEL ON KIDNEY TRANSPLANT WAITLISTING IN THE US

Chen Peng¹; Vishnu Potluri^2,3; Yuvaram N. Reddy^2,4; Sri Lekha Tummalapalli^5,6; Amol S. Navathe^1,3; Qian Huang⁷; Genevieve Pham-Kanter⁸; Jingsan Zhu

¹Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²Renal-Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ³Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; ⁴Center for Health Equity Research and Promotion, VA Medical Center Corporal Michael J Crescenz, Philadelphia, PA; ⁵Population Health Sciences, Weill Cornell Medicine, New York, NY; ⁶Division of Nephrology & Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY; ⁷Medical ethics and Health policy, University of Pennsylvania, Philadelphia, PA; ⁸Health Management and Policy, Drexel University, Philadelphia, PA. (Control ID #3876766)

BACKGROUND: The ESRD treatment choices (ETC) model is a new mandatory payment model in 2021 implemented by the Centers for Medicare and Medicaid Services which randomized 30% of hospital referral regions in the US to receive payment adjustments for nephrologists and dialysis facilities. The ETC model incentivizes home dialysis uptake and kidney transplant waitlisting. However, the effects of the ETC model on the kidney transplant waitlist additions have not been evaluated.

METHODS: Data was obtained from the United Network for Organ Sharing (UNOS) national transplant registry between January 1, 2017, and June 30, 2022. We used an interrupted time series design with unadjusted linear regression modelling, with participants not in the ETC model as the control arm and participants in the ETC model as the intervention arm, to evaluate the effects of the ETC model on kidney transplant waitlisting during the pre-COVID period (before February 29, 2020), post-COVID period (March 1, 2020 to December 31, 2020) and post-ETC period (after January 1, 2021).

RESULTS: After COVID-19, there was a significant level change of -110.2 (95% CI -146.5 to -74.0) in the intervention arm and -206.9 (95% CI -279.8 to -134.0) in the control arm. The linear regression model revealed trend changes after COVID-19 and ETC model implementation, showing a slope change of 13.7 (95% CI 1.7 to 25.7; p = 0.0265) after COVID-19 and a slope change of -14.7 (-27.6 to -1.8; p = 0.0259) following the ETC model in the control arm, and a slope change of 6.3 (0.3 to 12.3; p = 0.0395) after COVID-19 and a slope change of -7.8 (-14.2 to -1.4; p = 0.0173) following the ETC model in the intervention arm. The slope change of kidney transplant waitlist additions was not significantly different between the intervention and control arms after ETC model implementation (p-value for interaction = 0.3407).

CONCLUSIONS: Our results suggest that the ETC model did not have a significant effect on kidney transplant waitlisting in the model’s first 18 months. However, COVID-19 led to significant reductions in kidney transplant waitlisting that have not recovered to pre-pandemic levels.

IMPACT OF THE MEDICAID CONTINUOUS COVERAGE POLICY ON CHURNING DURING THE COVID-19 PUBLIC HEALTH EMERGENCY

Daniel B. Nelson¹; Anna Goldman²; Fang Zhang¹; Hao Yu¹

¹Population Medicine, Harvard Medical School, Boston, MA; ²Medicine, Boston Medical Center, Boston, MA. (Control ID #3874905)

BACKGROUND: During the COVID-19 Public Health Emergency (PHE), all US states implemented a continuous coverage policy for Medicaid enrollees in April of 2020. Enrollees were permitted to keep Medicaid coverage regardless of nearly all changes in circumstances, including increases in income, that would normally make them ineligible. This policy was intended to reduce the amount of Medicaid “churning”, defined as an insurance transition or loss, which can lead to fragmentation of care and poorer health outcomes. Our work evaluated whether the continuous coverage requirement was associated with changes in the frequency of Medicaid churning during the PHE.

METHODS: We performed a controlled interrupted time series analysis of churning among Medicaid enrollees before and during the PHE, using Medical Expenditure Panel Survey two-year longitudinal data files. Our sample included children and non-elderly, non-disabled adults who reported Medicaid coverage during one of the first three months of data collection. The treatment cohort were members of the 2019-2020 MEPS panel, while the control cohort were from the 2018-2019 panel. We implemented generalized estimating equation models, controlling for sociodemographic factors (e.g., age, gender, income, chronic disease status, etc.). Our outcomes were monthly rates of 1) transitions from Medicaid to any other insurance and 2) transitions from Medicaid to uninsurance. We also performed Cox regression to evaluate whether the continuous enrollment survival functions differed across cohorts.

RESULTS: Among adults, the PHE was associated with a 1.6 percentage point decrease ([-2.9, -0.2] p = 0.02) in the likelihood of a transition from Medicaid to other insurance and a 1.4 percentage point decrease ([-2.5, -0.3] p = 0.01) in the likelihood of a transition from Medicaid to uninsurance relative to the control group. These represent approximately 1.1 million and 970,000 enrollees avoiding churning, respectively. Children were 0.1 and 0.2 percentage points less likely to transition to other insurance and uninsurance, respectively; neither effect was statistically significant. In survival analysis, adults and children were less likely to experience disenrollment (HR 0.46 [0.31, 0.68] and 0.49 [0.30, 0.80]; p <.0.001 and p = 0.004) during the PHE relative to the control cohort.

CONCLUSIONS: The continuous coverage requirement led to significant reductions in insurance coverage transition and loss among Medicaid enrollees, particularly adults. These findings support future continuous coverage policies as a means of reducing churning. However, disenrollment appears to have continued despite a policy that should have virtually eliminated churning; future work should explore why this occurred despite policy preventing it.

NON-AVOIDABLE EMERGENCY CARE FAILS TO REBOUND AFTER PANDEMIC ONSET FOR SOCIOECONOMICALLY DISADVANTAGED PATIENTS

Richard K. Leuchter¹; John N. Mafi^1,4; Melody Craff²; Sitaram Vangala¹; Chi-Hong Tseng³; Julia C. Arbanas¹; Cheryl Damberg⁴; Catherine Sarkisian^1,5; Katherine L. Kahn¹

¹Division of General Internal Medicine & Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Milliman, MCG Health, Seattle, WA; ³Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁴RAND Corporation, Santa Monica, CA; ⁵VA Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, CA. (Control ID #3855663)

BACKGROUND: Emergency departments (EDs) are important sources of avoidable and non-avoidable care for socioeconomically disadvantaged patients who frequently experience poor access to office-based care. It is unknown whether the Covid-19 pandemic was selectively associated with only reductions in avoidable ED visits, or if it also reduced non-avoidable ED visits which include potentially life-saving care.

METHODS: In this retrospective nationwide cohort study of U.S. ED visits (1/1/2019-2/28/2021) using multi-payer claims from MedInsight’s Emerging Experience Database, we used a difference-in-differences approach to assess how ED visits during the pandemic's first year differed from expected rates had the pandemic not occurred (based on trends in pre-pandemic ED utilization). We compared changes in ED use rates during the pandemic with those during the prior year, stratified by insurance type and avoidable/non- avoidable visits using Medi-Cal avoidable ED visit criteria. We estimated age-sex adjusted Poisson regressions of bi-monthly use counts per 100 patients, offsetting for total patient-months.

RESULTS: We studied 11 million ED visits (avoidable=6%/non-avoidable=94%) across 14.5 million U.S. adults during the pandemic’s first year. Non-avoidable ED visits declined to 71% (95% CI 71-72%) of expected rates in March-April 2020, and rebounded to a peak of 97% (96-97%) in Nov-Dec 2020 before falling again to 85% (84-85%) by the end of Feb 2021. This rebound to near-expected rates only occurred among Medicare fee-for-service (111% [95% CI 110-112%]), Medicare Advantage (91% [90-92%]), and commercially insured (98% [97-99%]) patients, but not among Medicaid (81% [80-81%]) or Medicare/Medicaid dual-eligible (86% [84-87%]) patients. During the Nov-Dec 2020 peak in non-avoidable visits, avoidable ED visits remained low without rebound for all insurance types: Medicare fee-for-service (66% [64-68%]), Medicare Advantage (59% [57-62%]), commercial (46% [45-47%]), Medicaid (46% [45-47%]), Medicare/Medicaid dual-eligible (59% [55-63%]).

CONCLUSIONS: Following early declines in overall ED visits, non-avoidable visits rebounded for Medicare and commercially insured patients but not for Medicaid/dual-eligible patients, who qualify for insurance based on low-income and/or disability. Prior work suggests that Medicaid/dual-eligible patients did not preferentially adopt telehealth in place of ED care. These analyses thus raise concern that socioeconomically disadvantaged patients are disproportionately forgoing potentially life-saving ED care, which may lead to excess morbidity/mortality. These findings are relevant to policymakers and Congress, which have noted increasing ED utilization by Medicaid/dual-eligible patients prior to the pandemic. This study is the first to demonstrate a national post-pandemic reversal in ED utilization trends; policymakers should continue to monitor whether this trend persists and whether it signals poor health care access and/or reductions in potentially wasteful spending.

PARTICIPATION IN GOVERNMENT ASSISTANCE PROGRAMS AND HEALTHCARE UTILIZATION IN A NATIONALLY REPRESENTATIVE SAMPLE OF U.S. ADULTS WITH LIFETIME CRIMINAL LEGAL SYSTEM INVOLVEMENT

Harini Shah¹; Laura Hawks²; Rebekah J. Walker²; Leonard E. Egede²

¹School of Medicine, Medical College of Wisconsin, Wauwatosa, WI; ²General Internal Medicine, Medical College of Wisconsin, Wauwautosa, WI. (Control ID #3874935)

BACKGROUND: A holistic approach to reduce healthcare costs from acute care services ensures basic needs so that patients can prioritize their health needs. Individuals with lifetime criminal legal system involvement (CLSI) are at high risk for acute care utilization. No study has investigated participation in government assistance programs (GAPs) and healthcare utilization in this population. In this study, we describe the population of Americans with lifetime CLSI and GAP enrollment to examine the relationship between GAPs and healthcare utilization in this group.

METHODS: We performed a cross-sectional analysis with negative binomial regression models using nationally representative data from the National Survey of Drug Use and Health (2015-2020), including all U.S. adults with lifetime CLSI (N=37,279). Our independent variable was participation in ≥1 GAPs (supplemental security income, food stamps, welfare payments, welfare services). Our outcomes included acute care (ED visits and nights hospitalized) and outpatient visits, adjusting for relevant socio-demographic and clinical covariates and reporting the relative risk of acute care and outpatient use by participation in GAPs.

RESULTS: In our sample, 11,664 participants (28.5%) participated in ≥1 GAPs. Those in GAPs were more likely to be women, non-Hispanic Black, and have lower socioeconomic status with higher risk for all measured chronic diseases except cancer (heart condition, hypertension, diabetes, kidney disease, COPD, asthma, cirrhosis, hepatitis B/C, and HIV) including past-year substance use and mental illness. In unadjusted models, participation in ≥1 GAPs was associated with increased rates of all forms of healthcare utilization, compared to those with no GAP participation: outpatient visits (IRR 1.3, 95% CI [1.3, 1.4]), ED visits (IRR

2.3, 95% CI [2.2, 2.5]), and inpatient stays (IRR 2.3, 95% CI [1.9, 2.7]). After adjustment for all covariates, the estimates were largely attenuated but remained statistically significant for outpatient visits (IRR 1.1, 95% CI [1.1, 1.2]), ED visits (IRR 1.3, 95% CI [1.2, 1.4]), and marginally, inpatient stays (IRR 1.2, 95% CI [0.9, 1.4]).

CONCLUSIONS: Participation in GAPs is associated with increased acute care services and outpatient care, though largely explained by confounders. In this population with concentrated social and medical risks, more comprehensive governmental assistance combined with targeted interventions may be necessary to alleviate the need for acute care services.

PHYSICIAN PERSPECTIVES ABOUT THE IMPACT OF PRIMARY CARE PAYMENT REFORM ON MEDICAID PATIENTS: A NATIONAL SURVEY

Jubi Y. Lin^1,2; Joseph H. Joo^1,2; Lingmei Zhou^1,2; Joshua M. Liao^1,2

¹Medicine, University of Washington School of Medicine, Seattle, WA; ²Value & Systems Science Lab, Seattle, WA. (Control ID #3874668)

BACKGROUND: There is widespread enthusiasm for improving care for Medicaid populations via accountable care incentives and better incorporation of behavioral, social, and equity-related factors into quality measurement and payment. However, the success of these reforms depends on participation and engagement from practicing physicians, which in turn depends on their beliefs about whether these reforms will improve the quality of care for patients. These beliefs are unknown.

METHODS: 2018 survey of practicing physicians in the US who were members of the American College of Physicians. Physicians were asked whether Medicaid Accountable Care Organizations (ACOs), an accountable care model, can ultimately improve the value of care beyond Managed Care Organizations (MCOs). Respondents were also asked how they believed the quality of care for Medicaid patients would be impacted by (a) providing primary care physicians with financial incentives to reduce overall costs and achieve minimum quality thresholds (defined as accountable care incentives), and quality measurement and payment methods with greater inclusion of (b) behavioral factors, (c) social factors and (c) measures that account for health equity.

RESULTS: Survey response rate was 45% (330/730). Most (94%) respondents reported seeing Medicaid patients (94%) and caring for patients insured through Medicaid MCOs (64%), while 44% reported caring for patients in ACOs.

Overall, 31% of physicians agreed that Medicaid ACOs would yield additional value beyond Medicaid MCOs. This belief was more prevalent among both physicians caring for patients in Medicaid ACOs and physicians caring for patients in Medicaid MCOs.

Over half of respondents reported that the quality of care for Medicaid patients would improve under accountable care incentives (56%) and measurement and payment methods with greater inclusion of behavioral (65%), social (65%), and equity-related factors (60%). Perspectives about the impact of these factors on quality did not vary by physicians’ existing ACO or MCO participation.

CONCLUSIONS: In this sample of US physicians, most believed that the quality of care for Medicaid patients would improve through accountable care incentives and greater incorporation of behavioral, social, and equity-related factors. Most physicians did not agree that Medicaid ACOs would improve the value of care beyond what is possible in Medicaid MCOs. These findings suggest that incorporating accountable care incentives and greater inclusion of behavioral, social, and equity-related factors may be promising strategies that could be integrated into Medicaid MCOs.

POST-DISCHARGE FOLLOW UP AND DISPARITIES IN RISK OF READMISSION BY PAYER

Elizabeth Boggs¹; Sharon Scarboro^1,3; Renuka Tipirneni^4,5; Richard C. Lindrooth^2,6

¹University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²University of Colorado Anschutz Medical Campus, Aurora, CO; ³Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO; ⁴University of Michigan Division of General Medicine, Ann Arbor, MI; ⁵University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI; ⁶Colorado School of Public Health, Department of Health Systems, Administration, and Policy, Aurora, CO. (Control ID #3873109)

BACKGROUND: Ensuring post-discharge follow up is a key target for health policy interventions aimed at reducing the rate of hospital readmissions. Disparities in rates of readmission among patients with private insurance compared to Medicaid are well documented. Post-discharge follow up is associated with reduced risk of readmission among select patient populations, but it is unknown whether timely follow-up reduces disparities in risk of readmission based on insurance status.

METHODS: This is a retrospective cohort study using logistic regression to estimate the association between insurance status (Medicaid vs. commercial), post-discharge follow up, and 30-day readmission for patients with an index admission to an academic medical center in the Mountain West. Patients were included if they were 21-64 years of age and admitted from 4/2017-9/2019 (to exclude disruptions in follow up related to the COVID-19 pandemic) for one of five pre-selected medical diagnoses associated with high rates of readmission across payers. Electronic medical record data was linked to Colorado All Payer Claims Database to ensure capture of subsequent patient encounters outside the academic medical center. Mediation analysis was used to examine if disparities in readmission based on insurance status were mitigated by follow up. We conducted mediation analysis to identify whether the intermediary factor of timely follow up (mediator) could explain the association between insurance status (exposure) and readmission (outcome).

RESULTS: In this cohort, Medicaid beneficiaries had higher rates of post-discharge follow up, but also had more comorbidities putting them at higher risk of readmission. Medicaid beneficiaries had higher rates of readmission compared to those with commercial insurance. Post-discharge follow up was strongly associated with lower risk of readmission regardless of insurance status (p<0.01), though the effectiveness of follow up was greater in patients with Medicaid, reducing the probability of readmission by 19.0% points, compared to those with commercial insurance (-12.8% points). Decomposition analysis demonstrated that 89.6% of the disparity in readmission rates was explained by higher risk in Medicaid beneficiaries. This was partially offset by the increased likelihood of follow up among Medicaid patients, which reduced the disparity in readmission rates based on insurance status by 53.4%.

CONCLUSIONS: Timely post-discharge follow up for select conditions reduced risk of readmission for both privately insured patients and those with Medicaid. Increased post-discharge access to care for patients with Medicaid is associated with a significant reduction in readmission rate disparity in relation to patients with commercial insurance.

PUNITIVE STATE LEGISLATION FOR PERINATAL SUBSTANCE USE AND ITS EFFECT ON OPIOID-RELATED OUTCOMES: DESCRIPTIVE ANALYSIS, 2010-2017

Kristen E. Sparagna

Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #3876078)

BACKGROUND: Over the past 30 years, an increasing number of states have enacted punitive legislation for perinatal substance use. The format, severity and enforcement of such legislation varies greatly. Arguments often cited in favor of punitive legislation are limiting fetal drug exposure and discouraging substance use among pregnant patients. The goal of this study is to analyze different types of punitive legislation and using state-level data on rates of neonatal abstinence syndrome (NAS) and maternal opioid- related diagnoses (MOD) between 2010 and 2017, evaluate the likelihood that such laws actually achieve those ends.

METHODS: Legislation from 2010 to 2017 was analyzed using the Guttmacher Institute’s legislation tracker and state government websites. States with significant legislative changes during this time period were excluded. Of the remaining 42 states, seven groups were formed on the basis of different combinations of the most common legislation. State-level data regarding natality, substance use and substance treatment was obtained from the CDC WONDER and SAMHSA NSDUH databases. All 7 groups underwent one-way ANOVA analysis to compare group characteristics including the prevalence of substance use in women of child-bearing age, the percentage of substance use treatment programs with pregnant/postpartum-targeted services, and the rates of adequate prenatal care by state (PNC). Finally, the groups were compared by the change in rate of both NAS per 1000 hospitalized births and MOD per 1000 hospitalized births from 2010 to 2017.

RESULTS: The groups were formed on the basis of the following legislative combinations, listed in order of severity: (A) Criminal Child Abuse, (B) Civil Commitment, (C) Civil Child Abuse, Mandated Testing and Reporting, (D) Civil Child Abuse and Mandated Reporting, (E) Civil Child Abuse, (F) Mandated Reporting and (G) None. None of the group characteristics were found to be statistically significant including the prevalence of substance use among in women (F_1,6=0.729,p=0.629), the rates of adequate PNC (F_1,6=1.761,p=0.136), or availability of treatment facility with specific pregnant/postpartum services (F_1,6=0.460,p=0.833). Finally, the changes in rates of MOD and NAS between 2010 and 2017 were not statistically significant between groups (F_1,6=0.871,p=0.526; F_1,6=0.327,p=0.918, respectively).

CONCLUSIONS: Upon analyzing these characteristics, the groups were found to be fairly similar in terms of their disease burden, care availability and ability to treat substance use in the pregnant population. Ultimately, even the rates of change in NAS and MOD over this period were not statistically significant between groups—suggesting that compared to more lenient states, states with harsher punitive legislation fared no better in protecting fetuses or mothers from drug exposure.

REMOVAL OF MEDICAID PRIOR AUTHORIZATIONS FOR BUPRENORPHINE DID NOT RESULT IN A SUBSTANTIAL CHANGE IN PRESCRIPTIONS

Paul J. Christine¹; Marc LaRochelle²; Allison Lin³; Jonathon McBride⁵; Renuka Tipirneni⁴

¹Internal Medicine, Boston Medical Center, Boston, MA; ²General Internal Medicine, Boston University School of Medicine, Boston, MA; ³Psychiatry, University of Michigan, Ann Arbor, MI; ⁴Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, MI; ⁵Anesthesiology, University of Michigan Michigan Medicine, Ann Arbor, MI. (Control ID #3874328)

BACKGROUND: Buprenorphine is a highly effective treatment for opioid use disorder (OUD). Despite its effectiveness, buprenorphine uptake has been limited relative to the burden of OUD. Prior authorizations (PAs) for buprenorphine may be a substantial barrier to treatment for Medicaid enrollees, but few studies have evaluated if removing PAs increases treatment.

METHODS: Using state-level, serial cross-sectional data from 2015-2019, we examined if states that removed Medicaid PA requirements for buprenorphine experienced differential change in buprenorphine prescriptions compared to states that maintained PA requirements. Data on Medicaid PA requirements came from the team’s in-depth review of state Medicaid policies. Quarterly buprenorphine prescriptions per 1000 Medicaid enrollees came from Medicaid State Drug Utilization Data. We employed difference-in-differences models to estimate changes in buprenorphine prescriptions comparing states that removed PAs versus states that did not. All models controlled for state and year fixed effects and the following state-level covariates: opioid overdose deaths per 100,000; number of X-waivered buprenorphine providers (log transformed, due to skewed distribution); number of individuals on methadone for OUD per 100,000; percent population with income below poverty; state Medicaid expansion status; proportion of Medicaid enrollees covered by a comprehensive managed care plan; and state prescription drug monitoring policies.

RESULTS: From 2015-2019, 24 states removed Medicaid PAs for at least one formulation of buprenorphine for OUD. Compared to states that removed buprenorphine PAs, states that maintained PAs had lower baseline buprenorphine prescriptions per 1000 Medicaid enrollees (median 7.1 vs 10.0), were less likely to have expanded Medicaid (43.5% vs 64.7% of states), and had fewer Medicaid enrollees in managed care plans (median 47.9% vs 78.7%), though had similar levels of opioid overdoses and X-waivered buprenorphine providers per 100,000 population. In fully adjusted difference-in-differences models, compared to states maintaining buprenorphine PAs, states that removed buprenorphine PAs did not experience a substantial increase in buprenorphine prescriptions (7.5% increase per 1000 enrollees, 95% CI -11.6% to 30.8%).

CONCLUSIONS: In this state-level study of Medicaid PA requirements for buprenorphine, removal of PAs was not associated with a substantial increase in buprenorphine prescriptions. Given the ongoing burden of opioid-related morbidity and overdoses, there is a need for continued multipronged efforts to remove barriers to buprenorphine care.

THE EFFECT OF BASIC INCOME ON HEALTH CARE UTILIZATION: EVIDENCE FROM A RANDOMIZED STUDY OF CASH BENEFITS

Sumit Agarwal¹; Benjamin Cook²; Jeffrey Liebman³

¹Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, MA; ²Cambridge Health Alliance Department of Psychiatry, Cambridge, MA; ³Harvard University John F Kennedy School of Government, Cambridge, MA. (Control ID #3871853)

BACKGROUND: A better understanding of the effect of income on health care utilization could help inform current policy debates around a guaranteed or basic income. A cash benefit could theoretically increase health care utilization by improving access, or it could decrease health care utilization, particularly acute care, by improving health. During the first two years of the COVID-19 pandemic, the City of Chelsea, a city just outside of Boston, Massachusetts, allocated monthly cash benefits over ten months and worth up to $4000 in total via lottery. This lottery provided a unique opportunity to evaluate the casual effects of income on health care utilization using a randomized controlled design.

METHODS: We matched and obtained electronic health record data from the 2129 participants who were randomly selected to receive the cash benefit and 1273 who were not selected. Outcomes included emergency department use, outpatient use, COVID-19 vaccination, and clinical measures such as glycated hemoglobin (a measure of diabetes control), blood pressure, and cholesterol. Leveraging the random assignment via lottery, we calculated the effect of the cash benefit on these outcomes using linear regression. Since participants could qualify for more than one lottery ticket based on certain criteria at enrollment, the model included indicators for number of lottery tickets to account for differential probability of winning the lottery. All outcomes and analyses were prespecified (ClinicalTrial.gov number, NCT05622903).

RESULTS: The cash benefit significantly decreased the probability of having an emergency department visit (12.8% versus 15.6%; adjusted difference, -3.5 percentage points [95% confidence interval, -6.0 to -0.9]) and the number of emergency department visits (203 vs 279 per 1000 population; adjusted difference, -94.1 [95% confidence interval, -158.4 to -29.7]). In the subset of participants for whom vaccination records were available, there was no significant effect of the cash benefit on COVID-19 vaccination rates (79.7% versus 78.4%; adjusted difference, 1.1 percentage points [95% confidence interval, -2.3 to 4.5]).

CONCLUSIONS: This randomized controlled study showed that a monthly cash benefit generated reductions in emergency department utilization. Analysis of the remaining measures will provide further understanding of the cash benefit’s effect on use of outpatient care and clinical measures of health. In assessing the potential impacts of a guaranteed or basic income program, the health benefits should be considered alongside labor market and other outcomes.

THE EFFECT OF CENTRALIZING BREAST CANCER SURGERY ON TRAVEL DISTANCE Nina Bickell¹; Liliana E. Pezzin⁴; Emily L. McGinley³; Purushottam Laud⁵; Nicole Fergestrom⁶; Ann Nattinger²

¹Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, NY; ²Medicine, Medical College of Wisconsin, Milwaukee, WI; ³Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI; ⁴Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI; ⁵Biostatistics, Medical College of Wisconsin, Milwaukee, WI; ⁶Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3873552)

BACKGROUND: Using reimbursement strategies to centralize care to improve patient outcomes is an effective strategy. However, particularly in the case of cancer, its impact on access (and outcomes) is uncertain. We sought to determine the effect of a 2009 New York State (NYS) policy restricting Medicaid reimbursement for breast cancer surgery to hospitals performing >30 breast cancer surgeries annually on travel distance for surgical treatment.

METHODS: From a linked dataset merging the NYS tumor registry with hospital discharge data, we identified 76,057 women with Stage 1-3 first breast tumors diagnosed pre-policy (2004-08) and post-policy (2010-13). Network distance from the population-weighted centroid of the patient’s block group of residence at diagnosis to the surgical treatment facility was calculated using street data for NYS. A multivariable difference-in-differences model was used to estimate the policy effect on the distance traveled by Medicaid insured patients before and after policy implementation relative to the experience of commercially or otherwise insured patients unaffected by the policy change.

RESULTS: Of 76,057 NYS women with breast cancer, 9,371 (12%) had Medicaid. Multivariate estimates indicate that, regardless of the time period, Medicaid beneficiaries traveled shorter distances for treatment than commercially-insured women (-3 miles; 95% CI=-3.6 to -2.5, p<0.001). Regardless of insurance status, the more recently-treated breast cancer patients traveled farther (1.4 miles, 95% CI=1.14 to 1.67, p<0.001) suggesting a temporal trend of longer distances to treatment unrelated to the regionalization policy. Difference-in-differences estimates, however, indicate that the distance increase among Medicaid patients (from 9.7 to 10.4 miles) was not significantly larger than the increase among patients not affected by the policy (from 12.7 to 14.1 miles). Controlling for time trends and policy effects, we find that older women, nonwhite, those with fewer comorbidities, and those with HR-positive/borderline/unknown traveled less than their young, white, healthier, HR-negative counterparts. Finally, women living in rural areas traveled significantly farther than those living in urban (+25 miles, 95% CI=24.6 to 25.8, p<0.0001) and suburban (+12 miles, p<0.001) areas.

CONCLUSIONS: Access to breast cancer surgery was not significantly affected by a NYS policy promoting centralization of breast cancer surgery to higher volume hospitals.

THE EFFECTS OF TELEMEDICINE ON DISPARITIES IN ACCESS TO U.S. AMBULATORY CARE DURING THE COVID-19 PANDEMIC, 2019-2022

John N. Mafi^1,2; Sitaram Vangala¹; Melody Craff³; Julia C. Arbanas¹; Manying Cui¹; Michelle S. Rockwelll⁴; Chi-Hong Tseng¹; Dale Skinner³; Michael Hadfield³; A. Mark Fendrick⁵; Cheryl Damberg²; Catherine Sarkisian¹; Katherine L. Kahn^1,2

¹University of California Los Angeles Division of General Internal Medicine and Health Services Research, Los Angeles, CA; ²RAND Corporation, Santa Monica, CA;³MedInsight, Milliman Inc., Seattle, WA; ⁴Family & Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA; ⁵Internal Medicine, Health Management and Policy, University of Michigan Medical School, Ann Arbor, MI. (Control ID #3870689)

BACKGROUND: Since the pandemic’s onset, the Centers for Medicare & Medicaid Services (CMS) has reimbursed telemedicine visits at the same rate as in-person visits. While these and other flexibilities allowed for rapid increases in telemedicine use during COVID-19 surges, telemedicine’s role in care delivery post- pandemic remains an open question. To inform post-pandemic policy, we examined telemedicine’s effects on access to, and disparities in, U.S. ambulatory care during 2019-2022.

METHODS: We used a difference-in-differences design, comparing visit rate changes between telemedicine users vs non-users using the MedInsight Emerging Experience Database, which contains patients’ claims from all 50 U.S. states. We included patients enrolled in ≥12 months of Medicaid, Medicare-Medicaid (dual eligible), traditional Medicare (TM), Medicare Advantage (MA), and commercial plans in each month between January 1, 2019-April 30, 2022. Dual-eligible patients could enroll in TM or MA. Telemedicine users were those using ≥1 telemedicine visit after the pandemic’s onset regardless of pre-pandemic use. Access to care was defined as telemedicine or in-person visit rates for primary care, specialist, emergency department, and preventive screening (e.g., USPSTF recommended screening colonoscopies) per 100 patients. To study disparities, we estimated age-sex adjusted Poisson regressions of monthly visit counts, offset for total patient-months, and stratified by two different measures of socioeconomic status: (1) Medicaid and dual-eligibility were proxies for socioeconomic disadvantage, per CMS guidance, and (2) CDC’s Social Vulnerability Index (SVI) integrates social determinants of health (e.g., race/ethnicity, income) for patients’ census tract.

RESULTS: We identified 22 million U.S. adults, mean age 53 [±20] years and 54% female during 2019-2022. Compared with non-users, telemedicine users (35% of sample) were more likely to be older, female, and insured by Medicare. Comparing March-April 2020 with March-April 2019, telemedicine users had 85% [95% CI 84.6-85.3%] higher total visit rates than non-users. Two years later, comparing March- April 2022 with March-April 2019, telemedicine users had 32% [31.4-32.0%] higher visit rates than non- users, with variation by insurance: Medicaid: 63% [60.9-64.1%]; dual-eligible: 44% [43.6-44.8%]; TM: 23% [22.5-23.3%]; MA: 18% [17.5-18.5%]; and commercial: 25% [24.8-25.4%]. During that same period (i.e., March-April 2022), telemedicine use was associated with a greater rise in visit rates for those living in the most vulnerable SVI quintile (37% [36.1-37.4%]) compared with the least vulnerable quintile (29% [28.6-29.4%]).

CONCLUSIONS: In this nationwide analysis of major U.S. payers, telemedicine use was associated with enhanced access to, and narrowed disparities in, ambulatory care visits during COVID-19. As telemedicine flexibilities could expire as soon as June 11, 2023, these findings can inform CMS policymaking as it finalizes post-pandemic telemedicine payment rates.

THE IMPACT OF CRITICAL ACCESS HOSPITAL CONVERSION ON RURAL HOSPITAL MEDICARE PATIENT SHARE, CHARGE MARKUPS AND PROFITABILITY

Sebastian Linde¹; Leonard E. Egede²

¹Medicine, Medical College of Wisconsin Department of Medicine, Milwaukee, WI; ²Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3874527)

BACKGROUND: Hospital closures present a significant access problem to patients within rural communities. Since 2005, 183 rural hospitals have been forced to close, and several more remain financially vulnerable. As such, it is important to examine the effect that policy levers may have upon improving the financial stability of rural hospitals. To this end, the objective of our study was to examine whether Critical Access Hospital (CAH) conversion by hospitals was associated with changes in hospital operations (patient mix and charge markup practices) and profitability.

METHODS: We used CMS hospital cost report data for the period of 1996 – 2019 (T=24), across 50 US states, to estimate hospital specific average treatment effects due to CAH conversion. Our approach utilized several recently developed panel data counterfactual models (fixed effects, interactive fixed effects and matrix completion), and model selection was done using cross validation. Goodness of fit of our final model

was further validated using pre-trends tests.

RESULTS: Our analysis sample consisted of an unbalanced panel of 28,338 observations (a total of 1477 unique hospitals across 24 years). This corresponds to 432 treated (with CAH certification), and 1045 control (untreated, without CAH certification), hospitals. CAH conversion was found to be associated with a 2.86% (95%CI: 1.86-3.92, p-value < 0.001) increase within the Medicare patient share; a -54.4% (95%CI: -59.94- -48.90, p-value < 0.001) decrease in charge markups above costs; and a 2.98% (95%CI: 2.34-3.63, p-value < 0.001) increase of hospital profit margins. These results were found to be robust to the use of alternative estimation approaches such as the traditional generalized difference in difference estimator.

CONCLUSIONS: CAH conversion was found to be associated with a shift towards serving a larger share of Medicare patients, reduced charge markups above costs and with increased profitability. As such, CAH certification appears to provide an important option for rural hospitals that may struggle financially under traditional CMS reimbursement models.

THE IMPACT OF THE 2020 MEDICAID EXPANSION IN A COMMUNITY CLINIC SERVING THE MARSHALLESE POPULATION IN A RURAL STATE

Robert Brand¹; Samantha Robinson²; Mohammod Rahman²; Alshaimaa Hazaa³; Sheena CarlLee^1,3; Hanna K. Jensen¹

¹Northwest Regional Campus, University of Arkansas for Medical Sciences College of Medicine, Fayetteville, AR; ²Mathematical Sciences, University of Arkansas Fayetteville, Fayetteville, AR; ³Internal Medicine Northwest Regional Campus, University of Arkansas for Medical Sciences College of Medicine, Fayetteville, AR. (Control ID #3874444)

BACKGROUND: In December of 2020, the US government passed into law a bill allowing states to enroll Compact of Free Association citizens into Medicaid [1], and this expansion included individuals native to the Republic of the Marshall Islands. Our region in the Southern United States hosts the world’s largest population of Marshallese people residing outside of the Marshall Islands. This study analyzes the impact of this expansion on the healthcare of Marshallese patients at a dedicated community clinic serving this unique population.

METHODS: This study was a retrospective review of patients who utilized the community clinic both before (05/2020 to 02/2021) and after (05/2021 to 02/2022) the Medicaid expansion. Patient medical records were examined to compare patient demographics and insurance information, as well as the number of patients, patient visits, referrals, and completed referrals in each time period. Chi-squared tests were performed to compare patients using Medicaid, visits with referrals, and completed referrals from the pre- and post-expansion groups.

RESULTS: In total, 378 patients were included in the study. The mean age was 53 years, 67% were female, and 100% identified as Native Hawaiian/Pacific Islander. The results demonstrated that a significantly higher number of patients with documented insurance utilized Medicaid in the post-expansion group when compared to the pre-expansion group (9.76% vs. 2.89%, p<0.01). The percentage of clinic visits that included referrals also showed a significant increase after Medicaid expansion (52.15% vs. 36.16%, p<0.01). The percentage of referrals that were completed also rose significantly in the post-expansion group when compared to the pre-expansion group (62.17% vs. 18.44%, p<0.01).

CONCLUSIONS: The study’s findings suggest an increase in the use of healthcare services following the expansion of Medicaid. Patients were not only given a higher percentage of referrals per visit, but those referrals were also being completed at a higher rate. In addition, the results indicate that more clinic patients employed Medicaid as their form of insurance following the expansion. These findings may help health policymakers in designing and implementing new strategies to increase healthcare access and utilization in target populations. Future research is needed to determine how these healthcare-related behaviors affect patient health and how expanding healthcare policies may elucidate such results on a larger scale.

TIMING AND SETTING OF ADVANCE CARE PLANNING AMONG MEDICARE DECEDENTS IN 2016-2019

Jessica J. Zhang¹; Hiroshi Gotanda²; Anne Walling^3,4; Haiyong Xu³; Yusuke Tsugawa^3,5

¹Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; ³Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁴Greater Los Angeles Veterans Affairs Healthcare System, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁵Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA. (Control ID #3872799)

BACKGROUND: Advance care planning (ACP) is a process that prepares patients and their surrogate decision-makers to participate with clinicians in making medical decisions that are consistent with their values, goals, and preferences. Evidence is limited on how the timing and setting of ACP visits have changed since ACP billing codes have been introduced. We sought to characterize the utilization of the first ACP claim among Medicare decedents to inform future modifications to ACP billing codes.

METHODS: Using a random 20% sample of Medicare fee-for-service beneficiaries aged 66 years and older who died between 2016 to 2019, we identified the first billed ACP discussion for each beneficiary from 2016 through 2019 and calculated the time (in months) from the date of first ACP discussion to the date of death. We also investigated the setting of ACP discussion using the place-of-service code in the claims data.

RESULTS: Our study included 820,695 beneficiaries (mean [SD] years of age, 83.1 [8.8]; 54.2% female). The proportion of beneficiaries who had at least one ACP discussion increased from 5.1% in 2016 to 21.9% in 2019. We found that approximately three in four of the first billed ACP discussions for Medicare decedents in 2019 were conducted more than one month before death, a major increase compared to the previous years (Figure). There was an increase over time in the proportion of the first billed ACP discussions held in the office or outpatient setting billed along with Medicare Annual Wellness Visit.

CONCLUSIONS: Our results suggest that ACP discussions may be occurring earlier in an individual’s care and more frequently in the office or outpatient setting with Medicare Annual Wellness Visit. Our findings may inform future modifications to ACP billing codes to promote further dissemination of ACP among Medicare beneficiaries.

TRENDS IN CARE PROVIDED DURING PRIMARY CARE PREVENTIVE VISITS FROM

2002-2018

Lisa Rotenstein¹; John N. Mafi²; Bruce E. Landon³

¹Medicine, Brigham and Women's Hospital, Boston, MA; ²Medicine, University of California Los Angeles, Los Angeles, CA; ³Health Care Policy, Harvard Medical School, Boston, MA. (Control ID #3873890)

BACKGROUND: There is substantial debate about the value of annual preventive visits in primary care, and multiple health policy and care delivery trends over the last 15 years have influenced the likelihood of US adults undergoing preventive primary care visits. We sought to characterize temporal trends in the proportion of visits with a primary preventive focus and the differential characteristics of these visits.

METHODS: We analyzed nationally representative serial cross-sectional data on visits to outpatient primary care physicians by patients ages 18 and older from the 2002-2018 National Ambulatory Medical Care Survey. We characterized a visit as having a primary preventive focus if the physician respondent selected the major reason for visit as being “preventive care.” For each visit, we quantified the time spent by the physician and the reasons for visit addressed. We additionally quantified the proportion of visits in which at least one of counseling, preventive labs, or a preventive procedure/imaging took place.

After characterizing the study sample using descriptive statistics, we quantified the proportion of visits with a primary preventive focus in each two-year period and used logistic regression to identify changes over time. We used Wilcoxon rank tests to compare time spent by the physician and reasons for visit addressed in preventive versus non-preventive primary care visits and chi-square tests to compare the proportion of preventive versus non-preventive visits in which a patient received at least one of counseling, preventive labs, or preventive/imaging procedures.

RESULTS: The sample consisted of 133,325 unweighted (5,233,334,785 weighted) US primary care visits. The prevalence of all primary care visits with a primary preventive focus significantly increased from 2002 to 2018 (12.3% of visits in 2002-2003 versus 25.3% in 2016-2018 (p<0.001)), with the greatest rate of increase for individuals with Medicare. This translated into an increase in the US population prevalence of preventive visits from 284.3 visits per 1,000 individuals in 2002-2003 to 424.9 visits per 1,000 individuals in 2016-2018.

Primary care visits with a preventive focus were significantly longer (22.6 minutes for preventive vs. 19.5 minutes for non-preventive visits; p<0.001) and addressed fewer reasons for visit (1.43 in preventive vs. 1.73 in non-preventive visits; p<0.001). At least one of counseling provision, ordering of preventive labs, or ordering of a preventive image/procedure was significantly more likely (54.8% vs. 36.2%; p<0.001) during a preventive versus a non-preventive visit.

CONCLUSIONS: Across the US, the proportion of visits focused on preventive care has more than doubled between 2002-2018, particularly in Medicare. Preventive visits involve more time with the physician and are significantly more likely to involve counseling or ordering of preventive labs and services. Our findings suggest the importance of enhanced insurance coverage in influencing these trends.

WHO’S GETTING A MEDICARE ANNUAL WELLNESS VISIT? CHARACTERIZING MEDICARE ANNUAL WELLNESS VISIT UTILIZATION IN PRIMARY CARE PRACTICES

Sarah Marowski⁴; Aaron Winn¹; Nicole Fergestrom²; Joan Neuner^3,2

¹School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI; ²Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI; ³Medicine, Medical College of Wisconsin, Milwaukee, WI; ⁴Medical College of Wisconsin, Milwaukee, WI. (Control ID #3872437)

BACKGROUND: In an effort to improve preventive care and early intervention for patients 65 and older, Medicare established the Welcome to Medicare Visit (WMV) and follow-up Annual Wellness Visit (AWV) in 2011. Use of these visits have been assessed primarily in traditional Medicare practices early after its adoption, with little known about more recent years or Medicare Advantage enrollees.

METHODS: Medicare Advantage claims data was obtained from a full-state multiple-payer claims database in the Midwest. Primary care physicians and their demographic characteristics were identified using National Plan and Provider Enumeration System data. Physicians with at least 10 outpatient evaluation and management visits yearly for Medicare Advantage patients aged 65 and between 2016-2017 were identified. Physician characteristics (sex, year of receipt of a national provider identification number) and panel information (number of unique patients seen, Elixhauser measures of patient comorbidity, age, and median household income in patients’ census tract) were determined from billing information for those physicians. Logistic regression models were used to examine the association of these variables (in quartiles when noncategorical) with higher use of AWV, defined as being in the highest quartile for % of total nonprocedural office visits that were AWV/WMV.

RESULTS: After excluding 10 physicians with missing data, a total of 1958 physicians performing outpatient nonprocedural visits for Medicare advantage patients were identified. 46% of physicians were female, and 18.7% began practicing in the 10 years prior to the study. Estimated mean physician Medicare advantage patient panel sizes was 39.5 (S.D. 54.1). Physician female sex ((1.35 (1.08-1.68)) was, but younger age was not associated with AWV use. AWVs accounted for a median of less than 1% of nonprocedural office visits in practices in the lowest AWV utilization quartile, but 35% in the highest quartile. Practices with the highest (Adjusted Odds Ratio 3.28, 95% Confidence Interval 2.30- 4.68)) and second from highest (2.66 (1.89-3.76)) panel sizes were more likely to be in the highest quartile of AWV utilization. The association of patient income with AWV was more complex; practices in the highest quartile were no more likely to have high AWV use (0.78 (0.55-1.10)), while those in the second (2.03 (1.51-2.73)) and third from highest (1.61 (1.18-2.20)) were. Panel comorbidity was not associated with AWV utilization.

CONCLUSIONS: AWV utilization varies substantially in primary care physician panels that see Medicare advantage patients in a Midwestern state, with lower use among smaller patient panels and patients with lower income (when compared with middle quartiles of income). This is mostly consistent with prior work in traditional Medicare patients. Future work in this Medicare Advantage population, that often contract with primary care practice using AWV benchmarks, could give insight into the adoption and outcomes of AWVs.

Scientific Abstract - Medical Education and Scholarship

"NOT FEELING THAT YOU HAVE TO DO IT ALONE": TRAINEES' EXPERIENCES OF SYSTEMS-LEVEL HEALTH ADVOCACY THROUGH COMMUNITY-MEDICAL COLLABORATIONS

Natalie Lazarescou, Risha Khetarpal, Erin Goss

Department of Family and Social Medicine, Montefiore Medical Center / Albert Einstein College of Medicine, Bronx, NY. (Control ID #3875691)

BACKGROUND: With the increased integration of the structural determinants of health into medical education, there has been a growing interest in experiential learning of these topics through community- medical collaborations. Advocacy can be an effective strategy to address structural determinants of health. While few training programs offer formal training in physician advocacy, community-medical collaborations may be synergistic, providing valuable advocacy experience to trainees while supporting community-led advocacy efforts. This qualitative study explores how trainees can learn about systems-level health advocacy through community-medical collaborations.

METHODS: Using purposive and snowball sampling, we conducted 21 semi-structured interviews with key members of 10 community-medical collaborations based in Bronx, New York from June to December 2021. Key members included one member of each community-based partner organization, as well as a medical trainee, physician liaison, or both, involved in the collaboration. For some collaborations, the primary focus was community or legislative advocacy. For others, the relationship was focused on addressing social determinants of health for specific populations, but trainee involvement in the community partner’s advocacy efforts were explored. Interviews were recorded and professionally transcribed. Research team members identified emerging themes using the Sort and Sift, Think and Shift method.

RESULTS: Analysis of interviews with physician liaisons and community partners alike revealed several themes showing trainees’ learning of health-related advocacy through their engagement in the community- medical collaborations. These themes could be grouped into knowledge, attitudes, and skills acquired by trainees. Trainees gained unique knowledge of advocacy that allowed them to situate the care of individual patients in a larger context of health systems, local and state policies, and communities with common interests. Participation in collaborations reinforced trainees’ attitudes that physicians should advocate for patients beyond the individual clinical encounter. Participation also supported trainees to overcome attitudinal barriers to systems-level advocacy by emphasizing the value of interprofessional collaboration. Community partners showed trainees the impact of policies on the population they served, the timing of legislative cycles, and the development of relationships with elected officials. Finally, trainees acquired practical and interpersonal advocacy skills at community and legislative levels, for example through media publications or building awareness with other trainees.

CONCLUSIONS: Medical trainees gain distinct opportunities to learn about and participate in systems-level health advocacy through engagement with community-medical collaborations. Medical schools and residency programs could support these collaborations to help trainees address structural determinants of health and further develop advocacy skills.

(POD)CASTING A LARGE NET IN ADDICTION MEDICAL EDUCATION

Hannah Daneshvar²; Katherine P. Mullins¹; Kenneth L. Morford⁶; Shawn Cohen²; Zina Huxley-Reicher³; Irina (Era) Kryzhanovskaya⁴; Natalie Stahl⁵; Carolyn A. Chan³

¹Family Health Centers, NYU Langone Health, Brooklyn, NY; ²Yale University, New Haven, CT; ³Internal Medicine, Yale University School of Medicine, New Haven, CT; ⁴Medicine, University of California San Francisco, San Francisco, CA; ⁵Greater Lawrence Family Health Center, Lawrence, MA; ⁶General Internal Medicine, Yale School of Medicine, New Haven, CT. (Control ID #3876570)

BACKGROUND: In the past year, >20 million Americans were diagnosed with substance use disorders (SUDs), but only 12% received treatment in specialty centers. For this reason, integrating addiction medicine into generalist settings is essential. In order to enlist clinicians across a range of practice environments to respond to this treatment gap, novel, wide-reaching educational strategies are needed.

Podcasts disseminate knowledge quickly to large audiences. The production and consumption of educational podcasts has increased dramatically in the past two decades. Medical podcasts can target learners at all levels, offering flexibility in terms of timing, location, and accessibility.

The Curbsiders Addiction Medicine (TCAM) podcast was developed to educate learners and clinicians to incorporate addiction medicine knowledge into practice. The producers released 11 episodes from July- September 2022, each approximately one hour in length.

METHODS: Ten medical experts volunteered time to produce the podcast and a sponsor provided funding for technical support. The team used a logic model for program evaluation to determine the podcast’s progress toward its intended outcomes. Short-term outcomes included reaching an interprofessional audience with diverse levels of training and providing listeners with practice-changing knowledge on common addiction topics. Continuing medical education (CME) data was reviewed from five episodes to gather a more nuanced understanding of progress toward these goals. Question items reviewed included the responder’s profession, clinical applicability of the content, and potential of the episode to impact clinical practice.

RESULTS: Eleven episodes of TCAM were downloaded 34,785 times between July-October 2022. Ten episodes offered CME for listeners. Of 15,054 downloads of five episodes for which CME data was reviewed, 687 individuals provided survey feedback (4.6%). Most listeners identified as practicing MD/DO’s (50.9-60.1%), followed by NP/PAs (25.20-32.72%), with the remainder identifying as RN/LPN/Pharmacist /Student/Others (9.6-10.8%). Among physician respondents, 81.2 - 99.4% found most or all the information to be clinically applicable. 67.1 - 91.9% of respondents considered changing their practice in response to the episode. 67.1 - 77.1% of respondents stated they would make clinical, research or administrative changes in response to the episode.

CONCLUSIONS: While most TCAM listeners were physicians, program evaluation confirmed that the podcast succeeded in reaching a multidisciplinary audience. Listeners who completed CME reported either considering practice change or changing practice as a result of listening. Limitations include the use of CME data that by definition does not apply to all health professions learners, and low response rate compared to total listeners. Future directions include formal assessments to determine the intermediate and long-term impacts of the TCAM podcast.

MEDICAL STUDENT PERSPECTIVES ON BOARD EXPERIENCES AT WEILL CORNELL COMMUNITY CLINIC

Nicole Palmer¹; Elizabeth K. Benitez¹; Tiffany Merlinsky¹; Ashita S. Batavia^1,2; Pamela Charney¹

¹Medicine, Weill Cornell Medicine, New York, NY; ²Janssen Global Services LLC, Titusville, NJ. (Control ID #3876026)

BACKGROUND: Student-run free clinics (SRFC) provide underserved and uninsured patients with no-cost primary care services. While supporting the mission, medical students are able to develop and hone their clinical skills under the supervision of a board-certified physician. Student Board Members also serve in this SRFC’s administrative and operational roles. This abstract describes the educational value for medical students participating in an academic based SRFC when volunteering on the board as well as within its daily operations.

METHODS: A cross-sectional quality improvement study was performed with current and past board members of an academic based medical student SRFC. An online survey comprised of 13 questions on a 7-point likert scale were administered to all Student Board Members since 2019 to evaluate attitudes toward their experience working with the SRFC and its impact on their career aspirations. Data were analyzed using descriptive statistics.

RESULTS: A total of 72 of 102 student board members responded across four medical school classes (70.6% response rate). A majority indicated that their time with the SRFC was a valuable educational experience (65.0%), and participating in the SRFC positively affected their overall sense of wellbeing during medical school (61.1%). Of the Student Board Members that had also volunteered within the clinic (n = 66), they perceived their experiences to have improved their ability to take a patient history compared to conducting a physical examination (p < 0.05). Among survey responders, 90.3% report they are interested in working with underserved populations after graduation and 84.7% agree that volunteering with the SRFC positively influenced their attitude toward working with these populations. Of those surveyed, 19.4% (n=14) planned to apply to primary care residencies.

CONCLUSIONS: This is the first study to assess perceptions on the medical educational value of volunteering at a SRFC and serving as a Student Board Member. The results indicate that the majority of board members are interested in working with underserved populations after graduation and their experiences with the SRFC had positively affected that attitude. Previous literature and internal retrospective data from our SFRC shows that students who are board members in the SRFC are more likely to pursue careers in primary care than those who are not. It is also notable that student’s overall wellbeing at medical school is positively impacted by their time volunteering with a SRFC. This study indicates that student board experiences with SRFCs are valuable for personal and professional development.

PERSPECTIVES OF MEDICAL STUDENTS AND STANDARDIZED PATIENTS ON GENDER- AFFIRMING-SPECIFIC COMMUNICATION DRILL EXERCISES

Nicholas D. Martin^2,1; Deepa R. Nandiwada¹; Anita Lee¹

¹General Internal Medicine, University of Pennsylvania, Philadelphia, PA; ²Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA. (Control ID #3876270)

BACKGROUND: Transgender and nonbinary (TGNB) patients experience disproportionately negative health outcomes and can avoid seeking medical care based on their past experiences with providers. Acknowledgement of these health disparities has led to an increase in curriculum development centered around gender affirming care. There is a wide range of curricula in the literature with the goal of improving knowledge and communication skins regarding providing gender affirming care. However, trainees cite that even with the acquired communication skills and medical knowledge, there is still room to grow in terms of teaching and setting an example for peers regarding gender affirming practices. With this in mind, we explored a fast, easy-to-implement educational intervention utilizing TGNB standardized patients (SPs) to improve communication skills and promote an environment of educating peers regarding gender affirming practices.

METHODS: The study took place at the Perelman School of Medicine in August 2022. The communication drill was implemented on first-year medical students during their first month of medical school during an already existing OSCE focused on building rapport with patients. Both medical students and SPs identifying as TGNB completed the survey. We utilized an anonymous 10-question survey to assess whether drills implemented prior to an SP encounter would impact the use of gender affirming language with TGNB SPs. We also assessed the SP’s perceived allyship between provider and patient. We defined allyship as whether students spoke up to a colleague or supervisor to correct use of language that was not congruent with the SP’s gender identity. A survey was also administered to students to assess perceived confidence with using gender affirming language. We also assessed how confident students felt in speaking up to correct a colleague or faculty member who misgenders an SP.

RESULTS: In total, 80 students and 9 SP’s completed the survey. We found that after the drill session, 90% of students felt the drill session improved their confidence in using gender affirming language compared to 82% in the control group. Additionally, we found that after the session, 50% of SPs either somewhat agreed or strongly agreed that students felt prepared to meet the needs of TGNB patients compared to 0% in the control group.

CONCLUSIONS: Overall, the results of our study lay a foundation for future interventions with the goal of improving communication skills and empower providers to have a sense of allyship to deliver the best care for TGNB patients. This communication drill was fast and easy to implement and required little additional resources. Some limitations of this study include the small sample size and lack of control for demographic characteristics or prior education in gender affirming language. Future studies should evaluate this intervention on a larger scale.

30 YEARS OF UNANNOUNCED STANDARDIZED PATIENTS: A SYSTEMATIC REVIEW AND CALL FOR STUDY STANDARDIZATION

Zoe Phillips¹; Jeffrey A. Wilhite³; Gabriel Hernan³; Raphaella Lambert³; Lisa Altshuler⁴; Joey Nicholson³; Kathleen Hanley²; Colleen Gillespie⁵; Sondra Zabar²

¹General Internal Medicine, NYU Langone Health, New York, NY; ²Medicine, NYU School of Medicine, New York, NY; ³Medicine, New York University Grossman School of Medicine, New York, NY; ⁴Medicine, NYU Langone Health, New York, NY; ⁵PrMEIR/IIME, NYU Grossman School of Medicine, New York, NY. (Control ID #3873684)

BACKGROUND: Over the past 30 years, unannounced standardized patients (USPs), actors trained to portray a medical case without detection, have increasingly been used for medical training and care quality assurance. This systematic review aims to characterize the breadth of research involving USPs for patient safety and care quality, particularly the extent of standardization in project design and implementation.

METHODS: A medical librarian conducted a comprehensive review of the USP literature from 1991-2021. The search strategy included (unannounced OR incognito OR covert) AND (standardized patient* OR standardized patient* OR patient simulation* or simulated patient*). Following initial coding of trends and breadth of research design and purpose, we developed a tiered system to explore quality of reporting of inter-

rater reliability (i.e., is the USP a reliable clinician evaluator?) and case fidelity (i.e., does the USP portray the case in a standardized way?). For reliability, a “gold standard” practice involves a statistical comparison between USPs and an external rater; a lower tier mentions standardized checklist training. For fidelity, “gold standard” practice includes external case validation during project implementation; a lower tier involves case training prior to implementation.

RESULTS: 128 articles out of 796 identified met inclusion criteria. Articles represented research teams from over 16 countries and included descriptive (67%), RCT/controlled experiment (24%), quasi-experimental (12%), cross-sectional (3%) and longitudinal/time series (1%) designs. The most common purpose of USPs was to capture snapshot-style descriptions of current practices (76%). The quality/safety measures most prevalently assessed were communication skills (22%), global quality of care (20%), assessment (20%), and correct diagnosis (16%).

Reporting of efforts to ensure high rater reliability and case fidelity varied. 35% of the articles made no mention of measuring standardization between USP ratings, 23% attained the lower tier definition of reliability, and 42% achieved the gold standard. Regarding case fidelity, 36% of the articles did not report efforts to ensure standard USP case portrayal, 12% attained the lower tier definition, and 52% were categorized as the gold standard. The most common fidelity method and inter-rater reliability method was audiotape review (37%) and use of multiple raters (33%) respectively. Only 34% reported training time for USPs (mean of 8.3 hours). 53% of articles reported USP detection rates (mean rate = 15%).

CONCLUSIONS: USPs have been used broadly to assess health systems and care workers in many contexts, but training methods and quality assurance in project implementation appear highly variable and unstandardized. As research using USPs advances, our work to characterize standardization in rater reliability and case fidelity can be used to ensure quality of design, implementation, and reporting.

A FOUR-STEP APPROACH FOR SUCCESSFUL RESIDENT-PRINCIPAL INVESTIGATOR DRIVEN RANDOMIZED CONTROLLED TRIALS; THE DRIP MODEL.

Yonatan P. Dollin¹; Brian Elliott²; Kathryn Burtson¹; Matthew Koroscil¹

¹Internal Medicine and Neurology, Wright State University Boonshoft School of Medicine, Dayton, OH; ²Internal Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH. (Control ID #3870716)

BACKGROUND: Randomized controlled trials (RCTs) are considered the highest quality clinical evidence and regularly involve resident physicians, but few of these are led by resident principal investigators (PIs). Resident specific obstacles to implementing RCTs include cost, adapting protocol to existing resources and infrastructure, creating a team, regulatory burden, and publicizing results. We created a model based on a successful resident driven RCT to assist residents in leading future RCTs; this model involves four steps: Design, Regulation, Investigator Team, and Promotion (DRIP).

METHODS: The DRIP model was created based on the resident driven Norepinephrine to Support Mean Arterial Pressure During Rapid Sequence Intubation (NCT05355974).

In this study, the design step involved creating a protocol that controls costs and utilizes existing resources/infrastructure by minimizing tests, choosing an inexpensive and readily available study medication, obtaining funding internally via a research grant, and adapting the protocol to the existing workflow of the ICU staff. The regulation step involved obtaining internal review board (IRB) approval, maintaining records, providing staff training, and publishing the study to a national registry. The team step involved creating a group of volunteer intensivists, resident physicians, medical students, and a research pharmacist to conduct the study protocol, consent patients, collect data, and determine billing. The promotional step involves national conference presentations and publication.

RESULTS: The design step created a pragmatic process that has consented 30 patients to date, with 15 successfully enrolled (15% of goal) after 3 months. The design has also kept present costs to just $160. The research grant provided $2,500, and the study is projected to finish under budget. The regulations step yielded IRB approval in 6 months, successful national registration, and 1 data safety monitoring meeting with no concerns. The investigator team step has yielded 5 intensivists, 8 resident physicians, and 3 medical students.

CONCLUSIONS: The DRIP model includes the steps of design, regulation, investigator team, and promotion make resident-PI driven RCTs possible by simplifying processes and focusing effort.

AKI EDUCATION OF INTERNISTS: A NEEDS ASSESSMENT

Sahil P. Sanghani¹; Patricia Kao^1,3; Michael Heung²

¹Internal Medicine, Washington University in St Louis, St Louis, MO; ²Nephrology, University of Michigan, Ann Arbor, MI; ³Nephrology, Washington University in St Louis, St Louis, MO. (Control ID #3874123)

BACKGROUND: Acute kidney injury (AKI) is one of the most common complications of hospitalized patients. The pooled incidence of AKI in North America is estimated to be 22.3%, and the trend appears to be increasing. AKI is associated with increased hospitalization costs of $1795 per admission, with AKI requiring renal replacement therapy costing greater than $42000 per admission. Non-nephrologists, primarily general internists, are often responsible for managing AKI. Our goal was to characterize the current state of AKI education at major internal medicine clinical meetings, specifically focusing on SGIM for the purposes of this study.

METHODS: This is a retrospective review of session titles, session agendas and accepted abstracts at SGIM Annual Meetings between 2018-2022. Any abstract, session title, or session description containing the keywords “kidney,” “renal,” or “nephrology” was manually reviewed by the authors for relevance to: A) prevention of AKI, B) treatment of AKI, or C) post-AKI care. Sessions or abstracts related to chronic kidney disease were excluded. Descriptive analysis was performed.

RESULTS: Among the 3230 abstracts presented at SGIM Annual Meetings between 2018-2022, 138/3230 (4.3%) contained one or more keywords. Of the keyword positive abstracts, 25/138 (18%) were related to AKI, representing <1% of the total abstracts (See Figure). From the pool of AKI-related abstracts, 21/25 (84%) focused on prevention of AKI, while 4/25 abstracts (16%) addressed post-AKI care. Among the 1022 educational sessions delivered between 2018-2022, only 2 session descriptions contained keywords; neither were directly related to prevention, treatment, or management of AKI.

CONCLUSIONS: Despite the clinical importance of AKI and the fact that AKI is often managed by non-nephrologists, we identified no SGIM Annual Meeting sessions dedicated to AKI education over a 5-year period. Similarly, less than 1% of accepted abstracts over the last 5 years were related to AKI, with a nominal decline in number since 2019. No AKI-focused abstracts were published in 2018. These findings underscore the need for nephrologists to engage with the internal medicine community towards a common goal of improving AKI awareness and education.

AN EXPOSITORY ECHO: THE EFFECT OF RESIDENT-LED MORNING REPORT ON MEDICAL MULTIPLE-CHOICE QUESTION PERFORMANCE

Joseph Glendening¹; Brian Elliott¹; Kathryn Burtson²

¹Internal Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH; ²Internal Medicine, Wright State University, Dayton, OH. (Control ID #3877245)

BACKGROUND: Morning report (MR) is a widely utilized academic conference in Internal Medicine (IM) residency programs. Structures vary, but MR is often a case-based format designed to teach core IM topics. Our institution utilizes a resident-led didactic presentation on an assigned topic aligning with the American Board of Internal Medicine (ABIM) certification exam blueprint, which acts as a primer for a case-based learning session in the afternoon. Residents began including medical multiple-choice questions (MCQs) to re- enforce the concepts discussed. The purpose of our study was to use these MCQs to assess the effectiveness of the resident-led MRs and the retention of key concepts with spaced repetition of the questions in the context of our unique conference structure.

METHODS: We conducted a prospective before-after cohort study assessing medical knowledge before and after resident-led MRs. Residents that attended MR were assessed with one MCQ (related to the morning report topic) immediately before (pre-MR) and immediately after the MR (post-MR). Residents were then assessed 3-6 weeks after the last MR (spaced-MR) of the study with a compilation of all the MCQs. The MCQs were delivered via a digital survey with a unique identifier for each individual. MCQs were obtained from ABIM preparation materials. Residents were assessed throughout 8 MRs which spanned about 3 weeks. Incidence of correct responses were compared pre-MR to post-MR to assess knowledge acquisition and post- MR to spaced-MR to assess knowledge retention.

RESULTS: Pre-MR and post-MR each received 155 responses, and spaced-MR received 104 responses. Pre- MR responses were 57% correct which increased to 74% post-MR (p < 0.01). Spaced-MR responses were 75% correct and similar to post-MR (p = 0.88) but significantly higher than pre-MR (p < 0.01). Of the 155 pre-MR responses, 41 changed post-MR. Of these, 73% changed from incorrect to correct, while 4% changed from correct to incorrect and 7% from incorrect to incorrect.

CONCLUSIONS: Resident-led MR successfully improved residents’ medical knowledge as assessed by MCQs. Residents sustained this knowledge several weeks after the initial MR. These findings suggest resident-led MR is an effective tool that can be used to prepare IM residents for the ABIM certification exam.

A NOVEL HUMAN TRAFFICKING CURRICULUM

Leah M. Azab²; susan levine¹

¹Medicine, University of Connecticut, West Hartford, CT; ²School of Medicine, UConn Health, Farmington, CT. (Control ID #3874831)

BACKGROUND: Human trafficking (HT) is a public health crisis, with an estimated 57,000 to 403,000 individuals currently being trafficked in the US. Most trafficked victims access health care during exploitation. Despite providers being positioned to identify victims, few studies have been done to assess student or resident perceptions or knowledge of HT. Research shows more practicing physicians than residents or students agreed that knowledge about HT was important to their practice, correctly estimated the prevalence of trafficked youth in the US or knew how to appropriately respond to a trafficked victim. The current study seeks to explore avenues to incorporate HT education into medical student and resident curricula.

METHODS: A pilot group of UConn medical and dental students (n=6) elected to take a 5-day, 15 hour interactive course on HT. This curriculum was adapted to a 3-hour session for the UConn Internal Medicine Residency Program's second (n=26) and third (n=22) year residents. Prior to and after each course, medical/dental students and residents were surveyed on their perceived knowledge of HT using a modification of a previously published instrument, as well as given a knowledge-based multiple choice question test. Additional long-term retention data (2.5 months out) was obtained from the student group.

RESULTS: Prior to the course, most students (83%) ranked themselves as having little knowledge of identifying a trafficked individual. Afterward, perceptions improved, and 50% of students felt very knowledgeable.

A paired T-test revealed a statistically significant difference between overall pre-test and post-test knowledge scores for students (P <.05), as well as residents (P<.05). Retention tests scores for students were also significantly higher than pre-test scores (P<.05).

Prior to the course, 58% of residents felt they had little knowledge identifying trafficked individuals; and in fact most believed victims rarely seek healthcare. Afterward, 56% ranked themselves as somewhat knowledgeable.

Questions answered by residents were categorized in four areas (1) general HT knowledge (2) risk factor identification (3) barriers to care (4) interview techniques. Pre- and post-general knowledge score averages were 57% and 68%, respectively (P<.05). Identification of risk factor scores were 62% and 76%, respectively (P<.05). Barriers to care scores were 57% and 68%, respectively (P<.05). Interview techniques scores were 53% and 52%, respectively (P=0.8).

CONCLUSIONS: Our measures of HT perception and knowledge identify a curricular need for education on HT and serve to inform how we expose medical students and residents to this important topic. This pilot course will be offered to additional UConn students as well as additional residents within the UConn Internal Medicine Residency Program. With future exposure of trainees to this subject area, we hope to improve health outcomes for victims of human trafficking.

APPLES AND ORANGES: DIFFERENCES IN STUDENT EXPERIENCES ACROSS COMMUNITY CLINIC SITES IN A LONGITUDINAL PRIMARY CARE CLERKSHIP

Brandon S. Altillo²; Aliza Norwood²; Kirsti Alvarez-Thomas¹; Nicholas Phelps³

¹Population Health, The University of Texas at Austin Dell Medical School, Austin, TX; ²Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; ³Medical Education, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #3874891)

BACKGROUND: In contrast with traditional clerkships, the Primary Care Clerkship at Dell Medical School is a longitudinal course that pairs students with a preceptor for a 2-year intermittent experience to foster patient continuity, which is at the core of primary care careers. However, students' experiences of primary care and continuity may vary by site. The purpose of this study was to quantify the continuity that students experience in this novel structure and to explore differences in experience between sites.

METHODS: We analyzed students’ patient logs from Sept. 2021 to June 2022. We used descriptive statistics to quantify encounter characteristics, including the number of repeat patient encounters. We divided students into 3 groups by site type: federally qualified health centers (FQHCs), private clinics, or Veterans' Administration (VA). We used single-factor analysis of variance (ANOVA) to assess differences in characteristics of students' experiences across site types, including continuity, social determinants of health (SDoH), patient age, insurance status, and students' level of participation.

RESULTS: Fifty-three students were included: 20 in FQHCs, 3 at VA, and 30 in private clinics. Students had a mean of 70.0 encounters, with significant differences between groups (FQHC 60.0, private 78.9, VA 47.7, p=0.01). There was a mean of 4.9 repeat encounters per student, with no significant between-group differences. Students logged a mean of 256 total conditions with no significant between-group differences, but there were differences in the number of conditions logged per patient (mean 4.0; FQHC 5.5, private 2.6, VA 7.3, p=0.001). VA students were less likely to see patients <40 years of age (FQHC 29.7% of encounters, private 37.1%, VA 8.5%, p=0.01) and had a higher proportion of patients aged ≥65 (FQHC 17.4%, private 26.0%, VA 56.9%, p<0.001). Differences in insurance status were as expected based on site (uninsured: FQHC 72.8% of encounters, private 5.1%, VA 0%, p<0.001; privately insured: FQHC 6.9%, private 67.5%, VA 0%, p<0.001). All groups reported that encounters addressed SDoH with high frequency (FQHC 69.6% of encounters, private 54.7%, VA 89.1%, p=0.04), but there were differences in which SDoH were most common in each group. FQHC students were more likely to achieve full participation (independent history, exam, and decision-making prior to presenting to attending) (FQHC 88.2% of encounters, private 57.2%, VA 62.3%, p=0.002) and to have encounters using an interpreter (FQHC 8.2, private 1.4, VA 0, p<0.001).

CONCLUSIONS: There are significant differences in the experiences of students at their clinic sites, which may lead to disparities in the education received and the likelihood of pursuing a primary care career. Ways to mitigate these differences may include educational initiatives that bridge the gaps between clinic experiences or exposing students to multiple clinics. More work is needed to promote continuity to realize the intended benefits of the longitudinal format.

A QUALITATIVE ANALYSIS OF THE DEVELOPMENT OF A HEALTH EQUITY CURRICULUM IN GRADUATE MEDICAL EDUCATION USING PUBLIC HEALTH CRITICAL RACE PRAXIS Iman Hassan¹; Ekua Ansah-Samuels²; Robert M. Rock³; Jaileessa Casimir⁴; Taussia Boadi⁵; Oladimeji Oki²; Nimaako Brown⁶; Cristina M. Gonzalez⁷

¹Internal Medicine, Montefiore Health System, Bronx, NY; ²Family and Social Medicine, Montefiore Medical Center, Bronx, NY; ³Medicine , Yale, Bronx, NY; ⁴The City University of New York Department of Cell Biology and Anatomy, New York, NY; ⁵University of Pennsylvania, Philadelphia, PA; ⁶Nimaako Brown Consulting, New York, NY; ⁷New York University Grossman School of Medicine, New York, NY. (Control ID #3876278)

BACKGROUND: As graduate medical education (GME) incorporates health equity-focused curricula, educational best practices are needed to avoid reinforcing racism and other systems of oppression. Public Health Critical Race Praxis (PHCRP) seeks to ensure equity and accountability and can serve to inform curricular design by actively centering marginalized perspectives in the process. To evaluate the utility of PHCRP for curriculum development, we conducted a qualitative investigation exploring perspectives of educators involved in PHCRP-informed restructuring a residency program’s month-long course in social medicine, Social Medicine Immersion Month (SMIM).

METHODS: As part of curriculum design, a core group of resident physicians and junior faculty who identified as underrepresented in medicine (URM) partnered with community leaders to develop SMIM. In contrast, White senior faculty and leadership had limited input into the curriculum design process. We interviewed core group course leaders about their experiences designing curriculum using PHCRP and centering marginalized voices. Individual interviews were 40–60-minutes, semi-structured, and led by a trained, independent facilitator. They were transcribed verbatim and coded by up to four independent coders using an iteratively developed code book. Codes were generated inductively from transcripts and extracted deductively using PHCRP principles. All coding was fully adjudicated. Content and thematic analysis was used to generate themes from codes. Themes were finalized through a process of investigator triangulation and member checking.

RESULTS: Nine of the twelve members of the core curriculum design group participated in interviews. Preliminary themes included: 1) Academic medicine actively perpetuates racism and oppression and promotes White saviorism. 2) PHCRP-informed curriculum development can fundamentally change the structure and culture of academic medicine for the better. 3) PHCRP empowered URM course designers’ freedom to bring their authentic selves to discussions. 4) Course design was disproportionately taxing for URM residents. PHCRP requires resources and dedicated time to support the efforts of core members and timely financial compensation to support community partners. Participants highlighted the importance of acknowledging the discomfort inherent to dismantling racial power structures in academic medicine while committing, especially on the part of White faculty, to engage completely with the process.

CONCLUSIONS: Our participants’ insights suggest PHCRP is a useful tool in amplifying the voices of URM trainees and faculty members in GME health equity curriculum design. This study informs how PHCRP can be a novel application used within GME to facilitate the leadership of URM trainees, faculty, and community partners in collective efforts to advance health equity curriculum design.

ASSESSING OPPORTUNITIES FOR FEEDBACK DURING NIGHT FLOAT ROTATIONS FOR INTERNAL MEDICINE RESIDENTS

Evan Merryman¹; Deepa R. Nandiwada²

¹Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; ²General Internal Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #3874800)

BACKGROUND: Duty hour reform has increased the time residents spend on night rotations as opposed to extended shift rotations. This now represents about 10% of total time in our residency program. This schedule increases resident autonomy overnight, but limits interaction with supervising physicians, depending on the availability of an overnight attending. At our institution we shifted away from night float presenting during rounds due to time and resident feedback. Our current system entails day residents accepting night float admissions during morning sign out without the attending present. The night float team receives no formal evaluations. This structure creates a unique opportunity for feedback for night residents that is currently underutilized given lack of face-to-face interaction with attendings. We conducted surveys of both residents and attendings to determine the current state of feedback on night rotations and to understand their opinions about potential improvements to this feedback structure.

METHODS: Surveys were conducted of both residents and attendings in the Department of Medicine at the Hospital of the University of Pennsylvania. Surveys contained questions about experiences with feedback for night float residents, opinions on this feedback, and their willingness to participate in a formal process to provide this feedback. All current residents were invited to complete the survey. The 50 attendings who had evaluated the most residents in the past year were invited to complete the survey.

RESULTS: A total of 78 residents completed the survey (57.4% response rate). Only 8.7% of respondents reported receiving feedback from an attending during their last night rotation. 70% of residents stated that they would like to receive feedback based on their work during night rotations. When asked about how they would like to receive feedback if a formal process were to be established, 70% were amenable to a process via email, 51% via an in-person process at sign out, 51% via text message, and 47% via phone call.

A total of 36 attendings completed the survey (72% response rate). 44% of respondents report giving feedback to a night resident in the previous year, however only 6% reported doing this about half of the time or more than half of the time they are on service. 94% of attendings were interested in providing feedback to night residents. When asked about how they would like to provide feedback if a formal process were to be established, 67% were amenable to an in-person process at sign out, 58% via phone call, 56% via email, and 42% via text message.

CONCLUSIONS: There is little feedback currently being delivered during night rotations, despite the majority of residents wanting this feedback and the majority of attendings being interested in providing it. There is a dissonance between residents’ wants for asynchronous feedback and attendings’ desire for in person feedback. We next hope to implement a formal process for providing this feedback based on the results of this survey.

ASSESSING RESIDENT PROFESSIONALISM USING OSCES: CONTEXT, CONSISTENCY AND COMMUNICATION SKILLS

Colleen Gillespie¹; Christine Beltran¹; Matthew D. Kijowski¹; Margaret Horlick²; Barbara Porter²; Lisa Altshuler²; Kathleen Hanley¹; Sondra R. Zabar¹

¹PrMEIR/IIME, NYU Grossman School of Medicine, New York, NY; ²Medicine, NYU Langone Health, New York, NY. (Control ID #3877251)

BACKGROUND: Despite recognition of the importance of professionalism, we still struggle to accurately and meaningfully assess it. Since professionalism is the ability to behave appropriately, especially in contexts of high emotion, stress, or conflict, OSCEs provide an opportunity to simulate those challenges while supporting accurate assessment. We report on a decade of assessing professional behaviors within OSCE cases in our medicine residency, describing the operationalization of professionalism, consistency of assessments, and relationships between professionalism behaviors and other clinical skills.

METHODS: Three cases were designed to capture professionalism: advanced directive based on worsening health/hospital admission (Adv Dir), communicating bad news to a family member about a complication (Complication), and a medical error where a diagnosis had not been disclosed (Error). Cases varied in terms of intensity--complication and error cases evoked the strongest emotions. We assessed professionalism using a behaviorally anchored scale of not done, partly and well done in the following domains (mapped to the ACGME professionalism competency): accountability (fully disclosed, took responsibility, apologized); responsiveness to patient needs (elicits patient emotions, avoids assigning blame,controls emotions); and respect (treats patient respectfully, addresses concerns, collaborates). We report on performance in these domains and cases, assess internal consistency (Cronbach’s Alpha), explore consistency of performance, and examine relationships between professionalism and core skills of communication, patient centeredness, and patient activation.

RESULTS: The following professionalism cases were fielded from 2010-2020: Adv Dir (110 residents); Complication (97 residents); and Error (124 residents). Performance was best in the Adv Dir case but fell off for the more stressful Complication (a third of residents did not prepare the family member for bad news/give them time to emotionally respond) and Error cases (half did not personally apologize or take responsibility). Items were internally consistent (Cronbach's alpha) (Adv Dir=.87; Complication=.82; Error=.88) for professionalism but varied at domain levels. Among residents who completed multiple cases (n=109), performance was moderately correlated [overall professionalism correlated .54 (p<.001) and domains correlated .24-.39 (p<.05)]. Finally, residents’ overall professionalism ratings were strongly correlated with their communication skills (r = .79-.87, p<.001) and moderately correlated with patient centeredness (r=.55-.75) and patient activating skills (.49-.69).

CONCLUSIONS: OSCEs provide an important tool for capturing the range of responses to professionalism challenges. While such assessments may not fully reflect professionalism in the real world, they differentiate among residents, are sensitive to case difficulty, have sufficient internal consistency, and therefore can provide feedback on what it means to be professional.

ASSESSMENT OF SHARED DECISION MAKING IN DEPRESSION MANAGEMENT USING UNANNOUNCED STANDARDIZED PATIENTS

Elizabeth L. Wargo¹; Isabella Dayani¹; Lillianne Liu¹; Jeffrey A. Wilhite²; Khemraj Hardowar³; Kathleen Hanley¹; Colleen Gillespie⁴; Sondra R. Zabar¹; Lisa Altshuler⁵

¹General Internal Medicine, New York University Grossman School of Medicine, New York, NY; ²Medicine, New York University Grossman School of Medicine, New York, NY; ³PRMEIR, New York University, South Ozone Park, NY; ⁴PrMEIR/IIME, NYU Grossman School of Medicine, New York, NY; ⁵Medicine, NYU Langone Health, New York, NY. (Control ID #3873672)

BACKGROUND: Shared decision making (SDM) has been linked with stronger adherence to care and higher patient satisfaction, yet implementation of SDM is low. SDM is particularly important in treatment of depression, where stigma and hesitancy about sharing symptoms can impede treatment. This work describes SDM in resident physicians’ response to Unannounced Standardized Patients (USPs), who were trained to present a fatigue case with underlying depression.

METHODS: As part of educational efforts, Unannounced Standardized Patients (USPs - “secret shoppers”), are sent to Residents Primary Care Clinics at two Mid-Atlantic safety-net hospitals. Communication is assessed by the USP on a behaviorally-anchored checklist. Learner consent is via an IRB-approved educational registry. In this case, USPs portrayed a 26-year-old male with fatigue and problems sleeping, a family history of depression, a positive depression screen, and open to medication and/or therapy if offered.

Audio tapes of 39 visits were reviewed by trained raters using Elwyn’s Observer OPTION-5 scale, assessing 1) identification of treatment options, 2) supporting partnership, 3) sharing information, 4) eliciting patient preference and 5) integrating preferences into treatment plans. Items are scored from 0 (no SDM) to 4 (exemplary SDM). Possible total scores range from 0-20. Each tape was coded by 2 raters who met to resolve discrepancies.

RESULTS: Mean OPTION score was 5.9 (S.D. 2.9, range 1-12). On each of the 5 individual items (range 0-4), the median score was 1 (minimal SDM), with 43%-56% of residents scoring 1 (minimal SDM) on items. Higher performance was seen on two items, with moderate/skilled effort at sharing information (31% and 10% respectively) and identifying treatment options (36% and 8%). The total OPTION score was significantly correlated with communication skills rated by the USP (r=.40, p=.01).

CONCLUSIONS: Medical residents exhibited little SDM when addressing a USP exhibiting symptoms of depression, with some steps in SDM more likely to be demonstrated than others. SDM was significantly related to USP-rated provider communication skills. Learners demonstrate the ability to inform patients but need more in-depth training in SDM, particularly in identifying patient preferences and partnering with them about depression care. Further educational efforts are needed to address this gap in patient-centered care.

BETTER TOGETHER: A NOVEL ONLINE PHYSICIAN GROUP-COACHING PROGRAM TO REDUCE BURNOUT IN TRAINEES: A LONGITUDINAL ANALYSIS

Tyra Fainstad¹; Adnan Syed¹; Vall Vinaithirthan¹; Pari Shah²; Christine D. Jones³; Kerri Thurmon¹; Adrienne Mann¹

¹Internal Medicine, University of Colorado, Denver, CO; ²Graduate School of Social Work, University of Denver, Denver, CO; ³Medicine, University of Colorado Denver School of Medicine, Aurora, CO. (Control ID #3862695)

BACKGROUND: Burnout disproportionately affects female physicians and contributes to negative long term outcomes. While physicians typically score higher in grit, resilience, and other adaptive qualities, they often report more self-condemnation and less self-compassion compared with other fields. Low self- compassion contributes to burnout and likely stems from perfectionism, negativity biases, and frequent comparison. Many burnout interventions have no or marginal effect on burnout. Little is known about their long-term impact. We piloted Better Together Physician Coaching (BT), a group coaching program focusing on self-compassion for female-identifying residents at the University of Colorado in an RCT which reduced burnout and imposter syndrome and increased self-compassion. Here, we evaluate long-term effects of BT.

METHODS: The BT program guides participants through the application of a metacognitive tool while grounding them in a psychologically safe space of non-judgement and self-compassion. We performed a secondary analysis of survey data from the pilot program implementation between January 2021 and June 2022. Two-sample t-tests between baseline and post-6 months and baseline and post-12 month results were completed for outcome measures.

RESULTS: Of 101 participants, 95 completed a baseline survey (94%), 66 completed a 6-month survey (69%) and 36 completed a 12-month survey (38%). No statistically significant differences were observed when comparing baseline to 6 months or baseline to 12 months scores in emotional exhaustion, depersonalization, or personal accomplishment. Compared to baseline self-compassion [mean = 33.2, SD= 6.74], participant scores significantly improved after 6 months (mean = 38.2 SD = 7.79, p < .001) which remained still significantly improved after 12 months (mean = 36.7, SD = 7.59, p = .020). Impostor syndrome scores improved significantly from baseline to 6 months (mean = 5.41 SD = 2.00 versus mean = 4.38 SD=2.37 respectively, p = .005) but were not sustained after 12 months (mean = 4.66 SD = 2.18, p = .081). Moral injury (mean = 41.2, SD = 10.7), scores improved after 6 months (M = 37.0, SD = 11.0, p = .018) but did not remain at 12 months (M = 38.1, SD = 11.1, p = .166).

CONCLUSIONS: This study showed significant, sustained improvement in self-compassion for BT participants. In the pilot RCT, BT mitigated the otherwise worsening burnout in residents over time. A lack of self-compassion has been linked to worsening burnout, sleep-related impairment, and a habit of deferring self-care. Furthermore, medical training often responds to mistakes with approaches which frame self- compassion as unnecessary or counterproductive. Reframing this belief about self-compassion and then teaching hands-on tools to create and protect self-compassion is foundational to the BT program, perhaps attributing to its sustained longitudinal self-compassion improvement in participating residents.

BREAKING THE CYCLE: A QUALITATIVE STUDY OF FACTORS THAT MITIGATE IMPOSTOR PHENOMENON AMONG INTERNAL MEDICINE RESIDENTS

Susan C. Mirabal¹; Alaina Chodoff²; Scott Wright¹; Rachel Levine¹

¹General Internal Medicine, Johns Hopkins University, Baltimore, MD; ²General Internal Medicine, Greater Baltimore Medical Center, Baltimore, MD. (Control ID #3834985)

BACKGROUND: Impostor phenomenon (IP) describes feelings of self-doubt often experienced by individuals who struggle to internalize success despite evidence to the contrary. Instead, those with IP attribute their success to external factors - including luck. The IP cycle¹ begins when an individual encounters an achievement-related task, experiences self-doubt and fear of being found out as an impostor and responds with maladaptive thinking and behaviors. Repeated IP cycles may lead to burnout, anxiety, and depression. Prior research describes characteristics of those experiencing IP, yet few studies have identified factors that mitigate the IP cycle among trainees.

METHODS: One-on-one semi-structured interviews about IP with 28 Internal Medicine residents were conducted from May-June 2020. Investigators independently coded transcripts to identify themes related to intrapersonal and environmental factors mitigating IP experiences, using the IP cycle as a conceptual model.

RESULTS: Most informants were female (75%). Mean age was 30 years. Post-graduate year distribution was: 36% PGY-3, 43% PGY-2, and 21% PGY-1. Intrapersonal factors that diminish feelings of IP: 1) Recognizing IP feelings are common; 2) Acknowledging achievements; 3) Gaining perspective; 4) Embracing uncertainty; 5) Reframing attribution beliefs.This trainee describes how increased experience helped to acknowledge her achievements:"It's useful to recognize these thought processes as detrimental and try to force yourself to reframe it … If thinking 'Oh I got lucky', change that [to] 'No, I have done a lot of these[procedures], I'm getting better at them'." –PGY-1, Female. When reframing attribution beliefs, a trainee shared that:"I come around to the idea that [IP] in some ways is inevitable. But it's how we process it that makes it a learning opportunity or a pathological thing." –PGY-1, Male.

Environmental factors can also ease feelings of IP: 1) Establishing formal opportunities to share IP experiences; 2) Coaching through learning gaps; 3) Debriefing culture; 4) Receiving genuine feedback; 5) Looking to role models for dealing with self-doubt.

This quote describes opportunities to share IP experiences:"I appreciate having the community of my class where you can feel open about this… 'Let's talk through it and get you through this spot where you're not feeling like yourself'." –PGY-3, Female. A trainee recalls that when a role model shared feeling of self-doubt, it helped to decrease his IP concerns:"The educators I admired were comfortable saying, 'I'm not sure about that.'…It's a good thing to show your learners that you don't know something. It helps them deal with their feelings of 'you need to know everything'.” –PGY-2, Male.

CONCLUSIONS: Intrapersonal and environmental factors can mitigate the IP cycle. Understanding these factors is crucial in supporting trainees experiencing IP and targeting institutional changes to diminish imposterism.

Reference: ¹Clance PR. The Impostor Phenomenon. Atlanta, GA: Peachtree Press; 1985.

CLINICAL REASONING CURRICULA IN UNDERGRADUATE MEDICAL EDUCATION: BRIDGING THE GAP BETWEEN RECOMMENDATIONS AND REALITY

Katherine Gavinski¹; Casey N. McQuade¹; Megan E. Hamm¹; Scott D. Rothenberger¹; Julia Wasilewski²; Sarah A. Tilstra¹; Deborah DiNardo¹

¹Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ²University of Pittsburgh, Pittsburgh, PA. (Control ID #3875439)

BACKGROUND: Multiple national organizations, including the Liaison Committee on Medical Education and the National Academies of Sciences have identified clinical reasoning training as an essential component of medical education. Similarly, expert opinion supports the inclusion of clinical reasoning education early and throughout undergraduate medical education (UME). However, the extent to which this type of education has been implemented within UME programs across the United States is unknown. This study aims to describe the current state of UME clinical reasoning curricula, barriers and facilitators to curricula implementation and assessment, and future directions of clinical reasoning education across the U.S.

METHODS: Experts in clinical reasoning education were identified through literature review of clinical reasoning publications within the last five years, public recruitment via the Society to Improve Diagnosis in Medicine, local expert recommendation, and a peer referral process. These experts were invited to complete a survey to describe their local clinical reasoning curricula and how the curricula and students are evaluated. This was followed by a semi-structured interview to elaborate the facilitators and barriers to implementation of clinical reasoning curricula, evaluation of curricula and skills, and future directions of clinical reasoning education on a local and national level.

RESULTS: Nineteen faculty representing all geographic regions of the U.S. participated in the survey, with 18 completing both the survey and interview. Explicit clinical reasoning education is present throughout all levels of UME: pre-clinical (94.4%), clerkship (85.6%), and post-clerkship (72.7%). Clinical reasoning is required coursework for preclinical (88.2%) and clerkship (83.3%) students, but less frequently for post- clerkship students (12.5%). Clinical reasoning performance contributes to students grades less frequently as students’ progress through UME. Qualitative interviews describe the challenges of building reasoning skills when early students have limited medical knowledge, the lack of local or national standards for reasoning skills, and little-to-no established means of assessing reasoning skills. Clinical reasoning education is also limited by the need for dedicated faculty, faculty development, and local clinical reasoning expertise. Faculty frequently expressed interest in increased sharing of clinical reasoning curricula and assessment tools between institutions.

CONCLUSIONS: This study establishes a foundational knowledge of the existing UME clinical reasoning curricula within the United States. It highlights discrepancies between national recommendations and local realities for clinical reasoning curricular efforts and evaluation. Faculty expressed multiple challenges for clinical reasoning education and next steps for local and national progress, including setting of universal milestones and inter-institutional sharing of curricular and evaluation resources.

COMPREHENSIVE COMPETENCY-BASED PROCEDURAL TRAINING AND ASSESSMENT PROGRAM FOR INTERNAL MEDICINE RESIDENTS - A PILOT STUDY

Brandon Fainstad¹; August Longino¹; Tiffany Gardner¹; Braidie Campbell¹; Julia Limes²; Irene Ma³; Geoff Connors¹

¹Medicine, University of Colorado, Denver, CO; ²Medicine, University of Colorado, Denver, CO; ³University of Calgary, Calgary, AB, Canada. (Control ID #3873309)

BACKGROUND: Invasive bedside procedures are essential to internal medicine (IM) clinical practice, yet methods and quality of resident procedural training vary widely, and no established competency assessment process exists to accurately and reliably determine when a resident can safely perform procedures independently. A modern, evidence-based framework for effective procedural training is “Learn, See, Practice, Prove, Do, and Maintain” (LSPPDM).

METHODS: We developed and implemented a comprehensive procedural curriculum for three core IM procedures (CVC insertion, paracentesis, and thoracentesis) modeled after the LSPPDM framework. A digital competency assessment tool (CAT) accessed by QR-code badges enabled competency assessments in simulation and clinical environments. To adequately identify pre-entrustable performances the CAT included minimum cut-off standards for three elements, a checklist, global skills assessment (GSA), and entrustment score (ES). A modified Angoff process with 27 national experts in procedural education established checklist cut-offs.

Simulation-Based Mastery Learning for each procedure was paired with the relevant rotation. Pre-procedural LEARNing included a procedural video and online quiz. During rotation-paired simulation-based mastery learning, residents would SEE an instructor demonstrate proper technique before PRACTICing on a low- cost, high-fidelity task trainer until they PROVEd mastery. Formative feedback was structured around

locally developed validated checklists. Residents could only DO the clinical procedure under supervision until they successfully completing a minimum of five procedures with the most recent two satisfying cut-off standards on all three elements of the CAT. Competency was MAINTAINed through repeated assessments.

RESULTS: By the sixth month of the curriculum, forty-three clinical CVC assessments were performed, 91% met passing checklist scores, but only 11% of GSAs and 2% of ESs met cut-offs. Similarly, in 63 paracentesis assessments, 89% of checklists, 8% of GSAs and 6% of ESs met cut-offs. In 22 thoracentesis assessments 91% of checklists, 18% of GSAs and 0% of ESs met cut-offs. None of the 70 PGY1s at 6 months achieved the threshold to perform any of the 3 procedures without direct supervision.

CONCLUSIONS: We successfully implemented a comprehensive LSPPDM competency-based procedure curriculum incorporating a validated checklist. A digital CAT accessed by QR code badges, locally developed low-cost simulation task trainers, and publically available online educational materials made implementation of this robust curriculum feasible.

Passing standards for three complimentary assessment elements provided reliable discernment of pre- entrustable procedural competence in first-year IM residents. The discordance between passing percentages with the checklist compared to GSAs and ESs highlights the limitations of assessing procedural competence with checklists in the clinical setting.

CURIOUS ABOUT CURIOSITY: PRELIMINARY VALIDITY EVIDENCE FOR A 5-FACTOR CURIOSITY SCALE IN MEDICAL STUDENTS

Kristen Vossler¹; Rachael Tan¹; Wendy Christensen^2,1; Tai Lockspeiser^3,1

¹School of Medicine, University of Colorado, Denver, CO; ²Department of Family Medicine, University of Colorado - Anschutz Medical Campus, Aurora, CO; ³Pediatrics, University of Colorado, Denver, CO. (Control ID #3875869)

BACKGROUND: Curiosity is essential to the work of physicians, making it important to promote in medical students. Limited previous literature has described stagnation of curiosity over the four years of medical school. Furthermore, the nuances of curiosity as a construct suggest it is not likely a singular trait, as has been measured previously in medical education but rather multifactorial. The purpose of this study was to gather initial validity evidence for Kashdan’s five-dimensional curiosity scale in medical students and determine if curiosity changes across medical school.

METHODS: Students at the University of Colorado, School of Medicine completed the five-dimensional curiosity scale in academic years 2020-21 (N=676) and 2021-22 (N = 648). Evidence of the scale’s internal structure and psychometric properties were explored using confirmatory and exploratory factor analysis and domain averages within-year were compared across the different phases of medical school. Furthermore, validity evidence for response process was obtained through cognitive interviews with students (N = 7) aimed at understanding students’ interpretation of questions and determination of answer choice. Thematic analysis generated key themes from the interviews.

RESULTS: For both academic years, the five-factor model (1) Joyous Exploration, 2) Stress Tolerance, 3) Social Curiosity, 4) Deprivation Sensitivity, and 5) Thrill-Seeking) better modeled the observed item covariance matrix than a one-factor model. The Social Curiosity sub-scale items did not consistently load on the same factor. No domain averages had significant differences across the different phases of medical school. Results from the cognitive interviews suggest that students found high scores in the Joyous Exploration and Stress Tolerance domain essential for medicine, as these reflect resilience and growth as well as ability to navigate new experiences respectively. Students described a low Deprivation Sensitivity score as a strength in medicine, as it signals comfort with ambiguity and the unknown. While students acknowledged the importance of Social Curiosity in medicine, students perceived some of the Social Curiosity items as intrusive and unnecessary for success in the profession. Lastly, the entire Thrill-Seeking domain was seen as irrelevant to medicine and more related to personality than professional identity.

CONCLUSIONS: This study provides preliminary validity evidence for a curiosity scale for medical students that can be used to determine the impact of curricular changes on medical student curiosity. Further investigation of the Social Curiosity domain and appropriateness of the items for medicine is warranted. Next steps include examination of the validity evidence for new items in this domain drafted by our team. The Thrill-Seeking domain seems less relevant to curiosity in medical students.

DEVELOPMENT AND PSYCHOMETRIC VALIDATION OF A SOCIAL DETERMINANTS OF HEALTH COMPETENCY-BASED ASSESSMENT FRAMEWORK AND OSCE ASSESSMENT TOOL

Milad Memari¹; Brielle Spataro¹; Catherine Gowl³; Scott D. Rothenberger²; Kathryn Leyens¹; Amar Kohli¹; Reed Van Deusen¹; Thuy Bui¹; Galen E. Switzer²; David M. Elnicki¹

¹Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ²General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ³University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #3875079)

BACKGROUND: Social determinants of health are defined as the nonmedical factors that influence health outcomes. Institutions employ a wide variety of unique approaches to SDH assessment, making it difficult to compare outcomes.¹

Expert consensus studies have summarized current approaches to SDH assessment and highlighted the need for more validatd assessment tools for learner and programmatic evaluation of SDH education.^2,3

We developed a framework and assessment tool for evaluation of SDH competencies at a medical school in the Mid-Atlantic region based on these expert consensus publications. We then conducted a multi-component psychometric evaluation of this tool in order to evaluate its validity and reliability.

METHODS: We developed a competency-based assessment tool to measure the specific knowledge, skills and attitudes relating to SDH as outlined in our assessment framework (Figure 1). This tool consisted of an SP checklist and a post-interaction questionnaire completed by the learner.

This tool was then sent to a diverse group of national experts in SDH education for content validation , consisting of a review of each item in the assessment tool with ratings of their relevance and clarity. Based on these ratings, the individual content validity index (I-CVI) was calculated for each item.

RESULTS: On expert review, all of the items on the SP checklist (10/10) were determined to be relevant to SDH assessment (mean CVI of 0.95). Raters found that all items (6/6) on the post-interaction assessment had relevance to SDH assessment (mean CVI rating of 0.91). All items on the two components of the assessment exhibited a minimum I-CVI agreement rating of 0.8 (considered strong agreement).

CONCLUSIONS: We successfully developed a competency-based assessment framework and tool and utilized expert review to build evidence supporting the validity of this new tool. We plan to further examine the known groups validity of the tool and determine its inter-rater reliability by comparing multiple SP raters’ scores on each assessment. Ultimately, this tool has the potential for use across institutions in the assessment of SDH-related competencies, allowing for better delivery of feedback to learners, as well as more accurate comparisons as part of a transition to competency-based development of learners across the medical education spectrum.

EXPERIENCES OF GENDER-BASED DISCRIMINATION AMONG FEMALE PHYSICIAN TRAINEES AND IMPLEMENTED INTERVENTIONS

Jissy Cyriac¹; Reema Tawfiq¹; Leslie Hassett²; Hannah Nordhues³

¹Internal Medicine, Mayo Clinic Department of Internal Medicine, Rochester, MN; ²Library-Public Services, Mayo Foundation for Medical Education and Research, Rochester, MN; ³Mayo Clinic Department of Internal Medicine, Rochester, MN. (Control ID #3871860)

BACKGROUND: While the number of female physician trainees is rising, gender-based discrimination in medicine is prevalent. We aim to review existing studies that evaluate experiences of discrimination among female physicians during training and the state of current interventions.

METHODS: A PubMed search was completed to identify studies that evaluated experiences of gender-based discrimination among female physicians during medical training between 1999-2022 and interventions implemented. All abstracts were screened for inclusion.

RESULTS: Our search identified 346 abstracts and letters and 30 met the prespecified inclusion criteria (10 qualitative, 18 quantitative, 2 mixed methods). Gender-based discrimination was identified at all levels of medical training with a majority in surgical subspecialties (N=14). A wide array of discriminatory experiences were identified. Trainees encountered these experiences from patients, supervisors, and multidisciplinary staff. Cumulative effects of these encounters led to burnout, mental health decline, and career dissatisfaction. There is little formal reporting of these encounters. Only 4 studies met the inclusion criteria for interventions. Among these studies, 3 out of 4 utilized mentorships to alleviate barriers, provide trainee support, and facilitate networking. One study implemented “doctor” identification badges which decreased role misidentification and experiences of gender bias by female physician trainees.

CONCLUSIONS: Gender-based discrimination in medicine is prevalent and female physician trainees do not feel empowered to address or report such actions. We identified very few studies reporting organized interventions to alleviate gender-based discrimination experiences. Until then, organized mentorship and role identification badges have demonstrated promising outcomes in mitigating gender-based discrimination experienced by female medical trainees.

EXPLORING ASSOCIATIONS BETWEEN CORE CLINICAL COMMUNICATION SKILLS AND TELEHEALTH COMPETENCY USING UNANNOUNCED STANDARDIZED PATIENTS

Jeffrey A. Wilhite¹; Zoe Phillips¹; Lisa Altshuler¹; Khemraj Hardowar¹; Kathleen Hanley^1,2; Andrew Wallach^2,1; Isaac Holmes²; Melissa S. Lee³; Colleen Gillespie¹; Sondra Zabar^1,2

¹Medicine, New York University Grossman School of Medicine, New York, NY; ²New York City Health and Hospitals Corporation, New York, NY; ³Ambulatory Medicine, Kings County Hospital, Brooklyn, NY. (Control ID #3875859)

BACKGROUND: In light of the COVID-19 pandemic, key medical education entities have moved telehealth competencies to the forefront of training and assessment efforts. Assessment of core telehealth skills has been incorporated into clinician training programs across the nation, but examinations of telehealth performance during independent practice remain less common. Further, explorations of the relationship between core clinical competencies and emerging efforts to measure telehealth performance are mostly absent from the literature.

METHODS: Unannounced standardized patients (USPs) are a nimble, feasible tool for incognito assessment of communication and clinical competencies during practice. Physicians in our urban, safety net hospital receive USP visits as part of quality improvement efforts. In the current study, physicians participated in a routine clinical telehealth encounter with one of two unique USP cases: an asthmatic patient presenting with worsening conditions (N=27 visits) and a smoking, hypertensive patient requesting a medication refill (N=24 visits). After completing each virtual visit, USPs rated clinicians’ performance using a behaviorally anchored checklist (items rated: not, partly, or well done) across the following domains: information gathering (4 items), relationship development (5 items), education and counseling (3 items), assessment (10 items), and patient satisfaction (4 items) and activation (4 items), and telehealth (6 items, including confirming identifiers, maintaining etiquette, nonverbal communication, optimizing tech, exhibiting confidence, and augmenting information gathering). Domain summary scores were calculated as mean % well done across items. Domain ratings and correlations were explored across cases.

RESULTS: Telehealth performance summary scores were notably different across cases (35% in asthma, 60% in hypertension, p=.001), as were education and counseling (76% in asthma, 46% in hypertension, p=.004). Within individual telehealth items, confirming patient identifiers was uniformly low for both cases (15% asthma, 21% hypertension), as was utilizing the live video interface to augment information gathering (11% asthma, 30% hypertension). In the asthma case, core communication skill scores were not correlated with telehealth whereas in the hypertension case, relationship development (r=.556, p=.005) and patient satisfaction (r=.475, p=.019) were positively correlated. Within domains, correlation between individual items and telehealth scores varied by case.

CONCLUSIONS: Findings of the current study suggest that in general, telehealth skills are related to good quality communication skills. Different clinical scenarios may call for specific skills, contributing to variations in relationships between telehealth and other communication domains. This exploration warrants further study, as identification of correlated measures has the potential to influence training requirements, educational efforts, and analytics in medical education research.

FEEDBACK CULTURE IN THE TUFTS MEDICAL CENTER DEPARTMENT OF MEDICINE Caitlin P. Fai¹; Laura K. Snydman²

¹Internal Medicine, Tufts Medical Center, Boston, MA; ²Internal Medicine, Tufts Medical Center, Boston, MA. (Control ID #3876812)

BACKGROUND: Research on feedback culture in residency programs has comprised mostly of single subspecialty focus groups or small needs assessments. The goal of our project was to study the feedback culture in the Department of Medicine (DOM) at Tufts Medical Center (TMC).

METHODS: We conducted a single institution needs assessment in the TMC DOM in Spring 2022. 3 cohorts were surveyed via Qualtrics: interns, PGY-2/ PGY-3s, and all inpatient attendings representing 9 subspecialties. Questions focused on satisfaction with feedback, barriers to giving feedback, and types of feedback received versus wanted. The results were analyzed within and across the cohorts.

RESULTS: 100% interns (N=26/26), 90% PGY-2/ PGY-3s (N=45/50) and 72% attendings (N=81/112) responded. 59% attendings felt that they provided “quite” or “extremely” clear expectations, but only 19% interns and 29% PGY-2/ PGY-3s felt that attending expectations were clear. Interns wanted feedback from attendings about clinical reasoning (69%), leadership skills (69%), and evidence-based decision making (62%). Residents wanted feedback from their attendings on leadership skills (82%), clinical reasoning (80%), and clinical skills (78%). Attendings wanted feedback on their teaching skills (93%) and leadership skills (80%).

Residents felt the biggest barriers to giving attendings feedback were hierarchical boundaries (81%), concerns about upsetting their attending (59%) and concerns of defensive behavior (46%). A minority felt that lack of skill or experience (22%) or lack of confidence (35%) were barriers to giving attendings feedback. Attendings felt that the biggest barriers to giving residents feedback were lack of time (67%), concerns of defensive behavior (44%) and concerns about upsetting residents (43%).

77% interns and 55% PGY-2/ PGY-3s took feedback personally “once in awhile” or “sometimes” from attendings. 57% attendings took feedback personally from residents “once in a while”. 88% of attendings felt “quite” or “extremely” open to receiving feedback, and 65% of attendings “often” or “almost always” incorporated resident feedback in the future. While 66% of attendings were “quite” or “extremely” honest in their feedback, 23% of interns and 20% of PGY-2/ PGY-3s were “quite” or “extremely" honest in their feedback to attendings.

CONCLUSIONS: Attendings provide feedback on clinical reasoning and medical knowledge and rarely on teaching skills, which residents want more of. Attendings believe their expectations of residents are clearer than they are perceived. A significant barrier to providing feedback is concern of upsetting colleagues and straining relationships. The majority of attendings want and incorporate feedback. Lack of skill or confidence giving feedback are not major barriers, yet feedback given is not always honest. Future interventions might include teaching attendings how to give feedback on teaching skills, teaching expectation setting, and teaching how to give honest feedback while preserving relationships.

FLIPPING THE CURRICULUM FOR RESIDENT DIDACTICS: IN-TRAINING AND CERTIFYING EXAMINATION SCORES IN AN INTERNAL MEDICINE RESIDENCY

Luke McCoy¹; Kathryn Burtson²; Ronald J. Markert³

¹Internal Medicine, Wright State University, Dayton, OH; ²Internal Medicine, Wright State University, Dayton, OH; ³Internal Medicine, Wright State University, Dayton, OH. (Control ID #3875804)

BACKGROUND: Flipped classroom is an active learning approach that improves knowledge acquisition and higher-order cognitive and interpersonal skills. Benefits from the flipped classroom and the goals of residency education are aligned.

METHODS: We converted an entire Internal Medicine residency didactics curriculum to active learning formats and examined impacts on examination scores using a before-after study design.

In 2017 we replaced a lecture-based curriculum with active learning sessions in a flipped classroom format. A 13 four-week block curriculum was created using an organ-system based approach.

RESULTS: Two hundred and seventy-nine residents who completed or will complete residency between 2014 and 2024 were included in this study. Residents in the flipped classroom curriculum had a higher mean percent correct score than those in the lecture-based curriculum for all three In-Training Exams: ITE1 (62.39% vs. 59.53%, p=0.008); ITE2 (69.78% vs. 66.54%, p=0.002); and ITE3 (73.42% vs.71.12%, p=0.029) but did not differ on mean standardized score for IM certification exam [IM-CE] (FC = 496 vs. LB = 481, p=0.32). The IM-CE first-attempt pass rate was higher for FC residents (95.5% vs. 84.0%, p=0.012).

CONCLUSIONS: Application of the flipped classroom in GME is burgeoning. Although effect sizes were small-medium, residents in the FC curriculum had higher IM-ITE scores than those in the LB curriculum and achieved a greater IM-CE pass rate. The learner-centered and collaborative advantages of the flipped classroom are accompanied by knowledge acquisition that is at least equal to the traditional lecture-based model.

HARD THEN, HARD NOW: IM RESIDENTS’ MORAL DISTRESS PRE- AND MID-COVID Harriet Fisher^1,3; Kathleen Hanley³; Sondra Zabar³; Tavinder K. Ark²

¹Medicine, Rush University Rush Medical College, Chicago, IL; ²Kern Institute, Medical College of Wisconsin, Milwaukee, WI; ³New York University Grossman School of Medicine, New York, NY. (Control ID #3874364)

BACKGROUND: Moral distress, which occurs when the ethically correct action cannot be taken because of internal or external constraints, is associated with depression, burnout, and the desire to leave the healthcare profession among healthcare workers. This study compares internal medicine (IM) residents’ experiences of moral distress while caring for patients with COVID-19 in the year prior to and during the first year of COVID-19.

METHODS: This is a mixed methods prospective observational cohort study that enrolled IM residents on a rolling basis beginning 12/2018. Data on a previously validated 36-item Moral Distress Scale (MDS) and open-ended questions were collected every 4-months, and through five focus groups. The MDS mean score is composed of the frequency (scale 1-4) with which a morally distressing event occurs and the intensity (scale 1-4) of distress it causes. Paired t-tests were conducted to determine if differences existed before and during COVID-19 pandemic in the MDS. Transcripts and free text were independently coded by investigators and analyzed by major themes and sub-themes.

RESULTS: Surveys from the 45 residents that completed at least one survey during the pre-COVID period (March 15, 2019 and March 14, 2020) and COVID (March 15, 2020 and March 14, 2021) were included. Paired-t-tests revealed no significant difference in individual’s pre-to-COVID mean moral distress scores, but significant differences between the MDS mean intensity scores pre-to-COVID (M=62.5;SD=13.7) to 68.3 (SD=13.2, p<.05). Of the 36 items, there was a significant mean increase in change in 2 items: (1) continue to participate in care for a hopelessly ill person who is being sustained on a ventilator, when no one will make a decision to withdraw life support (3.89 to 5.91, p<.05); (2) fear of retribution if I speak up (2.13 to 4.20, p<.05).

Qualitive findings suggest that pre-existing moral distress was exacerbated during the pandemic, especially inequality in care between public and private institutions and end-of-life care. Residents also described new drivers of moral distress that the survey could not capture including personal protective equipment, visitor policies, lack of moral framework, and tension between protecting one’s own health and caring for others.

CONCLUSIONS: The results of this preliminary analysis suggest that the COVID-19 pandemic exacerbated pre-existing experiences of moral distress and brought to light new and different moral distressing situations for trainees.

HOW READY ARE OUR NEAR-GRADUATES FOR INTERNSHIP? NIGHT-ONCALL IMMERSIVE SIMULATION DATA OVER TIME AND ACROSS CONSORTIUM SCHOOLS. Tavinder K. Ark²; Elizabeth L. Wargo¹; Ruth Crowe³; Dawn E. DeWitt⁵; Lisa Auerbach⁶; Verity Schaye¹; Lisa G. Dodson⁷; Maureen Francis⁴; Adina Kalet²; Sondra R. Zabar¹

¹General Internal Medicine, New York University Grossman School of Medicine, New York, NY; ²Kern Institute, Medical College of Wisconsin, Milwaukee, WI; ³Medicine, NYU Langone Health, New York, NY; ⁴Medical Education, Texas Tech University Health Sciences Center El Paso, El Paso, TX; ⁵Elson S. Floyd College of Medicine, Washington State University, Spokane Campus, Spokane, WA; ⁶Internal Medicine, Beth Israel - Mount Sinai, New York, NY; ⁷Medical College of Wisconsin Department of Medicine, Wausau, WI. (Control ID #3874513)

BACKGROUND: New interns are expected to effectively interact with health care team members and perform basic patient care activities unsupervised. Night-onCall (NOC) was developed to assess near- graduates’ preparedness to act independently by providing a 360 evaluation of performance from multiple health care team members (e.g., standardized nurse, resident and attending) and patients. Now conducted in 7 schools across the United States, NOC provides insight into the readiness of near-graduates across varying settings and medical curricula.

METHODS: NOC is a simulation consisting of three standardized patient (SPt) based clinical cases including assessments from a nurse (SN), an attending (SA) a resident (SR), and the patient's partner (SPartner). These raters assess core competencies across a range of activities an intern is expected to perform during a night on call: communication skills, history gathering, physical examination, and professionalism. NOC also measures students’ skills related to an oral presentation, a literature search to assess their point of care evidence-based medicine skills, clinical documentation and a patient handoff. Raters use behaviorally anchored checklists for all domains and rate students’ performance as well done (WD), partly done (PD) or not done (ND). The number of items performed in each of these categories is summated across cases and years of data and presented descriptively.

RESULTS: Data from 2020 to 2022 (n=864) across 7 medical schools was analyzed. SPts rated students’ communication skills (75% WD), higher than SR (61% as WD), and SNs (57% WD). Within communication skills, Patient Education and Counseling skills were the weakest (56% WD). Focused physical exam skills were also relatively weak (48% WD). Only 16% of students performed the literature search using search terms and data bases leading to best evidence and 48% of students articulated a well-formed clinical question. Faculty rated students’ clinical coverage notes as follows: 39% “beginning” with 56% “competent” in reporting and interpreting clinical data. Patient handoff skills were strong with 69% of students’ performances WD.

CONCLUSIONS: As a snapshot of how well our students are prepared for residency from various perspectives, we found that while, near-graduating students have strong basic patient communication skills, some still need to improve on education and counseling, and interprofessional communication, focused history gathering and physical exam skills. Their evidence-based medicine skills are rudimentary, specifically regarding question articulation and literature searching strategies. Students’ written documentation skills, including demonstration of clinical reasoning, is an area for improvement. CR is also demonstrated in handoff. NOC can provide actionable, specific feedback to individual students and aggregate data to medical schools and residency programs that may guide educational strategies that ensure patient safety and effective training early in residency.

HOW READY ARE OUR NEAR-GRADUATES TO BE ON CALL? SOME ARE AND SOME AREN’T.

Tavinder K. Ark²; Elizabeth L. Wargo¹; Sondra R. Zabar¹; Adina Kalet²

¹General Internal Medicine, New York University Grossman School of Medicine, New York, NY; ²Kern Institute, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3874546)

BACKGROUND: We have difficulty identifying how ready medical students’ are for internship because skill assessment is often done in isolated interactions (e.g., one preceptor) while novice physicians must balance many tasks and interact with several team members when caring for patients. In Night-onCall (NOC), a complex 3-case, 3-hour simulation designed around the AAMC’s core entrustable professional activities for entering residency, near-graduating medical students are independently rated by Standardized Patients (SP), Standardized Nurses (SN), a Resident (SR), an Attending (SA) and a patient’s family member (SPartner). Our 7-medical school consortium conducted latent profile analysis (LPA) to identify distinct patterns of student performance across many aspects of patient care to understand readiness for the transition to internship.

METHODS: At the 7 medical schools in our consortium, NOC raters use a behaviorally anchored checklist on a 3-point scale of not done (ND), partly done (PD), and well done (WD) to rate a student’s performance in communication, oral presentation, professionalism and history and physical examination skills among others. We identified patient communication skills patterns using LPA and then descriptively explored student performance by profile on the other NOC competencies.

RESULTS: Five student profiles emerged from analysis of SP communication data from 2020 to 2022 (n=864; VEI, BIC= 22432.95, entropy=0.95) across 7 medicals schools: one high-performing (HP n=200), two average-performing (AP1 n=273 and AP2 n=128), and two lower-performing profiles (LP1 n=84 and LP2 n=87). The profiles varied systematically by the SR rating (HP 70% WD vs. LP1 55%), the SPartner (HP 95% WD vs. LP1 59%), history gathering (HP1 70% WD vs. LP1 49%), and the oral presentation rated by the SA (HP 78% WD vs. LP1 68%). The SN rating (59% HP WD vs 55% LP1) of students’ communication skills, evidence-based skills (HP 57% WD vs. LP1 55%), physical examination (HP 52% WD vs. 48%), and handoff (72% to 68% WD) was consistent across profiles. The number of items performed WD decreased incrementally, and the number of items performed PD and ND increased incrementally from HP to LP profiles.

CONCLUSIONS: Students in the HP profile systematically performed well on all NOC domains as rated by the various independent raters in a complex authentic simulation, while students in LP1 struggled consistently. Although some of the differences in domains/raters (e.g. SN) were small in magnitude between the profiles, and others large (e.g., SPartner), these differences could be additive and compounding in their effect on the integration of skill for performers who struggle. LP1 students, about 10% of the cohort, appear to be struggling with mastery of basic competencies and thus may require and would benefit from more supervision early in internship. This data could guide tailored educational handoffs from medical school to residency to maximize patient care quality and safety during this transition.

INCORPORATING BRIEF, REAL-TIME NARRATIVE REFLECTIONS FOR STUDENT EMPATHY DEVELOPMENT IN AN INTENSIVE PRIMARY CARE CLINIC – A QUALITATIVE STUDY

Brian C. Hilgeman¹; Kurtz Kevin³; Mary Hoeschen³; Lana M. Minshew²

¹General medicine, Medical College of Wisconsin, Milwaukee, WI; ²Kern Institute, Medical College of Wisconsin, Milwaukee, WI; ³Medical College of Wisconsin, Milwaukee, WI. (Control ID #3857391)

BACKGROUND: Empathy is an essential clinical skill that improves patient satisfaction and quality but declines during the clinical years of medical school. Narrative reflections on patient encounters support empathy development but writing traditional long reflective narratives may be unfamiliar, burdensome and detached from the clinical context for students.

METHODS: The Enhanced Care Program (ECP) serves medically, socially, and psychologically complex patients. During each half day in the ECP, 4th year students were asked to write 3 HIPAA secure reflections limited to 280 characters. 18 students completed 131 reflections; an average of 2 reflections per clinic.

Qualitative analysis was completed by 3 researchers using in an iterative process of inductive and deductive coding to develop a codebook describing the content of the brief reflections. Inter-coder agreement was 82%. An independent auditor analyzed a 20% subset of the reflections to ensure accuracy of code application and reached 100% agreement with the coders after reconciliation.

RESULTS: Three major codes were identified: Descriptive, Emotional, and Cognitive reflections. Descriptive reflections retold a patient encounter or experience. Emotional reflections demonstrated a student recognizing their own, patient, or caregiver emotions surrounding the patient encounter. Cognitive reflections displayed active and intentional cognitive processing on thought process or learnings. Additional codes were identified. The code New Perspective highlighted how an experience with a patient changed student perspective around the patient's lived experience or biomedical aspects without mentioning practice change. The code Professional Development highlighted a self-reflection upon practice demonstrating growth as a physician with clear elements of practice change. Finally, the Human Component to Care acknowledged the student’s recognition of social, economic, and interpersonal components to care on health beyond biomedical aspects. Reflections could contain multiple main codes.

The majority (50%) of reflections were Cognitive in nature. The codes of New Perspective, Professional Development, and Human Component to care were found in 56% of reflections and largely associated with narratives that were cognitive (71%, 100%, 78%) and these codes rarely included Emotion or Descriptive reflections.

CONCLUSIONS: Brief, real-time narrative reflections are an effective way to allow students to process important components of caregiving in a convenient, contextual, and familiar manner. Further research is planned to understand the impact on empathy, feasibility in general curricular activities and other health professions, correlations of tweets with precursors of empathy, and impact on preceptor-student interactions.

INTERNAL MEDICINE RESIDENTS’ NEEDS IN HOSPITAL MEDICINE COMPETENCIES Christopher Sankey^1,2; Anisha Advani²; Donna Windish¹

¹Internal Medicine, Yale School of Medicine, New Haven, CT; ²Yale New Haven Health System, New Haven, CT. (Control ID #3869171)

BACKGROUND: HM is a frequently chosen career option for graduate medical trainees. Published data suggest residency graduates have knowledge and skill deficiencies upon arrival to HM positions. Specific training in HM competencies during residency is heterogeneous and often absent, little data exist regarding IM learner confidence and desire for additional instruction in HM competencies.

METHODS: Survey study of Yale IM residents from December 2021-June 2022 evaluating confidence in 44 HM competencies (scale of 1-4), and desire for additional training (yes/no). Competency domains: procedures, POCUS, clinical skills, palliative care, transitions of care, patient-level and system-level competencies. Confidence data were aggregated and dichotomized. Responses 1-2 represented ‘not confident’ and 3-4 ‘confident’. PGY-1/2 were ‘junior’ and PGY-3/4 ‘senior’. Chi-squared analysis was used to determine differences between groups.

RESULTS: The study had a 30% response rate. Confidence was lowest across all learners for procedures, POCUS, and system-level competencies, and highest in care transitions, palliative care, and patient-level competencies. Junior learners reported significantly lower confidence than senior learners across all domains. A desire for more teaching was highest in POCUS, system-level competencies, and procedures, without significant differences between juniors and seniors. Desire for more teaching was lowest in care transitions, patient-level competencies, and palliative care. Junior learners expressed a significant difference in desire for more teaching in care transitions and clinical skills compared to seniors.

CONCLUSIONS: IM learners’ desire for more teaching was highest in the same HM competency domains in which they have the lowest confidence. Junior learners have significantly lower confidence levels across all competency domains as compared to seniors, but desire more teaching in only clinical skills and care transitions. These data can be used to inform local and national educational curricula.

INTERPROFESSIONAL TEACHING OBSERVATION PROGRAM: BENEFITS FOR THE TEACHER AND OBSERVER

Maria A. Wamsley²; Josette Rivera¹

¹Medicine, University of California San Francisco, San Francisco, CA; ²Medicine, University of California San Francisco, San Francisco, CA. (Control ID #3874379)

BACKGROUND: It is recognized that health professionals must have skills in interprofessional collaboration to work effectively in clinical environments. In response to this need, interprofessional education (IPE) for students and residents is increasingly common. However, many faculty have limited experience and low self-reported knowledge of IPE and interprofessional practice (IPP). Peer observation of teaching can increase teacher confidence, change behavior, and facilitate creation of an educator community.

We created a peer observation program for faculty focused on IPE to increase confidence and skills and foster a community of IPE educators. To our knowledge, this is the first IPE-focused peer teaching observation program.

METHODS: We created a 3-hour workshop to train volunteer peer observers recruited from faculty engaged in IPE at our institution, an academic health center with 5 health professional training programs. We solicited observees to participate in the program via emails to IPE course facilitators and to the educator community. Faculty requesting observation were paired with a trained observer. Faculty pairs were instructed to meet briefly before the observation to establish goals for the feedback and to set a time to debrief. Goal duration of observation was 60 minutes. Observers and observees completed a 16-item anonymous post-observation survey including demographics, motivating factors for participation, valuable aspects of the program and suggestions for improvement.

RESULTS: Fourteen observations took place over 2 years. Observees had 0-5 years of experience teaching IPE while observers had a median of 6-10 years. Observees reported participating to improve their teaching skills (100%); observers reported participating to improve the IP teaching of a peer (86%), to improve their own IP teaching (79%), and to connect with a community of IPE educators (71%). Observees reported that receiving peer feedback was highly valuable, while observers reported that observing a colleague’s teaching and reflecting on their own teaching were program highlights. All observees and 93% of observers agreed/strongly agreed that they would recommend iTOP participation to a colleague.

CONCLUSIONS: An interprofessional teaching observation program is feasible and well-received with benefits for observers and observees.

INVESTIGATING A HIDDEN CURRICULUM: TEACHING SOCIAL DETERMINANTS OF HEALTH IN MEDICAL EDUCATION

Megan R. Sinik²; Craig H. Syrop^1,2; Karen M. Summers³; Johanna Knutson⁴; Michael L. Haugsdal^1,2

¹Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA; ²Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA; ³University of Iowa Hospitals and Clinics, Iowa City, IA; ⁴Health Administration, The University of Iowa College of Public Health, Iowa City, IA. (Control ID #3874741)

BACKGROUND: Emerging literature has demonstrated the broad influence of social determinants of health (SDoH) on patient outcomes and population health, prompting progressive medical education governing bodies to address the weight of these determinants with new teaching frameworks and curriculum guidelines. The AAMC Curriculum Inventory Report notes that only 6% of medical schools require SDoH curriculum into the fourth year, in comparison to 66% within the first year, demonstrating that a longitudinal integration of these concepts remains infrequent. This discrepancy between SDoH emphasis in didactic teachings and actual integration of these concepts into clinical care could represent a “Hidden Curriculum”, wherein students gain knowledge of SDoH importance to patient health outcomes, but no modelling of translation into practice. The goal of this study was to explore medical education students’ perceptions of their SDoH- oriented didactic and clinical education at one Midwestern, integrated academic medical center.

METHODS: The ecological perspective of SDoH were used as a heuristic model to develop a 31-question survey regarding different aspects of trainees’ experiences with SDoH throughout their undergraduate medical education, with specific attention drawn to discrepancies between didactic and clinical training. The anonymous survey was distributed electronically through the Office of Student Affairs and Curriculum to all medical doctor (MD) and physician assistant (PA) students with active student email accounts.

RESULTS: Of the 684 MD and PA students who received the survey, the 180 who completed it were primarily white (76%), female (70%), clinically experienced (59%) , MD students (86%), from an urban area (48%). Sixty-seven percent of students believed they received good or excellent quality SDoH didactic teachings, but only 34% reported the same quality of clinical teaching. Similar discrepancies were found in students’ perception of institutional dedication to SDoH in didactic teaching versus clinical practice. A self- reported preparedness gap was found between screening and addressing SDoH concerns as 78% of students reported confidence in screening, but only 65% expressed confidence to actually address these concerns in practice. Students’ qualitative responses identified major barriers to SDOH-oriented practices as provider time, interest and awareness, organizational support, and payment models.

CONCLUSIONS: While governing bodies of medical education are advancing requirements for SDoH training and assessment, this “top-down” guidance only pervades the structured, didactic classroom and is not yet reflected in ground level, clinical student experiences. This inability to see “textbook learning” translated into practice by those creating the cultural and behavior status quo of medicine reveals a “Hidden Curriculum” and appears to create cognitive dissonance within new learners.

MAPPING MEDICAL EDUCATION’S BLIND SPOTS: AREAS THAT REQUIRE INCREASED ATTENTION TO DRIVE REFORM.

Susan C. Mirabal¹; Darcy Reed³; Yvonne Steinert²; Scott Wright¹; Sean Tackett¹

¹General Internal Medicine, Johns Hopkins University, Baltimore, MD; ²Family Medicine, McGill University Faculty of Medicine and Health Sciences, Montreal, QC, Canada; ³Community Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #3857536)

BACKGROUND: We as human beings have blind spots. It is easy to acknowledge visual blind spots, such as where the optic nerve meets the retina and the fact that we can’t see behind ourselves. It can be more difficult to acknowledge other types of blind spots like unexamined beliefs, assumptions, or biases. When we notice blind spots, we can avoid pitfalls and expand our collective fields of vision to recognize “adjacent possibilities,” future states near enough to be envisioned but not so distant as to be unimaginable.

Identifying blind spots can ensure that medical education is grounded in inclusivity, transparency, and humility. Based on a conceptual model we developed,¹ the goal of this study was to systematically identify blind spots influencing medical education in the U.S.

METHODS: We conducted group concept mapping (GCM) with stakeholders from the medical education system (i.e. learners, educators, regulators, researchers, and commercial resource producers) and the broader U.S. health system (i.e. patients, nurses, pharmacists, public health professionals, and system administrators). The stakeholders independently brainstormed responses to the focus prompt: "To educate physicians who can meet the health needs of patients in the U.S. health system, medical education should become less blind to (or pay more attention to) ...". After synthesizing responses, a subset of stakeholders sorted each idea into piles based on conceptual similarity. The GCM software combined all sorting to produce a point map and options for cluster solutions. We reviewed and interpreted cluster options to arrive at the final concept map.

RESULTS: 27 stakeholders produced 298 blind spots during brainstorming that were further reduced to 208 after idea synthesis. 10 stakeholders sorted the blind spots into a range of 5-22 piles (mean 12.7, median 12.5). After reviewing cluster options, the final concept map with descriptions of the 9 domains was created (Figure).

CONCLUSIONS: The map of blind spots describes areas that deserve more attention in medical education from the perspectives of diverse stakeholders, yielding a broader view than could have been derived from small groups of experts. The identified blind spots may be used to help reform ongoing problems in U.S. medical education with an eye towards innovation and change.

¹Tackett S, Steinert Y, Whitehead CR. et al. Blind spots in medical education: how can we envision new possibilities? Perspect Med Educ (2022). https://doi.org/10.1007/s40037-022-00730-y

MEDICAL IMPROVISATION ENHANCES MOTIVATIONAL INTERVIEWING EDUCATION AND LEARNER FLEXIBILITY: A QUALITATIVE STUDY

Carolyn A. Chan¹; Peyton Cabaniss²; Donna Windish³; Andrés Martin⁴

¹General Internal Medicine, Yale School of Medicine, New Haven, CT; ²Yale School of Public Health, New Haven, CT; ³Internal Medicine, Yale University, Cheshire, CT; ⁴Child Study Center, Yale University School of Medicine, New Haven, CT. (Control ID #3873133)

BACKGROUND: Medical improvisation (improv) is a novel pedagogy that utilizes improvisation theater techniques to improve communication and teamwork in healthcare. We developed a medical improv-based course to enhance motivational interviewing skills among internal medicine residents. Little is known about the participants’ experience learning through this novel pedagogy.

METHODS: Participants were internal medicine residents who completed a medical improvisation-based motivational interviewing course. After the course, conducted in April-May 2022, we conducted four focus groups utilizing a semi-structured interview guide. We transcribed interviews and coded them aided by NVIVO software. For our qualitative phenomenology study, we used thematic analysis and a constructivist epistemology. Two individuals open-coded the transcripts, with consensus meetings to iteratively develop, refine, and finalize the codebooks.

RESULTS: The spirit of motivational interviewing (MI) aligns with three basic rules of improv 1) “Yes And” aligns with the spirit of MI through the following mechanisms: it creates a radically accepting patient environment, it builds a collaborative environment, and affirmation can build relationships; 2) “Make each other look good” overlapped with the partnership and collaboration components of the spirit of MI. Furthermore, it the rule of 3) “No mistakes” allowed for a low-stakes, supportive learning environment. In addition, themes aligned with the construct of cognitive flexibility as follows: thinking on your feet is reflective of clinical practice, no right answer and no one right way, MI skills can be applied broadly, and it prevents learners from feeling stuck. In addition, psychological flexibility is based on three pillars of: 1) Being present; 2) Being open, and 3) Doing what matters. Themes that aligned with this construct included 1) active listening creates focus and presence, and 2) it creates openness, acceptance, and curiosity.

CONCLUSIONS: Residents who complete a medical improvisation-based course may experience benefits in their cognitive and psychological flexibility. In addition, principles of improv align with the spirit of motivational interviewing, supporting that improv exercises may successfully enhance learner MI skills.

MPOX SIMULATION: A NIMBLE EDUCATIONAL TOOL DURING AN EMERGENT PUBLIC HEALTH OUTBREAK

Renee E. Heller¹; Zoe Phillips²; Jeffrey A. Wilhite³; Katherine A. Hochman³; Andrew Wallach⁴; Sondra R. Zabar^1,3

¹Division of General Internal Medicine, NYU Langone Health, New York, NY; ²General Internal Medicine, NYU Langone Health, New York, NY; ³Medicine, New York University Grossman School of Medicine, New York, NY; ⁴Medicine, NYU/NYC Health + Hospitals, New York City, NY. (Control ID

#3874039)

BACKGROUND: Newly recruited clinicians have heterogeneous clinical training and experiences; therefore, it is important to evaluate competencies and establish expectations for patient communication, safety, and performance. Recent emergent pathogen outbreaks presented a unique opportunity to explore just- in-time education for clinicians during public health crises. We designed an experiential onboarding simulation to train new internists and hospitalists on counseling patients concerned about Mpox.

METHODS: As part of a 3-station virtual Objective Structured Clinical Exam with Standardized Patients (SPs), we adapted a 2021 case assessing telemedicine skills during a post-discharge follow-up call in order to prepare clinicians during the rise of Mpox in the summer of 2022. The case begins as a routine follow-up, but shifts as the SP brings up Mpox concerns and reveals their partner has developed lesions. Case objectives include gathering post-discharge information and counseling on Mpox precautions, vaccination, and testing. Following the 10-minute encounter, SPs completed a 32 item behaviorally anchored checklist to evaluate clinician’s skills rated on a scale of not, partly, or well done (WD) and then delivered feedback on communication skills. Clinicians debriefed with facilitators, received an institutional Mpox resource guide, completed a program evaluation, and later received individualized performance reports.

RESULTS: 69 new faculty members (<18 months) participated in the onboarding program. For the Mpox case, participants scored highly on communication domains, averaging 83% WD for information gathering and 94% WD for relationship development. Participants did not score as well in the domains of education/counseling, telemedicine, and Mpox recommendations (53%, 50%, and 35% WD, respectively). Overall, SPs rated clinicians 71% WD across patient satisfaction items, but only 41% WD on patient activation items. There was no difference in MDs vs APPs or inpatient vs outpatient clinician performance.

Participants who reported addressing Mpox concerns “a few times” vs “never” scored significantly better on advising vaccination/testing and for patient activation. SP comments frequently mentioned not receiving enough information on testing/vaccination, and congruently, clinician reflections repeatedly stated that providing information about such a new and developing disease was most challenging. 95% of participants who completed the program agreed that the program helped them feel more confident about counseling a patient about Mpox concerns.

CONCLUSIONS: Our results show that an experiential onboarding program is valuable to newly-hired clinicians and effective for keeping clinicians informed during emerging public health crises. Case-specific education and patient activation may be connected, and our findings suggest that targeted simulation education could be key to preparing clinicians during unfamiliar disease outbreaks and ensuring that patients receive high quality care.

NUTRITION EDUCATION IN INTERNAL MEDICINE: WHAT DO RESIDENTS WANT?

Michael Charles¹; James S. Love¹; Jeffrey D. Taylor¹; Isaye S. Barton²; Bernice Man¹

¹Internal Medicine, University of Illinois Chicago, Chicago, IL; ²Medicine, University of Washington Department of Medicine, Seattle, WA. (Control ID #3873843)

BACKGROUND: The certification exams of the American Board of Family Medicine and the American Board of Pediatrics test physician knowledge of patient population-specific and age-specific nutritional needs. Such an expectation is vague in the exam blueprint of the American Board of Internal Medicine (ABIM). As clinical guidelines increasingly promote nutrition as a therapeutic intervention, primary care residency programs should commensurately strengthen training in clinical nutrition. There are few structured curricula addressing this knowledge gap, and the most practical methods of delivery remain uncertain. This study investigates resident preferences in learning about nutrition.

METHODS: We developed a survey to explore senior residents’ attitudes toward nutrition education and their preferred methods of learning. Respondents were also asked to assess their knowledge and competence in counseling on nutrition topics. The survey was distributed electronically to Internal Medicine (IM) and Internal Medicine and Pediatrics (MP) residents. At the time of the study, the IM and MP residency programs did not offer formalized training in nutrition.

RESULTS: Of the respondents (28.6% response rate) in IM (n=19) or MP (n=5) who completed the survey, 62% reported no prior nutrition training. Though they all agreed that nutrition can be used as a therapeutic intervention, 58.4% did not feel that their training prior to residency prepared them to provide dietary counseling to patients. Respondents reported being uncomfortable with providing nutrition resources to their patients (12.5%), providing detailed dietary counseling to patients (20.9%), and screening for food insecurity (37.5%). They were very or extremely interested in learning nutrition content from the ABIM (58.4%), key nutrition literature (50%) and core nutrition principles (58.4%) compared with culinary education (37.5%) and skill building activities, such as motivational interviewing and nutrition counseling (41.7%). They were partial to lectures with visual aid (63.6%) and problem-based learning (50%) compared with question-and- answer sessions (31.8%), simulation (27.2%), self-paced computer-based modules (22.7%), and journal club (22.7%). According to respondents, the more relevant competencies to clinical practice were disease prevention (73.9%), disease treatment (73.9%), and nutritional assessment (65.2%). Over half (52.2%) believe that two to three 30-60-minute workshops over an academic year was the ideal length of a curriculum.

CONCLUSIONS: Curricula designed to effectively address the gap in nutrition training in graduate medical education must consider the trainees’ preferences in learning. This study revealed that residents want to learn nutrition through board-relevant, clinically applicable, case-based examples delivered through a several one hour-long lectures with visual aid.

PREPPING FOR PREP: ATTITUDES AND KNOWLEDGE OF PRE-EXPOSURE PROPHYLAXIS AMONG INTERNAL MEDICINE RESIDENTS

Alexandra Cardy, Olivia Ogline, Molly A. Fisher

Internal Medicine, Allegheny Health Network, Pittsburgh, PA. (Control ID #3875678)

BACKGROUND: Human immunodeficiency virus (HIV) decreases immunity and is transmitted through bodily fluid exchange. Approved medications that can reduce viral load and prevent transmission are called pre-exposure prophylaxis (PrEP). PrEP can be over 90% effective at preventing HIV infection; however, prescribing is limited in outpatient practices. One limiting factor to prescribing is inadequate knowledge and comfort among providers. We evaluated the attitudes and knowledge of PrEP among internal medicine residents.

METHODS: Our project consisted of an education intervention, pre-intervention survey, and a post- intervention survey. The intervention was a PowerPoint lecture given as part of an established didactic series for residents in the outpatient primary care setting. It was approximately 60 minutes in length and primarily consisted of a description of PrEP, indications for use, and guidelines for patient monitoring while on PrEP. The same survey was used for both the pre-intervention and post-intervention survey, and examined resident comfort with and knowledge of PrEP. The survey was distributed immediately before and after the intervention to categorical and preliminary internal medicine residents employed by Allegheny Health Network in 2022. Missing data was treated as deficit data and did not impact the reporting of other data. The chi-square test of Fisher’s exact test was used to determine differences between categorical variables. A value of p<0.05 on two-tailed testing was considered statistically significant. Statistical analysis was performed using MedCalc® Statistical Software, Version 20.011.

RESULTS: Eighty-three residents completed the pre-intervention survey and 56 residents completed the post-intervention survey. The following concepts from the survey were statistically significant and associated with the intervention: populations for whom PrEP is effective at preventing HIV, including men who have sex with men, people who inject drugs, and adolescents at risk for HIV; PrEP availability and coverage through insurance; and frequency of laboratory monitoring and HIV testing for patients while on PrEP.

CONCLUSIONS: Our results suggest that an education intervention helps improve resident knowledge of indications, patient monitoring, and insurance coverage of PrEP. Future work should evaluate longitudinal prescribing practices following an education intervention.

PROCESS AND IMPACT OF CORE IM’S “BYTE”-SIZED INFOGRAPHIC TEACHING

Marissa LoCastro¹; Amy Ou²; Gregory Katz³; Nicholas M. Mark⁴; Clement Lee⁵; Sheila Okere⁶; Shreya Trivedi⁷

¹School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY; ²University of California San Francisco, San Francisco, CA; ³NYU Langone Health, New York, NY; ⁴Pulmonary Critical Care, University of Washington, Seattle, WA; ⁵Boston Children's Hospital, Boston, MA; ⁶Mayo Clinic Department of Internal Medicine, Rochester, FL; ⁷Medicine, Beth Israel Deaconess Medical

Center, Waltham, MA. (Control ID #3875266)

BACKGROUND: Bite-sized content on digital platforms may be used to supplement and enrich knowledge in clinical settings for group and independent learning. Core IM is a virtual medical community consisting of medical trainees and faculty at various levels that produce weekly clinically applicable educational resources. “Bytes” are bite-sized teaching points presented in an infographic slide deck. Byte content areas include cardiology (“12 lead Thursday”), radiology (“Reading Room”), point of care ultrasound (“POCUS”), statistics (“Stats with Core IM”), trivia (“Trivia Tuesday”), and holidays (“Holidays”). We present the process of Byte production and analyze the impact of Core IM Bytes released on social media platforms.

METHODS: After pilot Bytes received initial interest on social media platforms, the Core IM team developed a formalized workflow for Byte production that allows for structured collaboration amongst content creators and digital artists. Data on Byte engagement was collected on three social media platforms: Twitter, Facebook, Instagram. Descriptive statistics were used to analyze Bytes on the various platforms from January 2021 to December 2022.

RESULTS: Byte production includes five phases: 1) Creation, 2) Content Feedback, 3) Digitalization, 4) Design Feedback, and 5) Publication. Content creators develop iteratively, with feedback from the broader Core IM team at multiple time points with focus on relevance, accuracy, and scope. Initial content is then passed onto the digital artist with additional cycles of feedback with focus on cognitive load, visual presentation, and accessibility. The turnaround time from idea to finalization for publication can take 1 month to 6 months. Core IM has produced 168 Bytes (12 lead Thursday: 47, Reading Room: 26, POCUS: 9, Stats with Core IM: 12, Trivia Tuesday: 52, and Holidays: 22). Currently, there are 37,600 Twitter followers, 14,000 Instagram followers, and 2,318 Facebook followers.

Since January 1/1/21, 64 Bytes were published. Twitter: Mean “retweets” and “likes” were 31.5 (SD 36.4) and 98.5 (SD 124.0), respectively. POCUS had most engagement with 77.0 (SD 12.7) “retweets” and 206.0 (SD 59.4) “likes,” followed by 12 lead Thursday with a mean of 46.0 (SD 19.3) “retweets” and 152.4 (SD

67.7) “likes.” Instagram: Mean “likes” were 167.1 (SD 110.3). 12 lead Thursday had most engagement with mean “likes” of 238.1 (SD 86.7), followed by Trivia Tuesday with mean likes of 202.2 (SD 99.6). Facebook: Mean number of people reached was 528.1 (SD 305.5). Reading room reached most people with a mean of 705.7 (SD 341.0), followed by POCUS with a mean of 688.7 (SD 102.3).

CONCLUSIONS: Core IM Bytes engage hundreds of followers on social media, allowing for wide distribution of asynchronous, self-directed, visually appealing educational content. Bytes are an accessible and impressionable model of disseminating educational content for those who wish to expand the scope of their teaching to a virtual audience.

PROFESSIONALISM, POWER, AND IDENTITY: A CRITICAL ANALYSIS OF MEDICAL STUDENTS’ AND RESIDENTS’ PERSPECTIVES ON PROFESSIONALISM

Daniela Maristany¹; Karen E. Hauer¹; Andrea Leep Hunderfund²; Martha L. Elks³; Justin Bullock⁴; Ashok Kumbamu⁵; Bridget C. OBrien¹

¹Medicine, University of California San Francisco, San Francisco, CA; ²Neurology, Mayo Clinic Minnesota, Rochester, MN; ³Medical Education, Morehouse School of Medicine, Atlanta, GA; ⁴Medicine, University of Washington, Seattle, WA; ⁵Biomedical Ethics Research Unit, Mayo Clinic, Rochester, MN. (Control ID #3874415)

BACKGROUND: Professionalism remains a powerful force in medicine because it both identifies core values that unite members of the profession and establishes rules to guide physician behaviors. However, there are growing concerns that viewing professionalism through dominant cultural norms disadvantages physicians and trainees who do not align with the majority culture in medicine. While multiple articles have explored learners’ perspectives on professionalism through interviews and written reflections, none have centered the context of race/ethnicity or learners from historically marginalized groups. This study explored how learners, particularly those from historically marginalized groups a) describe the purpose and value of professionalism and b) understand and experience professionalism, particularly its role in perpetuating racism and oppression.

METHODS: The authors conducted a qualitative study with a critical orientation. In 2021 and 2022, they interviewed fourth-year medical students and senior residents from multiple specialties at 3 academic institutions in the California-Hawaii, Mid-West, and Southern Regions about their experiences with professionalism. After cataloguing participants’ stories, the authors combined critical theory with narrative and thematic analysis to identify mechanisms by which professionalism empowered or disempowered individuals or groups based on identities.

RESULTS: Forty-nine trainees (31 students and 18 residents) participated; 17 identified as a race/ethnicity underrepresented in medicine and 15 as people of color not underrepresented in medicine. Trainees, especially those from historically marginalized groups, identified professionalism as a homogenizing force that sometimes encoded racism or discrimination. Participants described differences in race, speech, body type, and sexual orientation/gender identity conflated with unprofessionalism, double standards of professionalism, and institutional polices that hindered trainees’ abilities to enact their professional values. Participants noted the negative effects of professionalism on their learning and mental health. By contrast, participants also described professionalism wielding power in positive ways by conferring credibility and helping trainees address racism and oppression in medicine. Participants’ stories revealed how they recast professionalism to align with their identities and used various mechanisms to subvert reductive ideas of professionalism.

CONCLUSIONS: Trainees’ experiences of professionalism are complex and influenced by their intersecting identities. Trainees from historically marginalized groups experience professionalism dually as a restrictive, assimilative force and as a valuable construct. Understanding both the oppressive and empowering aspects of professionalism can be used to improve the framing of professionalism in medical education to support diverse learners and has important implications for trainee wellbeing and assessment and teaching of professionalism.

RESIDENT AND FACULTY PERSPECTIVES ON THE UTILITY OF THE PHYSICAL EXAM DURING THE COVID-19 PANDEMIC

Matt Haley^1,2; Alec O'Connor³

¹Hospital Medicine, Providence St Joseph Health, Portland, OR; ²Internal Medicine, University of Rochester Medical Center, Rochester, NY; ³Medicine, University of Rochester, Rochester, NY. (Control ID #3875538)

BACKGROUND: Physicians’ understanding of the utility of the physical examination (PE) seems to have declined over the past few decades. We sought to understand how internal medicine (IM) residents and faculty perceive the utility of the PE relative to other sources of clinical information, and how that changed during the Covid-19 pandemic. Frequency of use on meaningful clinical decisions was also assessed.

METHODS: We sent a survey assessing how clinicians use different clinical sources of information to IM interns, residents, and faculty affiliated with a university-based IM residency program in February 2021. Likert-style questions asked respondents to rate the usefulness from “1(not useful)--2--3(neutral)--4--5 (very useful)” across 4 domains: history, PE, labs, and imaging; for the analysis, scores of 4 or 5 were combined and described as “useful.” Multiple-choice questions asked how often the PE impacted respondents’ diagnosis and management of patient care, with options ranging from “never” to “multiple times a day.” Attending and senior residents were asked to provide answers about their practice for two time points “pre- COVID” and “post-COVID”, while interns were only asked about the “post-COVID” setting.

RESULTS: Response rates were 50% (13/26) for Interns, 62% (37/60) for Senior Residents, and 42% (24/57) for Faculty. Among all sources of clinical information, PE was rated the lowest. Respondents rated the usefulness of the PE lower during the pandemic. Pre- and post-COVID ‘useful’ responses were: faculty: 89% and 63% (P=0.05), resident: 70% and 43% (P=0.03), intern: n/a and 46%, respectively.

Respondents reported that the PE impacted diagnosis at least daily less frequently during the pandemic (Pre- vs. Post-COVID): faculty 78% vs 74%, residents 68% vs 46%, and interns n/a vs 46%. Reports of the PE impacting management at least daily were (Pre- vs. Post-COVID): faculty 81% vs 85%, residents 70% vs 46%, and interns n/a vs 54%. Compared to residents, faculty rated the impact of the PE on diagnosis (P=0.04) and management (P=0.003) more highly post-COVID.

CONCLUSIONS: Among sources of clinical information, trainees tended to rate the PE as less useful than faculty. Residents and faculty rated the usefulness of the PE significantly lower during the COVID pandemic. During the COVID pandemic, residents used the PE less frequently for diagnosis and management decisions than the faculty.

While a relatively small sample in a single institution, this survey highlights differences in perception and use of the PE as a source of clinical information, suggesting generational, situational, and/or educational differences. The observed effect of COVID on housestaff use of the PE, coupled with all groups reporting lesser perceived utility of the PE during the pandemic raises concerns as to a potential shift in emphasis of medical education during the pandemic. This shift during the most formative years of bedside learning may be a harbinger of shifting future practice habits of future physicians.

SAME-DAY SIMULATION-BASED PRIMARY CARE PROCEDURE TRAINING PROGRAM FOR INTERNAL MEDICINE RESIDENTS: A SINGLE-BLINDED CROSSOVER STUDY.

Brandon Fainstad¹; Lisa Thompson²; Molly Brett²; Michael J. Battistone³; Andrea Barker³

¹Internal Medicine, University of Colorado, Denver, CO; ²VA Eastern Colorado Health Care System, Aurora, CO; ³VA Salt Lake City Health Care System, Salt Lake City, UT. (Control ID #3875717)

BACKGROUND: Performing procedures is an integral component of Internal Medicine (IM) practice and has been shown to improve job satisfaction among primary care physicians. However, IM residents and academic faculty report insufficient training to safely incorporate or supervise these procedures in clinical practice.

METHODS: We designed a single-blinded crossover study to evaluate the impact of SBML on checklist- based procedural performance and learner-perceived cognitive load. The study was performed in a pre- existing weekly VA IM resident procedure clinic. Each week of the rotation residents simulated one of three procedures: subacromial space injection (SAI), knee injection (KI), and large-volume paracentesis (LVP).

Following the simulation, residents were randomly assigned to procedures. Thus, some performed procedures they had just simulated, and others performed procedures they had not yet simulated. Both groups were offered procedure videos and validated procedural checklists as pre-work. During each procedure, a blinded research assistant, with previously demonstrated inter-rater reliability, used an error-counting checklist to document the number of procedural mistakes committed and those prevented by interventions from the supervising provider. After the procedure, residents filled out an adapted 12-point cognitive load survey.

RESULTS: Qualitative analysis

Theme 1: “The intentional training structure of the Rapid Access Procedure Clinic created an optimal environment conducive to enhanced learning, resident confidence, and patient-centered care.”

Theme 2: “The greatest value was perceived to be the consistency in training materials and practice standards across all settings.”

Amongst 38 first-year residents enrolled in the study, there were 30 SAIs, 45 KIs, and 38 LVPs assessed. With SAI, the control group performed 3.5 of25 possible errors and the simulation group performed 2.2525 errors (95% CI difference, -0.09, 2.59). With KI, the control group performed 3.35/25 and the simulation group 1.68/25 errors (95% CI difference of 0.33, 3.02). The LVP control group performed 4.64/39 and the simulation group 2.56/39 errors (95% CI difference, -0.96, 5.12). There were no significant differences in intrinsic, extrinsic, or germane cognitive load between the simulation group and the control group.

CONCLUSIONS: Residents perceived that an optimal procedural training environment was achieved through comprehensive and consistent teaching in the pre-work, SBML, and clinical environment.

Exposure to simulation training alone demonstrated a significant improvement in checklist-based performance of KIs but not SAI, LVPs, or in resident-perceived cognitive load. There are several possible explanations. Access to standardized educational materials among both groups likely decreased the relative impact of simulation. Additionally, the study was likely not sufficiently powered to detect differences in errors or CL for the low-complexity procedures evaluated.

SELF-DIRECTED LEARNING WITH DIGITAL EDUCATION RESOURCES AMONG INTERNAL MEDICINE RESIDENTS: A MULTI-INSTITUTIONAL SURVEY

Melina Manolas¹; Timothy Rowe³; Adam Rodman²; Shreya Trivedi²; Jafar Al-Mondhiry⁴; Robert L. Jones⁵; Martin Fried⁶

¹Internal Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY; ²Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ³Pulmonary/Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL; ⁴Hematology/Oncology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁵Internal Medicine, Oregon Health & Science University School of Medicine, Portland, OR; ⁶Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #3873985)

BACKGROUND: Digital educational resources (DERs) such as podcasts, videos, and social media have become increasingly important in the self-directed learning of internal medicine residents. We sought to explore internal medicine residents’ motivations, barriers, breadth of use, clinical application and the influence of their community of practice on their DER choices.

METHODS: Informed by prior qualitative work, we developed a survey using a systematic process for designing high-quality questionnaires on DER utilization among internal medicine residents. Investigators administered the survey to 10 different residency programs across the United States.

RESULTS: We sent the survey to 1,126 residents; 769 (68.3%) responded. Among respondents, 57.0% (n=439), 56.5% (n=435), and 39.5% (n=304) reported using videos, podcasts, and social media respectively. Low activation energy and convenience for daily routine were the top motivators for using DERs. Paradoxically, convenience and activation energy were also cited as major barriers for non-users of specific DERs. The majority of podcast users (74.7%, 169 of 226) reported credibility as a motivator for their use, whereas only 29.9% (41 of 137) of social media users felt credibility was a motivator. Both peers and faculty routinely recommended digital resources. Podcast users (212, 93.4%) and video users (205, 89.1%) noted more peers recommending those resources to them than social media users (99, 71.7%).

CONCLUSIONS: Our results suggest perception of activation energy and convenience for DERs is unique to each individual resident and their learning choices. We also found that residents assign different degrees of credibility depending on the DERs.

STUDYING GRADUATE MEDICAL EDUCATION DURING CRISES: USE OF PUBLICLY AVAILABLE DATA TO CONFIRM THE REPRESENTATIVENESS OF SURVEY RESULTS

Michael Kisielewski³; Rachel Simmons²; Kathleen M. Finn¹

¹Tufts University School of Medicine, Boston, MA; ²Brown University Warren Alpert Medical School, Providence, RI; ³Surveys and Research, Alliance for Academic Internal Medicine, Alexandria, VA. (Control ID #3874941)

BACKGROUND: Research surveys are a powerful tool for studying graduate medical education (GME) during crises such as the onset of the SARS-CoV-2 (COVID-19) pandemic. However, the very stressors that arise during those periods can constrain survey response rates. This research presents the process used to survey U.S. internal medicine (IM) residency program directors (PDs) on how the early pandemic affected residency training, including effects on the learning environment and resident care of patients. It illustrates how publicly available data can help confirm the representativeness of survey results when response rates are suboptimal due to stressful events.

METHODS: In the fall of 2020, a non-anonymous web survey was administered to 429 IM PDs with membership in a professional association, representing 83% of 520 IM programs accredited by the Accreditation Council for Graduate Medical Education. The survey primarily addressed how the early COVID-19 pandemic affected GME, including, for example, use of telemedicine in resident ambulatory education and the extent to which residents cared for COVID patients. Most essential program characteristics (“covariates”) were compiled from official, web-based publicly available residency program databases. Probit regression models identified the covariates that explained the most population variance as well as PDs’ likelihood of responding. A multivariate test of covariance confirmed that the 429 “survey-eligible” PDs closely represented the complete population of 520 “study-eligible” PDs. The Adjusted Wald Chi-Square statistic and Mann–Whitney–U test were used to assess the statistical representativeness of the results.

RESULTS: The survey response rate was 61.5% (264/429), or 50.8% of 520 study-eligible programs. Residency program type (e.g., university, community-based), accreditation status, accreditation year, U.S. Census Region, Veteran’s Affairs hospital affiliation, number of participating hospital sites, and number of approved resident positions demonstrated the most explanatory power for the study population (pseudo R²=0.58). Using those covariates, the multivariate test confirmed close similarities between the study and survey populations (adjusted LR Chi-Square: 635.0; p=0.209). Comparisons between respondents and non- respondents (using the covariates) did not demonstrate differences at an alpha level of p<0.05, demonstrating that the respondents broadly represented the larger population. Four thematically separate scholarly works were published within 1.5 years after survey fielding.

CONCLUSIONS: Survey data are difficult to collect during crisis periods but, if and when possible, medical education researchers can use tools such as publicly available data to assess the representativeness of the results. The collection of publication-quality data for the survey process used in this study underscored the advantage of such an approach, which also has applications for smaller data-gathering projects such as assessments.

THE DEVELOPMENT OF MEDICAL WISDOM: A QUALITATIVE ANALYSIS OF GROWTH FACTORS AND BARRIERS IN MEDICAL EDUCATION

Tony Liu¹; Jordan Milhollin¹; Nic M. Weststrate²; Wei Wei Lee^4,1; Lars Osterberg³; James N. Woodruff^4,1

¹Pritzker School of Medicine, The University of Chicago, Chicago, IL; ²University of Illinois Chicago, Chicago, IL; ³Stanford University School of Medicine, Menlo Park, CA; ⁴Medicine, The University of Chicago, Chicago, IL. (Control ID #3872670)

BACKGROUND: Medical training emphasizes the acquisition of explicit technical knowledge. In contrast, clinical medicine is ambiguous and dynamic requiring problem solving approaches beyond technical knowledge. Some have argued that wisdom is required to close this gap. Previously, we found that physicians define wisdom as a complex and integrative concept representing adaptive capacity properly informed by technical knowledge and guided by values (the Tripartite Model of Medical Wisdom). Building upon this study, we examined factors that contribute to and hinder the development of medical wisdom.

METHODS: 19 of 104 invited physician faculty from three medical institutions participated in Zoom interviews structured around an iteratively developed interview guide. Reflexive thematic analysis was conducted on transcripts using Dedoose software until theme saturation and consensus were reached. Supportive factors and barriers to medical wisdom growth and models of medical wisdom development were proposed and refined through iterative discussion.

RESULTS: Out of the 104 invited faculty, 19 responded and each was interviewed via Zoom. Thematic analysis of wisdom development factors revealed four major themes: Environmental Resources, Social Resources, Personal Resources, and Reflection. Subthemes for Environmental Resources included 1) Experience with frustrating or challenging situations, 2) Observing others in practice, 3) Modeling after others, and 4) Learning from patients. Social Resources were differentiated on whether one was a mentee or mentor at the time of the experience. Personal Resource subthemes consisted of 1) Identifying and affirming personal and professional values, 2) Knowing one’s own limits, 3) Retaining curiosity, and 4) Developing emotional intelligence. Finally, Reflection themes consisted of 1) Self instigated reflection upon experience or 2) Reflection on feedback or outcomes. Additionally, 15 major themes for wisdom development barriers were identified: 1) Lack of Meaningful Communication or Relationships, 2) Productivity Driven Medicine, 3) Ageism, 4) Lack of Respect, 5) Personality Limitations, 6) Lack of Trust, 7) Inability to Keep up with Technical Knowledge, 8) Intolerance of Uncertainty, 9) Financial Incentives, 10) Fragmented Care, 11) Heavy Workload and Stress, 12) Mistaking Technical Knowledge and Certainty for Wisdom, 13) Overemphasis of Technical Knowledge, 14) Restricting Environment, and 15) Technology and EHR.

CONCLUSIONS: This study identified 3 development factors for medical wisdom: Environmental, Social, and Personal Resources. Analysis suggests factor processing by Reflection fosters integration of personal resources towards medical wisdom. Identified wisdom barriers impair Reflection or directly impair integration of personal resources (the Tripartite Model). These findings identify targets for intervention in the curriculum to optimize the acquisition of implicit knowledge necessary for practice in complex clinical environments.

THE EFFECT OF A MULTI-LEVEL CURRICULUM ON USE OF CLINICAL REASONING TERMINOLOGY IN NATIONALLY PRESENTED CLINICAL ABSTRACTS

Katherine Gavinski, Deborah DiNardo, Eliana Bonifacino

Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #3875423)

BACKGROUND: There has been national recognition of the need for clinical reasoning education to improve diagnostic reasoning and reduce diagnostic error, but without guidance on best practices. Optimal educational strategies for explicit instruction and assessment of clinical reasoning have yet to be established. The University of Pittsburgh Medical Center (UPMC) Clinical Center for Medical Decision-Making implemented a longitudinal curriculum to establish shared language to discuss clinical reasoning concepts. This project aims to evaluate the impact of this multi-modal, multi-level clinical reasoning curriculum on faculty and resident interest in and comfort with clinical reasoning concepts as reflected by inclusion of clinical reasoning terminology in national conference vignette submissions.

METHODS: Published clinical vignettes by the Society for General Internal Medicine (SGIM) from three time points were reviewed for study inclusion: 2014, prior to UPMC clinical reasoning curriculum implementation, 2018, after implementation, and 2022, as a follow-up interval. Vignettes were catalogued by affiliation with UPMC, based on the presence of one author with UPMC-affiliation, and a dichotomous characterization of whether or not they included a clinical reasoning term. These terms were pre-defined as the top terms published in clinical reasoning cases and ranked in importance by educators. Frequency and type of clinical terms utilized were analyzed and compared for differences between years and across institutions.

RESULTS: Data demonstrated a significant, four-fold increase in clinical reasoning term use in abstract submissions from UPMC from 2014 to 2018 (11.1% to 42.9%; p < 0.05). Non-UPMC affiliated vignettes also saw an approximate three-fold increase in clinical reasoning term use from 2014 to 2018 (1.9% to 5.4%; p < 0.05). However, there was a decline in clinical reasoning term use by 2022 both locally at UPMC (42.9% to 6.9%, p < 0.05) and nationally (5.4% to 4.0%), though the decline at the national level was not statistically significant. The majority of abstracts that included a clinical reasoning term included a discussion of “bias” or “anchoring.”

CONCLUSIONS: Prior research studies have postulated that use of clinical reasoning-specific terminology can serve as a cognitive scaffolding that can inform self-directed learning and skill-specific education. These findings suggest that a multi-pronged clinical reasoning curricular effort can impact trainee interest in and comfort with clinical reasoning concepts. It is unclear what the recent, universal decline in term use represents, though may be related to waning interest, passage of time since the call to action from the National Academies of Sciences, or pandemic-related factors.

THE IDEOLOGY OF MEDICINE AND PROFESSIONAL IDENTITY STRUGGLE IN RESIDENCY TRAINING: A QUALITATIVE STUDY

Adam P. Sawatsky¹; Caroline L. Matchett²; Frederic Hafferty³; Sayra Cristancho⁴; Jonathan S. Ilgen⁵; William E. Bynum⁶; Lara Varpio⁷

¹General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; ²Medicine, Mayo Foundation for Medical Education and Research, Rochester, MN; ³Program in Professionalism & Ethics, Mayo Clinic Minnesota, Rochester, MN; ⁴Centre for Education Research and Innovation, Western University Schulich School of Medicine & Dentistry, London, ON, Canada; ⁵Emergency Medicine, University of Washington School of Medicine, Seattle, WA; ⁶Family Medicine and Community Health, Duke University School of Medicine, Durham, NC; ⁷The Children's Hospital of Philadelphia, Philadelphia, PA. (Control ID #3876002)

BACKGROUND: To enter a profession is to take on a new identity. Professional identity formation can be difficult, with medical learners struggling to adopt professional norms. For example, professional norms can clash with individual identities, or present competing messages between formal and hidden curricula that challenge professional identity formation. To better understand how these norms affect the developing identities of medical learners, we use the concept of ideology to explore residents’ experiences with identity struggle during residency.

METHODS: We conducted a qualitative exploration of residents in three different specialties at three academic institutions in the U.S. Participants engaged in a 1.5-hour session consisting of drawing a rich picture and a one-on-one interview. Interview transcripts were coded and analyzed iteratively, with developing themes compared to new data as it was collected. We met regularly to develop a theoretical framework to explain findings.

RESULTS: We identified three ways in which ideology contributed to residents’ identity struggle during their training. First was the intensity of the work of being a resident and becoming a physician, along with high performance expectations. All participants discussed the compelling forces of residency work requirements, future practice expectations, underlying perfectionism, and the limitations of simply being human. Second were messages regarding the subjugation of personal identities to the all-encompassing goal of developing a professional identity as a physician. Multiple participants expressed a desire to be more than just physicians but reported feeling that the message from the medical context was that “more” wasn’t possible. Third were instances where the imagined professional identity (e.g., “why I went into medicine”) clashed with the reality of medical practice. Many residents described how either their ideals were not aligned with the ideals of the profession, or how the system constrained their ability to align their practice with their ideals.

CONCLUSIONS: This study uncovers a deeper ideology that calls residents into being as they seek to construct their personal identity—an ideology that creates struggle as it often calls them in impossible, competing, or even contradictory ways. The findings suggest new ways that educators might explore identity struggles and effectively support trainees. Medical educators can support residents through explicit discussion of the struggle, intentional coaching and support through the struggle, and collaboration to dismantle and rebuild problematic aspects of the ideology of medicine.

THE IMPACT OF COMPLETING X-WAIVER TRAINING AND CLINICAL ADDICTION EXPERIENCE ON INTERNAL MEDICINE RESIDENT ATTITUDES AND BELIEFS, PREPAREDNESS AND PRACTICES TREATING PATIENTS WITH OPIOID USE DISORDER

Catherine Callister¹; Sam Porter¹; Philip Vatterott¹; Angela Keniston³; Lauren McBeth⁴; Sarah Mann¹; Susan Calcaterra²; Julia Limes¹

¹Hospital Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ²Medicine, University of Colorado - Anschutz Medical Campus, Aurora, CO; ³Division of Hospital Medicine, University of Colorado, Aurora, CO; ⁴Medicine/Hospital Medicine, University of Colorado, Aurora, CO. (Control ID #3872093)

BACKGROUND: Treating opioid use disorder (OUD) with buprenorphine or methadone reduces overdose and all-cause mortality. Many patients do not receive these medications even after an opioid overdose. Prior studies demonstrate that clinicians and residents do not feel prepared to screen, diagnose, or treat OUD. Little is known about how X-wavier training or clinical experience impacts OUD treatment provision among resident physicians. We surveyed resident physicians to determine the effect X-waiver training or clinical experience treating patients with OUD on resident’s knowledge, attitudes, feelings of preparedness, and practices related to the care of patients with OUD.

METHODS: A cross-sectional survey delivered to 188 internal medicine residents at a large academic training program from August 2021- April 2022. Associations between a combination of clinical experience and X-waiver training with 4 survey domains: passing a knowledge test, exhibiting favorable attitudes, feeling prepared to treat OUD, and reporting use of clinical practices to treat OUD, were analyzed using a Fisher's Exact Test. In addition, differences between residents with and without clinical experience for survey questions related to clinical practices were tested using a Fisher's Exact Test.

RESULTS: Of the 91 resident respondents (48% response rate), 38.5% were PGY1, 27.5% were PGY2, and 29.7% were PGY3. Most respondents had not completed X-waiver training to prescribe buprenorphine (60%, n=55), however the majority provided clinical care to patients with OUD (64%, n=58). A majority of residents had favorable attitudes about addiction treatment (96.7%). Over half of residents (51.6%) reported feeling “unprepared” to treat OUD.

Residents with both clinical experience and X-waiver training (69%, n=18) and residents with only clinical experience (62.5%, n=20) felt more prepared to treat OUD than residents with only X-waiver training (50%, n=5), p<0.001. Residents with both clinical experience and X-waiver training (42%, n=11) and residents with only clinical experience (47%, n=15) were more likely to incorporate clinical practices to treat OUD than residents with only X-waiver training (40%, n=4),p=0.012.

Among respondents with clinical experience (with or without x-waiver training) and those without clinical experience, we observed significant differences in the responses: “To what extent do you feel prepared to use buprenorphine to treat patients with OUD?” (p = 0.0032), “How often do you prescribe or recommend naloxone for opioid overdose reversal for patients with OUD?” (p = 0.0002) and “How often do you continue methadone or buprenorphine for a patient who is already on these medications when they are admitted to the hospital?” (p < .0001).

CONCLUSIONS: Clinical experience treating OUD was more important than X-waiver training in helping residents feel prepared to treat patients with OUD. Residents with clinical experience were more likely to use recommended clinical practices for OUD.

THE NEED FOR STANDARDIZATION: A SCOPING REVIEW OF COMPETENCY-BASED CURRICULA IN THE INTERNAL MEDICINE SUB-INTERNSHIP

Nabeel Akhtar¹; Nicholas Duca¹; Ami DeWaters¹; Alex Harrington²; Paul Haidet¹; Jennifer S. McCall- Hosenfeld¹

¹Division of General Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA; ²Harrell Health Sciences Library, Penn State College of Medicine, Hershey, PA. (Control ID #3872774)

BACKGROUND: In 2012, the Alliance of Academic Internal Medicine (AAIM) recommended that Internal Medicine (IM) sub-internships (sub-I) transition to a competency-based curriculum in accordance with the Association of American Medical Colleges' development of core entrustable professional activities (EPAs). Competency assesses the ability of a learner to complete an activity, and an EPA, which is comprised of competencies, assesses the entrustment for a learner to complete an activity. Although some medical schools restructured their sub-I, there is still significant variability in curricula for this important rotation. This scoping review aims to identify models of and describe studies of competency-based curricula in the IM sub- I.

METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was used for this study. Original literature was obtained from systematic searches of PubMed, MedEd Portal, ERIC, SCOPUS, and Cochran. Inclusion criteria included English-language papers discussing competency- based curricula in the IM sub-I completed by seniors in United States medical schools. Four reviewers screened the search results - a primary review examined the title and abstract and a secondary review examined the full-text. Discrepancies were resolved via discussion and arbitration by a fifth reviewer as needed. The publications were then examined for data extraction and narrated.

RESULTS: The search strategy resulted in 2,955 publications; 592 duplicates were found. 30 met the criteria for full-text review, and 9 were included in the final result. Five publications were survey-based, quantitative studies, which characterized the rotation structure, clinical experience, and the competencies assessed at the respondents’ respective institutions. Three publications were conceptual papers, which described goals, objectives, and an EPA-framework for the IM sub-I; no outcome data were available for these curricular models. Another publication studied the use of individualized learning plans to improve competencies prioritized by IM sub-interns. There was no widely adopted curriculum used across multiple studies or institutions.

CONCLUSIONS: This scoping review reveals that there is limited data regarding educational outcomes of specific IM sub-I curricula and that there is no widely-accepted competency-based curriculum amongst medical schools, although innovations and recommendations have been published. The IM sub-I is a critical space in medical education because it is one of the last clinical opportunities for medical students to establish competencies prior to post-graduate training. IM sub-I directors must implement a standardized competency- based curriculum at their respective institutions. To facilitate this, stakeholders in the IM sub-I should explore barriers of implementing such a curriculum.

THE ROLE OF A REQUIRED HOSPITALIST ROTATION DURING RESIDENCY: COMPARING HOSPITAL MEDICINE AND TRADITIONAL GENERAL MEDICINE ROTATIONS THROUGH RESIDENT SATISFACTION SURVEYS

Erin Lebold, Sarah Hartley, Kathryn L. Levy, Lauren Heidemann

Internal Medicine, University of Michigan, Ann Arbor, MI. (Control ID #3875801)

BACKGROUND: Hospital medicine (HM) is a rapidly growing field however, many IM residency programs do not require a HM rotation in their core training. The purpose of this study was to examine the impact of a required HM rotation on learner experiences and HM career choice.

METHODS: Participants included IM and Medicine Pediatrics (MP) senior residents at a single academic institution July 2021-June 2022. Senior residents rotate on a required HM service and care for 10 patients with a supervising hospitalist. The general medicine (GM) rotation involves 1 senior resident, 2 interns, and medical students with an average census of 12 patients, supervised by an IM Department faculty member. An electronic survey was developed by the authors in Qualtrics (Provo, UT) which included questions modified from the Veterans Affairs Learner Perceptions Survey. Participants were asked to rate their experience within different categories including Learning Environment, Faculty, Personal Satisfaction, and Future Career. Data was analyzed using non-parametric, unpaired t-tests with significance set at p<0.05 using GraftPad Prism software.

RESULTS: Residents who completed HM rotation (N=56, 58.3%) reported greater overall personal satisfaction compared to GM (N=30, 62.5%) , p=0.018. They also reported less perceived job stress (p=0.045), fatigue (p=0.046), and greater advancement of clinical skills and knowledge (p=0.048). Residents also reported greater interest in pursuing HM as a career after completing HM rotation (Figure 1). There was no significant difference within the categories of Faculty or Learning Environment.

CONCLUSIONS: IM residencies should consider adding a HM rotation to their training program. Not only does this expose residents to an important specialty and potentially impact future career choice, it may also help residents to grow and advance inpatient clinical skills.

THE SELECTION OF CHIEF RESIDENTS ACROSS PROGRAMS AT A LARGE ACADEMIC MEDICAL CENTER

Susan C. Mirabal, Paul O'Rourke, Scott Wright

General Internal Medicine, Johns Hopkins University, Baltimore, MD. (Control ID #3842924)

BACKGROUND: Chief residents have a unique role in graduate medical education (GME). They not only connect residents with program and hospital leadership, but also advocate for the health, wellbeing, and educational priorities of trainees. Previous studies have focused on describing the individual characteristics of chief residents, however little is known about how chief residents are selected across GME programs. This qualitative study explored all facets related to chief resident selection practices across GME programs at a single large academic institution.

METHODS: One-on-one semi-structured interviews with the GME program directors (PD) at the Johns Hopkins University School of Medicine were conducted from January-March 2022 (N=21). Assistant program directors were interviewed when PDs were unavailable. Investigators independently coded the transcripts using an inductive approach to identify meaningful segments of text; a coding framework culminated in identification of key themes.

RESULTS: Four main themes were identified; they are listed below with representative quotes:

(1) Identifying candidates – including timing, recruitment, and nominations as well as desirable attributes. "One of the main qualities we look for is, are they good at teaching…And if we get feedback … that [they] go out of the way to teach, then that'll be really taken into consideration." – PD # 7, Surgical specialty.

(2) Application processes – expression of intent, submission of materials, and participation in interviews were often required.

"Any resident who wishes to run for chief should send us an email …[with] a candidacy statement as to why they want the role." – PD # 15, Non-surgical specialty.

(3) Selection – voting and discussions of committees leading to consensus were commonplace. Rarely the PD makes the final choice themselves.

"I sit down with my leadership team…and the current chief residents, and we look at the votes. Sometimes it's very easy because the faculty, the residents and everybody agrees that these are the top [candidates]." – PD # 9, Non-surgical specialty.

(4) Confidence in chief resident selection – there was overall satisfaction with the practices employed given past successful outcomes.

"We tried to make the process as fair and transparent as possible. We don't advocate for any particular candidate. We really let the faculty and the residents choose who they think will do the best job, and it's worked out for us each time."

– PD #21, Non-surgical specialty.

CONCLUSIONS: This data collection resulted in a deeper understanding of the nuances associated with the selection of chief residents. It is hoped that the descriptions of the similarities and differences across GME programs will cause reflection about what is done at one institution such that all programs can consider what are the best practices to serve their individual goals and needs.

UNDERSTANDING MICROAGGRESSION RESPONSE AMONG INTERNAL MEDICINE RESIDENTS AT AN ACADEMIC MEDICAL CENTER

Maryam L. Famouri, Christine Sharkey, Andrea Schnell

Internal Medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #3873995)

BACKGROUND: Studies have shown that microaggressions have a large impact on medical trainees, particularly learners who identify as underrepresented in medicine (URM) or women. Many innovations in medical education have been developed in recent years to improve the clinical learning environment for trainees, including implicit bias training and upstander workshops to teach microaggression response to members of the healthcare team. We developed a needs assessment survey as part of a workshop on microaggression response training to better understand residents’ experiences with microaggressions and skills in addressing microaggressions in clinical encounters as a baseline to assess the effectiveness of the training.

METHODS: 33 PGY-2 and PGY-3 categorical internal medicine residents participated in an upstander training workshop to learn about microaggressions and strategies to respond to microaggressions in patient encounters. Prior to the workshop, participants completed a virtual survey consisting of 18 questions with Likert responses that assessed their knowledge and experience related to microaggressions, response to microaggressions, and the frequency of observed microaggressions during their training. Due to the small sample size, residents were also asked whether they identified with a minoritized group to maintain anonymity. The survey was delivered by email through Qualtrics. Descriptive statistics and Fisher exact tests were completed to compare responses by gender and identification with a minoritized group.

RESULTS: 33 residents completed the survey. 17 (51.5%) identified as female and 4 (12.1%) identified as part of a minoritized group. No residents reported that they were very or extremely comfortable acting in reducing microaggressions, while 4 (12.1%) reported that they were uncomfortable taking action to reduce microaggressions. 29 (87.9%) of respondents reported that they rarely or sometimes experienced microaggressions from patients. 2 (6.1%) reported experiencing microaggressions often or very often. 22 (66.7%) reported that they rarely or sometimes acted when a microaggression was directed at a coworker; 9 (27.3%) reported that they never took action. For those that took action against a microaggression directed at a coworker, the most commonly cited strategy was discussing the situation with the recipient of the microaggression (95.7%). Fisher exact tests showed no statistically significant differences in the responses by gender or identification with a minoritized group, likely due to the small sample size.

CONCLUSIONS: Despite the small sample size, our survey responses suggest that residents may not be comfortable addressing microaggressions and rarely take action when microaggressions occur in clinical settings. More evidence-based educational innovations are needed to teach microaggression response to medical trainees.

USE OF COMICS IN MEDICAL EDUCATION: A NARRATIVE REVIEW

Rebekah Gardner, Kate Cahill

Medicine, Brown University, Providence, RI. (Control ID #3873888)

BACKGROUND: Medical educators use varied strategies to engage learners, from slide-based lectures to chalk talks to narrative writing. Some medical educators have begun to incorporate graphic medicine into their teaching. Graphic medicine has been defined as the “intersection between the medium of comics and the discourse of healthcare.” The aim of this narrative review is to answer the question: How are comics used in medical education?

METHODS: We undertook a narrative review following the RAMESES methodological framework. We searched PubMed, GoogleScholar, and MedEdPortal, as well as the reference lists of identified articles, the National Library of Medicine Exhibition Collection of graphic medicine works, the Graphic Medicine International Collective website, and programs for the annual Comics and Medicine Conference. The last search date was December 8, 2022. Inclusion criteria specified that studies focus on learners in undergraduate and graduate medical education, involve comics, and describe an educational intervention. We excluded studies in which the comics were directed at patients, the larger public, or K-12 and college students; studies involving cartoons, animation, or traditional art; and commentaries.

RESULTS: After deduplication and screening of titles and abstracts, we identified 60 articles to include in the analysis. Although the first study was published in 1978, more than half were published in the past 5 years. We found that educators incorporated graphic medicine in two distinct ways. First, learners created comics as part of the educational activity. Common goals included processing challenging experiences, fostering professional identity formation, cultivating empathy, and reducing stigma. The second way involved learners reading comics that were selected or produced for a particular learning objective, such as understanding patient and caregiver perspectives of illness or disability, improving communication, and conveying clinical material. Most papers did not include a formal evaluation, and only a few studies

employed a randomized, controlled study design. Of the studies that included an assessment, all found that the comics were engaging for students. Four studies tested knowledge acquisition; three of the four demonstrated higher scores on knowledge assessment with use of comics-based materials.

CONCLUSIONS: Use of comics in medical education is a rapidly growing area. Comics may be effective in multiple domains of medical education, especially those related to professional identity formation and communication. With promising but limited data on the effectiveness of comics-based pedagogy, future work would benefit from more rigorous implementation and evaluation strategies.

USE OF SIMULATION-BASED LEARNING EXPERIENCE (SBLE) TO IMPROVE RESIDENT ACLS CONFIDENCE AND SKILL PERFORMANCE

RAJMOHAN RAMMOHAN¹; Atul Sinha²; Melvin Joy¹; Tulika Saggar¹; Dilman K. Natt¹; Charlene Curtis- Thomas¹; Susan Bunting¹; Prachi Anand¹; Achal Patel²

¹INTERNAL MEDICINE, NASSA UNIVERSITY MEDICAL CENTER, East Meadow, NY; ²Internal Medicine, Nassau University Medical Center, East Meadow, NY. (Control ID #3875267)

BACKGROUND: Cardiac arrest is the most urgent type of emergency, and favorable outcomes are best achieved by early resuscitation. Many Residents feel that they are inadequately trained in ACLS skills. Medical simulation Manikin has been proposed as a technique to bridge this educational gap. The objective of this quality improvement project was to explore the retention of knowledge and skills of 92 Internal medicine Residents who participated in an ACLS simulation-based learning experience (SBLE) METHODS: Simulation experts developed a pretest/posttest design with a 10-item survey. The questionnaire was composed of multiple choice questions and questions in which participants rated their agreement on a 5 point Likert scale. Residents were evaluated before and 5 weeks after the ACLS training. Paired T test was used to compare the confidence and skill level before and after the course. SPSS software was used for the statistical analysis. Testing was performed with a Laerdal manikin and standardized code carts.

RESULTS: 92 residents participated in the study. Thirty-six PGY 1 residents (39%) showed increased performance compared to the pre-test baseline (3.05±.78 vs. 4.11±.73, P<0.01, 0.666 correlation). Twenty-six PGY2 residents (28%) showed increased performance as compared to the pretest baseline (3.73±.23 vs 4.33±0.15, P=0.021, 0.71 correlation). Twenty-six PGY 3 residents (28%) showed no change in performance as compared to the Pretest baseline (4.07±0.83 Vs. 4.33±0.61, P=0.137).

CONCLUSIONS: Implementing a structured, formal curriculum can increase residents’ self-confidence in being effective leaders of ACLS teams. Simulation has become an integral part of postgraduate medical education, with the literature supporting its utility. In the era of patient safety and quality improvement, residents should be able to acquire and apply new knowledge under direct supervision without risk to any patient.

VALIDATING CLINICAL SKILLS COMPETENCY ASSESSMENT: INTERNAL CONSISTENCY ANALYSIS OF THE NYU GROSSMAN SCHOOL OF MEDICINE 7- STATION COMPREHENSIVE CLINICAL SKILLS EXAMINATION

Magdalena Robak¹; Matthew Haller²; Ilan Reinstein²; Colleen Gillespie³; Nikola Koscica²; Kelly Crotty⁴; David Kudlowitz²; Melvin Rosenfeld²; Victoria Harnik²; Sondra R. Zabar²; Verity Schaye²

¹Emergency Medicine, NYU Langone Health, New York, NY; ²NYU Grossman School of Medicine, NYU Langone Health, New York, NY; ³PrMEIR/IIME, NYU Grossman School of Medicine, New York, NY; ⁴Medicine, NYU Langone Health, New York, NY. (Control ID #3876463)

BACKGROUND: Since the dissolution of Step 2CS, individual medical schools’ must reassess the validity of their increasingly important comprehensive clinical skills examinations (CCSEs), including how to integrate standardized patient (SP) and patient note (PN) inputs. We review the internal consistency and content validity of the NYU Grossman School of Medicine (NYUGSOM) CCSE.

The NYUGSOM CCSE is a 7-station OSCE at the end of clerkships with 7 SP and 6 PN assessments. Passing decisions are based on 4 clinical skills domains: communication, history, physical exam and clinical reasoning. Communication, history and physical exam scores are derived from SP and clinical reasoning scores from PN assessments. The note template includes a history and physical, but these do not input into the history and physical grading.

METHODS: CCSE SP and PN assessments from 2020-2021, comprising 199 examinees, were collected for review. To assess internal consistency, Cronbach’s alphas were calculated for SP checklist overall, PN assessment overall, and clinical skills domains of communication, history gathering, physical exam, and clinical reasoning. For history gathering and physical exam, Cronbach’s alphas were calculated for SP checklists alone, PN alone, and a composite score.

For content validity, we reviewed this internal consistency data with a committee comprised of key experts: Deans, Clerkship Directors, Residency Program Directors, Clinical Skills Directors and Medical Students.

RESULTS: See Table 1 for internal consistency data.

The steering committee discussed that SP assessment of history gathering and physical exam performance and PN assessment of documented history and physical exam assess different constructs. However the group concluded that both are essential for competence in these domains and that composite scoring for history and physical exam affords a broader perspective on examinee performance.

CONCLUSIONS: In our exam, both SP and PN are reliable assessments of examinee performance in clinical skills domains, with moderate to high internal consistency in all calculated Cronbach’s alphas. For history and physical exam, although PN alone had a higher internal consistency than SP or SP/PN composite scores, our steering committee concluded that both inputs are meaningful in competency achievement and recommend utilization of the composite score to capture a wider perspective on these competencies at a small cost to statistical reliability.

VIBE CHECK: HOW DOES THE MINI-REZ BURNOUT SURVEY COMPARE TO THE ACGME WELLNESS SURVEY RESULTS? A MIXED METHODS STUDY

Byron C. Louw^1,2; Alia Chisty^3,2. ¹Medicine, The Pennsylvania State University, University Park, PA; ²Medicine, Penn State College of Medicine, Hershey, PA; ³Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA. (Control ID #3872526)

BACKGROUND: Resident physicians experience high levels of burnout, with prevalence ranging from 40-80% depending on specialty¹. In spite of increasing attention on resident physician well-being, how to positively impact resident wellness scores on the nationally-administered ACGME annual surveys remains unclear. We compared results from quantitative and qualitative sources to explore resident wellness in our program.

METHODS: Before each resident’s semi-annual and annual feedback sessions with the program director in November 2020 and June 2021, respectively, we invited residents to complete the Mini ReZ survey. This is a 15-item questionnaire designed to measure resident work life and wellness². The Mini ReZ shows whether scores are above or below the threshold for a (1) very positive learning environment (total score), (2) highly supportive work environment (sub-scale 1), (3) environment with good pace and manageable EMR stress (sub-scale 2), and (4) positive and healthy resident experience (sub-scale 3). We then analyzed the results from our 2020-2021 ACGME resident and well-being surveys which residents took from February to April 2021. Finally, in July 2021, we conducted a focus group with 5 of our 44 senior residents to reflect on ACGME well-being survey prompts.

RESULTS: A total of 67 and 50 residents completed the Mini-ReZ surveys at each interval. Total scores averaged at 55.99 and then 57.48, lower than the threshold of >=60². Sub-scale 1 scores were high and above the threshold of >=20, averaging 20.99 and then 21.42. These scores were comparable to results on the “I work in a supportive environment” item on the ACGME wellness survey, where 60.8% of residents “strongly agreed”. The ACGME survey does not report exactly on a “positive learning environment”, but 65% of the participating 51 residents provided an overall evaluation of our program as “very positive”. Conducting a thematic analysis of the focus group transcript, we identified 2 major factors impacting resident well-being: (1) the systems challenges in getting appropriate care for patients, and (2) a lack of respect in interprofessional interactions and when calling consults.

CONCLUSIONS: Our analysis suggests that Mini-ReZ and ACGME scores do appear to match for at least one or two items. If more of the ACGME survey items could be connected to validated measures like those on the Mini-ReZ, residency programs could assess if well-being interventions are actually impacting resident physician well-being, in the context of a nationally-administered annual survey. Our qualitative data suggest that systems-based improvements may be key to addressing resident burnout. Improving the work life of physicians is an important health systems principle, and our results can guide future endeavors targeted at enhancing physician wellness.

WHAT MAKES A GOOD PROBLEM REPRESENTATION? A MIXED-METHODS APPROACH FOR EXPLORING DIFFERENCES IN PROBLEM REPRESENTATION SYNTHESIS BETWEEN EXPERTS AND NOVICES.

Casey N. McQuade¹; Michael Simonson¹; Julia Lister²; Andrew Olson²; Laura Zwaan³; Scott D. Rothenberger¹; Eliana Bonifacino⁴

¹Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ²Internal Medicine, University of Minnesota Medical School Twin Cities, Minneapolis, MN; ³Institute of Medical Education Research Rotterdam, Erasmus MC, Rotterdam, Zuid-Holland, Netherlands; ⁴Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #3875208)

BACKGROUND: Formulating a thoughtful problem representation (PR) is a fundamental step in diagnostic reasoning. Experts recommend including pertinent demographics, the time course of illness, and a description of the clinical syndrome in PRs. However, aside from these structural recommendations, little consensus exists on what characterizes a good PR. This project analyzed differences in PR construction between novices and experts and investigated which characteristics correlate with diagnostic accuracy.

METHODS: Internal medicine interns (“novices”) and internal medicine teaching faculty (“experts”) from 2 major academic medical centers were given 2 written clinical vignettes and instructed to write a PR and

3-item differential diagnosis for each. Deductive content analysis was used to describe the characteristics comprising each PR. Based on a review of the literature, we developed an initial codebook of PR characteristics and refined it iteratively. Two authors coded 25% (n=42) of the PRs. Differences were resolved by consensus. One author coded the remainder. The primary outcome was differences in PR characteristic frequencies between groups. The secondary outcome was PR characteristics which correlated with diagnostic accuracy. Mixed-effects regression with random effects modeling compared case-level outcomes by group to account for within-participant correlation.

RESULTS: Overall, 167 statements were analyzed from 30 novices and 54 experts. Experts wrote an average of 0.8 fewer comorbidities (p=0.001) and 0.6 more examination findings (p=0.01) than novices while using a similar word count (p=0.23). They were less likely to include irrelevant comorbidities (OR 0.4, CI 0.2-0.8) or a diagnosis (OR 0.3, CI 0.1-0.8) in their PR compared with novices. Experts also tended to rename clinical data using more abstract terms (e.g. naming “sepsis” rather than “leukocytosis, fever, and tachycardia”) than novices (p=0.009). The total number of semantic qualifiers and the frequency of including pertinent negatives were similar between groups. Regardless of expertise level, including temporal semantic qualifiers in a PR was associated with diagnostic accuracy (p=0.003). Overall diagnostic accuracy was similar between novices and experts (p=0.48).

CONCLUSIONS: This study establishes concrete differences in how experts and novices construct problem representations. Compared with novices, experts include less irrelevant data, focus more on the physical exam, and synthesize data into higher-order concepts. These differences may reflect experienced clinicians’ ability to identify signal versus noise in clinical data or better knowledge of the diseases used in the vignettes.

Similar to previously published literature, temporal semantic qualifier use correlated with diagnostic accuracy, whereas expertise itself did not. Future studies should determine the cause of novice-expert differences and whether targeted educational interventions for PRs improve diagnostic accuracy.

Scientific Abstract - Medical Ethics and Humanities

DID COVID-19 PROMOTE ADVANCE CARE PLANNING, BY HOW MUCH AND BY WHOM? Randy G. Tsai²; Anne Walling^1,6; Ron D. Hays¹; Rebecca L. Sudore³; Maryam Rahimi⁴; Lisa Gibbs⁵; Neil Wenger¹

¹Medicine, University of California Los Angeles, Los Angeles, CA; ²Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ³Medicine, UCSF Medical Center, San Francisco, CA; ⁴Internal Medicine, University of California Irvine, Orange, CA; ⁵Family Medicine, University of California Irvine, Irvine, CA; ⁶Palliative Care, VA Greater Los Angeles Healthcare System, Los Angeles, CA. (Control ID #3875953)

BACKGROUND: COVID-19 posed the greatest health threat ever experienced by most Americans at the time. Early in the pandemic when vulnerable persons were dying of COVID-19, many suggested that COVID-19 could provide impetus for advance care planning (ACP). It is unknown whether COVID-19 stimulated ACP, and, if so, by how much and by whom. We surveyed seriously ill outpatients who had not previously engaged in ACP about whether they engaged in ACP due to COVID-19.

METHODS: Seriously ill (advanced cancer, heart failure, chronic obstructive pulmonary disease, end-stage liver disease, end-stage renal disease or ALS) primary care patients without an advance directive (AD) or POLST in the medical record in a multisite population-based ACP intervention were surveyed at baseline just before and early in the pandemic and 12 months later (mean 17 months after pandemic began). Surveys asked whether because of COVID-19 “you completed an advance directive,” “talked to your family and friends,” “talked to your doctor” or “changed any of your wishes” “about the kind of medical care you want if you become sick or are near the end of life?” We assessed whether patients who had not done so at baseline carried out ACP tasks due to COVID-19, and associations with gender, age, race/ethnicity and preferred language.

RESULTS: Of 1100 patients who completed a baseline survey, 842 completed the 12-month survey. Of 512 patients who did not complete official documentation at baseline, 45 (9%) reported completing an AD due to COVID-19. Spanish-speaking patients were more likely than English-speaking patients to complete an AD due to COVID-19 (22% v 8%, p=0.007). Of 435 patients who had not talked to their medical decision maker about wishes, 104 (24%) reported talking to their family and friends due to COVID-19 about the kind of medical care they desired. Hispanic patients were more likely than Whites (39% v 22%, p=0.003), and Spanish speakers were more likely than English-speakers (55% v 23%, p<0.001) to report talking to family and friends due to COVID-19. Of 645 patients who had not talked to their doctor about end of life wishes at baseline, 6% spoke with their doctor due to COVID-19 about the kind of medical care they desired. This was more common among older patients (p=0.03) but there were no differences by race/ethnicity or language. Only 2% of patients reported that they changed their wishes for the kind of end-of-life medical care they desired due to COVID-19.

CONCLUSIONS: COVID-19 prompted nearly a quarter of seriously ill patients to initiate ACP with family and friends, with a greater effect among Hispanic and Spanish-speaking patients, who were identified as vulnerable early in the pandemic. Yet provider communication and AD completion were modest. Clinicians should build on COVID-19-induced communication. A better understanding of what stimulated some patients to initiate ACP in the setting of COVID-19 might illuminate mechanisms for intervention.

EXPLORING PATIENT NARRATIVES IN GENE THERAPY CLINICAL TRIAL COVERAGE POST-2017: A CONTENT ANALYSIS

Rachele Willard, Hasmin Ramirez, Ashley Buscetta, Vence L. Bonham

Social and Behavioral Research Branch, Health Disparities Unit, National Human Genome Research Institute Division of Intramural Research, Bethesda, MD. (Control ID #3872420)

BACKGROUND: As the number of gene therapy clinical trials increases and FDA approvals begin, physicians may expect questions in the clinical encounter from their patients about the new technology and its potential for their disease. Patient understandings of gene therapy may be influenced by external sources of information that impact patient-provider communication. One such source of information is media coverage, which can shape understandings of the technology’s potential impact through its presentation of scientific information and patient narratives. This content analysis study examines news articles following the experiences of first-in-human trial participants and their families. Examination of reporting’s potential scientific inaccuracies and its treatment of multiple stakeholders’ perspectives is needed so that physicians can engage patients considering gene therapy with accessible and accurate information.

METHODS: Articles were collected systematically through focused searches across United States (U.S.) news websites and the LexisNexis databases of U.S. major newspapers and news transcripts from January 01, 2017-April 06, 2022. Forty-four articles were retrieved that met our inclusion criteria (n=18 from database searches, n=26 from external searches). Five pilot articles were used to develop an initial codebook, and subsequent article coding proceeded deductively using NVivo Pro 12 software.

RESULTS: Results showed diversity in genetic conditions featured (n=12), types and audiences of news articles, and trial participant demographics. Coverage was dominated by articles following patients living with sickle cell disease (n=18 articles), Hunter syndrome (n=6), severe combined immunodeficiency syndrome (n=4), and Leber congenital amaurosis (n=4). Three dominant themes were present across articles:

1) Impacts of living with a genetic condition, 2) Gene therapy risks, and 3) Gene therapy outcomes. The voices of both trial participants and scientific figures were included, with participants speculating on the hope and positive effects that their involvement in these trials may have and scientists reframing expectations around the uncertain long-term effects of the treatment. Further, articles inconsistently described gene therapies, alternating between experimental, therapeutic, and curative language.

CONCLUSIONS: Healthcare providers must attend to the way gene therapy narratives are portrayed in the media and the impact of this reporting on communication with patients considering experimental therapies.

HOW PATIENTS EXPERIENCE RESPECT IN HEALTHCARE: FINDINGS FROM A QUALITATIVE STUDY OF 74 MULTICULTURAL WOMEN WITH HIV

Sofia B. Fernandez³; Alya Ahmad¹; Mary Catherine Beach²; Gladys Ibanez³; Melissa K. Ward³; JESSY G. DEVIEUX³; Mary Jo Trepka³

¹General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD; ²Medicine, Johns Hopkins University, Baltimore, MD; ³Florida International University, Miami, FL. (Control ID #3876756)

BACKGROUND: Respect is essential to high quality healthcare, particularly for groups that have been historically marginalized and stigmatized. While ethical principles taught to health professionals focus on patient autonomy as the object of respect for persons, limited studies suggest that patients have a broader view of what ‘respect’ entails. The goal of this study was to expand conceptualizations of respect by exploring the perspectives of a diverse group of low-income women living with HIV regarding their experience of respect from physicians.

METHODS: We analyzed 74 interviews conducted at HIV case management sites in South Florida as part of a larger qualitative study that explored practices facilitating retention and adherence among women living with HIV. Women were eligible for the study if they identified as African American (n=33), Hispanic-Latina (n=26), or Haitian (n=15), and interviews were conducted in English, Spanish, or Creole. Women were asked about what respect means to them. Transcripts were translated, back-translated and reviewed in entirety for any statements or comments about “respect.” After independent coding by 3 investigators, we used a consensual thematic analysis approach to determine themes.

RESULTS: We grouped themes into two overarching classifications: respect manifested in the physicians’ orientation towards the client (interpersonal behavior in interactions) and respect in medical professionalism (clinic procedures and practices). Four themes emerged regarding respect in provider’s orientation towards the patient. (1) Treated as a person (e.g., when a physician “considers you a person,” “they look you in the eye and you can tell that they are interested in what it is you have to say” “the fact that your doctor remembers your name”). (2) Treated as an equal (e.g., “not like they better than us” “she makes me feel a connection, like […] we in this together”). (3) Treated without blame or prejudice (e.g., “she grabs me gives me a hug, gives me a kiss, whether I have the thing [HIV] or not”). (4) Treated with concern/ emotional support (e.g., “my whole team was like talking to me, consoling me. They supported me, like physically and emotionally,” “show me that he care”). Two main themes emerged regarding respect as evidenced by medical professionalism: (1) physician availability (e.g., being able to talk to a physician “even if I don’t have an appointment”) and (2) considerations of privacy (e.g., keeping sensitive patient information confidential).

CONCLUSIONS: These findings expand our understanding of what it means to be treated with respect for a diverse group of low-income women living with HIV. Particular attention to how patients experience respect will improve the quality care and patient outcomes. Moreover, the fact that women experience these interpersonal behaviors as the essence of being respected suggests that health professionals have a moral imperative to behave in these ways.

MAPPING CONVERSATIONS ABOUT MEDICATION ADHERENCE IN HIV ENCOUNTERS: A FRAMEWORK FOR IDENTIFYING CHALLENGES AND SOLUTIONS

Amanda McArthur, Somnath Saha, Richard D. Moore, Mary Catherine Beach

General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. (Control ID #3876598)

BACKGROUND: Antiretroviral therapy nonadherence can lead to unsuppressed HIV viral load, resulting in morbidity, mortality, and disease transmission. Studies suggest patient-physician communication about adherence is suboptimal, yet efforts to improve it lack empirical data about the interpersonal dynamics inherent in these conversations. We aim to address this gap by mapping the predictable stages of adherence conversations to provide a framework for identifying interactional challenges, discerning why they happen, and developing possible solutions.

METHODS: We conducted an observational study using conversation analysis, a qualitative method grounded in the linguistic and sequential details of naturally occurring conversations. We analyzed transcripts of 124 audio-recorded encounters between clinicians and patients with unsuppressed viral loads. Two investigators independently reviewed all adherence-related dialogue and inductively chunked sequences of talk into cohesive task-based phases that recurred across encounters.

RESULTS: Adherence conversations proceed through 5 phases. (1) Initial disclosure – the first moment a patient acknowledges missing medication – is often downgraded and minimally elaborated in terms of both extent and reasons. (2) Following disclosure, physicians usually pursue extent first. Sometimes physicians seek admission directly (“truthfully, when was the last time you took them?”); more often they pursue other details from which worse nonadherence emerges. (3) At some point during or following extent, physicians topicalize the reason(s) behind the patient's nonadherence. Issues of accountability make this interactionally challenging. Questioning ‘why’ (“why didn’t you call us?”) risks being heard as confrontational, whereas suggesting a reason can miss the mark. The focus is often on external constraints, which sidesteps important issues of personal responsibility and motivation. (4) Behavioral interventions look toward renewed adherence. Some intervention activities treat the problem as logistical, e.g., offering the patient a pill box; others treat it as motivational, e.g., informing, promising, threatening, shaming, or pleading. Physicians’ orientation toward the nature of the problem does not always align with how the patient presented it. (5) Physicians close adherence conversations by reviewing accepted solutions and making arrangements such as labs, referrals, and refills. However, there is often no real closure to the conversation, as physicians continually return to discussions of extent, reasons, and interventions. This is especially true in cases of persistent nonadherence and a suspected lack of patient commitment to renewed adherence.

CONCLUSIONS: The phases of adherence conversations reveal distinct interactional tasks and challenges, awareness of which can help clinicians reflect on their goals, anticipate challenges, and develop strategies for navigating these conversations more comfortably and effectively.

PHARMACOLOGICAL COGNITIVE ENHANCEMENT: PERCEPTIONS OF STIMULANT MISUSE IN RELATION TO AUTHENTICITY AND ACADEMIC INTEGRITY

Natalie M. Colaneri¹; Mark Antkowiak²; Mark Sheldon³

¹Internal Medicine, University of California San Diego, La Jolla, CA; ²General Surgery, University of California San Diego, La Jolla, CA; ³Philosophy and Medical Ethics and Humanities, Northwestern University, Evanston, IL. (Control ID #3875003)

BACKGROUND: In recent years, there has been increased attention toward prescription stimulant misuse for cognitive enhancement purposes. The prescription of stimulants and subsequent availability in the United States, in conjunction with the increasingly competitive culture in higher education, have led adolescents and adults to misuse stimulants for cognitive enhancement purposes. It is important to explore how stimulant misuse may affect a person’s sense of authenticity and perceived ownership of work, and consider potential implications of stimulant misuse on academic integrity.

METHODS: This quantitative study utilized a questionnaire examining perceptions regarding stimulant misuse for cognitive enhancement. The questionnaire was sent via email to 2500 undergraduate students at a university in the Midwest; the final sample consisted of 256 respondents. Descriptive and chi-square statistics were performed on results using R software. The study received approval from the Northwestern University Institutional Review Board.

RESULTS: Among the final sample, 9% of participants were previously or currently prescribed stimulants, 13% reported misusing stimulants and were never prescribed a stimulant from a physician, and 78% were never prescribed stimulants and never misused stimulants. 27% of all participants believed an individual was truly himself when misusing stimulants, while 28% believed an individual was not truly himself when misusing stimulants, and about half of participants weren’t sure. Perception varied by subgroup; 69% of students who had previously misused stimulants believed an individual was truly himself with stimulant misuse, compared to only 18% of students who had never misused stimulants (p<0.01). Only 63% of students definitively agreed that individuals have full ownership of work produced when misusing stimulants. With regard to academic integrity, 27% of students believed stimulant misuse was cheating, while 40% believed it was not cheating and 33% weren’t sure. Significant differences were noted among subgroups; about a third of students who never misused stimulants believed stimulant misuse was cheating, as did 27% of students who were prescribed stimulants, however only 3% of students who misused stimulants thought this was cheating (p<0.01).

CONCLUSIONS: This is one of the first studies to explore student perceptions regarding the ethics of stimulant misuse specifically in relation to its effect on perceived authenticity and ownership of work, and subsequently consider the potential implications of stimulant misuse on academic integrity. Our results showed varied perceptions amongst undergraduate students, highlighting a need for more interdisciplinary discussion regarding stimulant misuse and its implications in the academic setting. Furthermore, this study will hopefully inspire physicians to have open conversations with their patients about stimulant misuse and further consider the societal impact of this form of prescription drug misuse.

PHARMACOLOGICAL COGNITIVE ENHANCEMENT: PERCEPTIONS OF STIMULANT MISUSE IN RELATION TO PROFESSIONAL INTEGRITY

Natalie M. Colaneri¹; Mark Antkowiak²; Mark Sheldon³

¹Internal Medicine, University of California San Diego, La Jolla, CA; ²General Surgery, University of California San Diego, La Jolla, CA; ³Philosophy and Medical Ethics and Humanities, Northwestern University, Evanston, IL. (Control ID #3875221)

BACKGROUND: In recent years, there has been increasing discussion regarding prescription stimulant misuse for cognitive enhancement purposes. While there have been multiple studies examining stimulant misuse by students in higher education, there is limited research exploring stimulant misuse by individuals in the workplace. It is important to consider how stimulant misuse affects professional integrity, particularly stimulant misuse by physicians in health care.

METHODS: This quantitative study utilized a questionnaire examining perceptions regarding stimulant misuse for cognitive enhancement. The questionnaire was sent via email to 2500 undergraduate students at a university in the Midwest; the final sample consisted of 256 respondents. Descriptive and chi-square statistics were performed on results using R software. The study received approval from the Northwestern University IRB.

RESULTS: Among the final sample, 9% of participants were previously or currently prescribed stimulants, 13% reported misusing stimulants and were never prescribed a stimulant from a physician, and 78% were never prescribed stimulants and never misused stimulants. 28% and 27% of all respondents, respectively, believed stimulant misuse by professors and lawyers was a violation of professional integrity. In contrast, 40% and 42%, respectively, believed stimulant misuse by professors and lawyers was definitively not a violation of professional integrity. Interestingly, perceptions differed when considering professional integrity of physicians. Almost half (49%) of all respondents felt stimulant misuse by physicians was a violation of professional integrity, while only 27% of respondents felt stimulant misuse was not a violation of integrity by physicians. This significant difference in perceptions was consistent among all three subgroups of students as well, with more students finding stimulants to be a violation of physician integrity compared to other types of professional integrity (p<0.01). When considering the root causes of stimulant misuse, 93% of respondents believed that academic, professional, and/or societal pressures contributed to stimulant misuse.

CONCLUSIONS: This is one of the first studies to explore perceptions regarding the ethics of stimulant misuse specifically in relation to professional integrity. One significant finding that is worthy of further consideration is how more respondents believed stimulant misuse violated physicians' professional integrity, whereas fewer respondents overall felt stimulant misuse violated professional integrity among professors and lawyers. Further research is needed to better understand the implications of stimulant misuse in the workplace, and more attention is needed toward understanding the root causes of stimulant misuse to reduce its prevalence both in the workplace and society in general. This study will hopefully inspire interdisciplinary discussion regarding stimulant misuse and professional integrity, particularly among physicians in the health system.

THE IMPACT OF IMPROV ON EMPATHY: A RANDOMIZED CONTROL TRIAL OF MEDICAL STUDENTS

Maya Amjadi, Fauzia Osman, Jacqueline R. Kociubuk, Amy Zelenski. Medicine, University of Wisconsin- Madison, Madison, WI. (Control ID #3875840)

BACKGROUND: Empathy declines during medical training. Physicians’ roles require them to be adept at reading emotion, possess situational awareness, and respond with emotional intelligence. As empathic skills such as listening and perspective taking decline, consequences can be severe. Obvious detrimental effects include incorrect diagnosis, unrecognized medication side effects, inadequate pain control and unnecessary polypharmacy. More subtle outcomes may include distrust, avoidance of medical care and failure to meet treatment goals. In addition to harmful effects on patients, decreases in empathy among physicians can cause significant personal distress such as decreased work satisfaction, inability to relate or connect with others, feelings of isolation and exiting the medical field prematurely. Comprehensive and early interventions may provide medical students with the skills to respond empathically to the benefit of patients, healthcare teams and trainees. With an already demanding medical school curriculum, it may be difficult for medical students to attend longitudinal, in-person classes, making delivery of content an additional challenge.

METHODS: We conducted a randomized controlled trial with 51 medical students (26 randomized to improv and 25 randomized as controls). We analyzed data from 22 controls and 10 from the improv group who completed both the pre-and post-surveys from the trial. We used the Wilcoxon sign rank test to make the comparison of mean values and Fisher’s exact test for categorical comparisons. We reported the delta from mean changes and Cohen’s d for effect size. All analyses were conducted using STATA SE 15.

RESULTS: A total of 32 students completed both the pre and post survey (22 control, 10 improv). In the control group, we found worsening of personal distress from pre to post (M = 9.1 vs. M = 10.7, p = 0.05) and perspective taking (M = 20.1 vs. M = 18.6, p = 0.03). We found statistically significant differences in perspective-taking between our improv and control groups (P = 0.04, large effect of -081). Further, categories of late-stage students (4th and 5th year) showed an increase in empathic concern when compared to controls (P = 0.03, large effect of -1.68). A subgroup analysis within the improv showed no significant difference in empathic concern between early and late-stage students but the increase in empathic concern was larger in late-stage students compared to early-stage students respectively (MD = 0.86 vs. MD = 2.0, p = 0.51)

CONCLUSIONS: We found significant improvements or stability in empathy measures, using an improv intervention over zoom. Future research should delve into the most effective timing of these interventions since most of the medical improv at this time is implemented within the first two years of training. It is possible that our students who are later in their training may benefit from this more.

UNDERSTANDING THE AUTONOMY OF TRANSGENDER PATIENTS: A BROADER APPRECIATION FOR GATEKEEPERS

Zackary Berger

General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD. (Control ID #3874237)

BACKGROUND: While bioethicists define autonomy as self-governance without coercion, how self- governance actually proceeds in the constraints of daily life, the external environment, and one’s own varying life perspectives requires consideration for different types of patients. In the care of transgender patients, primary care providers and others who provide gender affirming hormone treatment are called upon to serve as gatekeepers to the legitimacy of the patient’s wishes. Billing entities, coding reviewers, the lay press and politicians ask whether transgender people are making autonomous decisions regarding this treatment.

METHODS: To understand how transgender people come to these decisions, we should consider how various theories of autonomy might apply to them, and what is missing descriptively. <div> </div>

RESULTS: The philosophical literature on autonomy understands the foundation of self-governance in two ways. The coherentist approach requires that decision-making be consistent or harmonious with the patient’s point of view on the action, which describes some transgender patients but not all, as one’s own self- representation of gender can change over time. According to the externalist approach, a patient only governs themselves if their decsion-making is responsible to external reasons; but, again, there are transgender patients whose gender-affirming care is done in the teeth of negative external incentives. What is lacking in the autonomy literature, especially regarding transgender patients, is a notion of cultural, economic, and social influences, as well as material inequities, which provide not reasons in themselves but a sense of self that might not be either primarily responsive to external reasons or consistent with regard to internal point of view. <div> </div>

CONCLUSIONS: To be transgender in the context of other people being transgender should be recognized as an equally legitimate path to recognize autonomy in gender-affirming care. <div> </div>.

USE AND MISUSE OF ARTIFICIAL INTELLIGENCE-GENERATED PROGNOSTICATION IN HEALTHCARE SETTINGS

Mika Hamer¹; Ahmed Alasmar¹; Kathryn F. Huber²; Matthew DeCamp^1,3

¹Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Aurora, CO; ²University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ³General Internal Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #3876101)

BACKGROUND: Artificial Intelligence (AI) is poised to change medicine. New AI algorithms can predict mortality with shocking accuracy, more quickly and efficiently than clinicians. This could dramatically change end-of-life (EOL) care, and health systems are implementing these algorithms in electronic health records (EHR) to support clinical decisions. This study explored perspectives of AI prognostication in EOL care, focusing on the ethical questions of privacy, appropriateness of AI in EOL, and bias in algorithms from historical data and disparities.

METHODS: Semi-structured interviews were conducted with 28 care team members (physicians, nurses, social workers, and spiritual care providers) and 12 patients and caregivers from 3 academic medical centers.

Interviewees were purposely chosen for diversity in self-identified gender, race, and ethnicity. Interviews were conducted from August-December 2022 and lasted 25-76 minutes. Data were analyzed using grounded theory.

RESULTS: Patients and care team members expressed different views on access and delivery of AI prognosis. Whereas care team members desired delivery of AI-generated prognosis from palliative care specialists who have unique skills to engage in discussions about EOL, patients and caregivers desired discussions with trusted members of their team, including primary care. Referencing sensitivity of prognostic information, some thought AI-based prognosis should be behind “break the glass” precautions in EHRs and not accessible to insurance companies.

Interviewees were concerned about AI prognosis as eligibility criteria for palliative/EOL care. Care team members emphasized personalized care, not a narrow focus on mortality prediction. Patients stressed the

importance of relationships; AI-based prognosis was viewed as only one piece of information to inform medical decisions.

Known biases in AI algorithms mean that the benefits and risks of AI-prognosis to privacy and care may not be experienced equitably. However, most care team members (while aware of AI bias generally) were unconcerned about bias in this setting (exceptions included minoritized interviewees). For some, implementation by their system signaled sufficient vetting to warrant trusting AI. Patients and caregivers expressed more concern about bias, even when they felt algorithms were unlikely to disadvantage them personally.

CONCLUSIONS: AI-based prognosis could improve access to high quality EOL care, but only if questions around who should access this information, how its use affects humanistic care, and how to manage biases are addressed. Additional clinician education about biases specific to healthcare AI may be needed, and future research should examine trust and use of AI-based prognostication across care settings.

WHEN PATIENTS PUSH BACK: PATIENT RESISTANCE TO DIAGNOSTIC CLOSURE IN PRIMARY CARE

Amanda McArthur

General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. (Control ID #3876920)

BACKGROUND: From symptom onset, people work to make sense of their condition and may develop theories about its underlying cause. In the doctor’s office, divergence between a clinician’s diagnosis and a patient’s perspective – their expectations, feelings, or beliefs about their condition – can adversely impact understanding, acceptance, and health outcomes. Little is known about how diagnosis divergence takes shape in primary care visits. This study examines whether and how patients push back, why this is interactionally difficult, and how clinicians can mitigate divergence and promote understanding and acceptance.

METHODS: We video-recorded and transcribed visits with 75 patients being seen for a new or acute problem by one of 5 primary care providers in 3 clinics. In these visits, 122 diagnosable problems were discussed. We analyzed patient and clinician dialogue following diagnosis using conversation analysis, a qualitative method grounded in the linguistic and sequential details of naturally occurring conversations.

RESULTS: Analyses revealed recurrent diagnosis demurral, whereby patients resisted diagnostic closure in cases of divergence. A total of 154 cases were identified across 59% of visits (n=44/75) and 48% of individually discussed problems (n=59/122). In 20% of cases, patient demurral constituted directly questioning a diagnosis, e.g., inquiring about an alternative (“is there any chance I could have torn a muscle?”) or questioning the fit of symptoms (“does it make sense that it doesn’t hurt?”); in the remaining 80% of cases, patients demurred indirectly, through repeated or elaborated descriptions of their own experience (“okay, because sometimes my feet fall asleep easier than before”). In terms of timing, patients demurred in immediate response to diagnosis only 6% of the time; 54% of cases occurred during later diagnostic talk and 40% occurred during treatment or other pre-closing talk. Patients often demurred more than once (mean=2.6 times), but they eventually abandoned their course of action even when their concerns were not addressed. Early clinician efforts to connect to the patient’s perspective, e.g., explaining how the diagnosis accounts for their symptom experience, seemed to reduce demurral.

CONCLUSIONS: Diagnosis demurral represents a difficult moment for patients, who speak up but downplay their resistance by waiting to demur, doing so indirectly, and ultimately abandoning their course of action. Demurral is also difficult for physicians, who face roadblocks to diagnostic and visit closure. Connecting to the patient’s perspective may be one way physicians can mitigate divergence and promote understanding and acceptance.

Scientific Abstract - Mental/Behavioral Health and Substance Use Disorders

ADEQUACY OF FOLLOW-UP CARE FOR MODERATE TO SEVERE DEPRESSIVE SYMPTOMS ON PHQ-9 SCREENING: PATIENT AND PROVIDER CHARACTERISTICS

Tess Battiola¹; Tanner Ellison²; Danica Dummer²; Katie Kaput³; Deepika Reddy³

¹General Internal Medicine, University of Utah Health, Salt Lake City, UT; ²University of Utah Health, Salt Lake City, UT; ³Department of Internal Medicine, Division of Endocrinology, University of Utah Health, Salt Lake City, UT. (Control ID #3876549)

BACKGROUND: Major depression is a common mental health disorder. Despite effective treatments such as behavioral health counseling and pharmacologic therapy, depression is often under-diagnosed and untreated. The Patient Health Questionnaire (PHQ-9) is a useful tool to identify those at risk for major depressive disorders in the ambulatory setting. Routine screening for depressive symptoms with the PHQ-9 has led to increased detection when positive scores are followed by additional diagnostic evaluation. However, a lack of follow-up and treatment for moderate to severe depressive symptoms limits the overall benefit of screening. Our study aims to identify patient and provider factors that predispose patients to inadequate follow-up for depressive symptoms with a goal to target areas for improved care.

METHODS: In this cross-sectional study, a retrospective chart review was conducted to identify adults who screened positive for depressive symptoms on the PHQ-9 at an ambulatory care visit between 1/1/2021 and 1/31/2022. Of those who met the inclusion criteria, we determined if subjects received follow-up care for the positive screen. Follow-up care was defined as a new antidepressant prescription or completed outpatient mental health visit. We then analyzed patient and provider characteristics to determine factors that were significantly associated with follow-up care. Statistical analysis was completed using paired t-tests for continuous variables and Chi square tests for categorical variables.

RESULTS: Of 17,651 subjects included in the study, 30.6% did not receive follow-up care for positive screens for depressive symptoms. Patient-related factors associated with lower rates of follow-up included older age group (p = 0.016), male gender (p = 0.013), non-white race (p<0.0001), non-English primary language (p<0.0001), non-commercial insurance coverage (including Medicaid, Medicare, and self-pay) (p<0.0001), and diagnosis of diabetes (p = 0.011). Provider-related factors associated with decreased rates of follow-up care included older age (p = 0.027), male providers (p = 0.0037), attending providers (p = 0.00053), and subspecialty providers (p<0.0001).

CONCLUSIONS: Follow-up care for patients with moderate to severe depressive symptoms as reported on the PHQ-9 is suboptimal and impacted by both patient and provider factors. Our study demonstrates that historically marginalized groups, including non-white patients and non-native English speakers, have significantly lower rates of follow-up for depressive symptoms in an academic, ambulatory setting. We also show that older providers and those practicing at an attending-level are significantly less likely to coordinate follow-up care for patients with positive PHQ-9 screens. Future efforts should focus on the development of a collaborative, coordinated referral pathway for those with a positive depression screen with an emphasis on these high-risk groups.

ASSOCIATION BETWEEN LOW-BARRIER ACCESS TO METHADONE IN AN OUTPATIENT CLINIC VIA THE “72 HOUR RULE” AND EMERGENCY DEPARTMENT UTILIZATION

Paul J. Christine¹; Jordana Laks²; Natalija Farrell³; James Evans¹; Karrin Weisenthal³; Andrea Stone⁴; Miriam Komaromy⁵; Marc LaRochelle⁶; Alexander Y. Walley⁶; Jessica Taylor⁶

¹Internal Medicine, Boston Medical Center, Boston, MA; ²Internal Medicine, Boston University School of Medicine, Dorchester, MA; ³Emergency Medicine, Boston Medical Center, Boston, MA; ⁴Population Health, Boston Medical Center, Boston, MA; ⁵Grayken Center for Addiction, Boston Medical Center, Boston, MA; ⁶General Internal Medicine, Boston University School of Medicine, Boston, MA. (Control ID #3877223)

BACKGROUND: Methadone is effective treatment for opioid use disorder, but access is limited to federally licensed opioid treatment programs (OTPs) that typically have barriers to entry. A rarely used DEA regulation (the “72-hour rule”) allows non-OTP prescribers to administer methadone for opioid withdrawal for up to 72 hours and link patients to further care. In our low-barrier substance use clinic, we implemented a program to treat opioid withdrawal via this pathway, followed by admission to an OTP. We evaluated if this approach was associated with changes in emergency department (ED) utilization.

METHODS: For a retrospective cohort of patients treated with methadone in our clinic between March 2021 and March 2022, we obtained data on sociodemographics (age, race/ethnicity, insurance), comorbidities (stimulant/benzodiazepine/alcohol use disorders), and ED visits from electronic medical record review at a large safety net hospital. We used interrupted time series models to compare the rate of monthly ED visits per 100 patients in the 12 months before and 8 months after methadone treatment. We included regression terms for baseline trend, and change in level and trend in ED visit rates after receiving 72-hour rule methadone. We excluded one month before and after methadone initiation due to spikes in ED visits that did not fit broader utilization trends and that often resulted from referrals to further medical care related to substance use treatment entry.

RESULTS: Between March 2021 and March 2022, 532 individuals not currently on methadone were treated via the 72-hour rule pathway. Two patients died during follow up and were excluded from analyses. Patients receiving methadone had a mean age of 40.7 years, were 68.1% male, 64.3% White, 15.9% African American, and 20.6% Hispanic. Medicaid insured most patients (86.4%). Comorbid substance use disorders were common (stimulants 26.4%, benzodiazepines 29.4%, alcohol 20.6%). In the 12 months prior to initiating methadone, the mean monthly ED visit rate was 23.2 per 100 patients. Interrupted time series estimates showed an immediate increase of 4.0 ED visits per 100 patients (95% CI -2.7, 10.6) the month after methadone initiation, followed by a decrease in visit rates of 2.7 per 100 patients per month (95% CI -3.8, -1.7). By 8 months after methadone initiation, monthly ED visits decreased from a projected estimate of 35.8 per 100 patients to 15.1 per 100 patients.

CONCLUSIONS: Methadone opioid withdrawal management and linkage to care via the 72-hour rule was associated with an immediate, but temporary increase in ED utilization followed by a sustained monthly decrease such that overall ED utilization was lower over 8 months of follow up. In addition to methadone’s well-described benefits for overdose and mortality reduction, our results suggest that lowering barriers to methadone treatment entry may decrease ED utilization, conferring individual and system-level benefits.

ASSOCIATION BETWEEN SMOKING ABSTINENCE AND SUBSEQUENT DEPRESSION AND ANXIETY SYMPTOMS IN ADULTS WHO STOP SMOKING AFTER HOSPITAL DISCHARGE: THE HELPING HAND 4 TRIAL

Catherine S. Nagawa^1,2; Nancy A. Rigotti^1,2; Yuchiao Chang^1,2; Douglas E. Levy^1,2; Joanna M. Streck^1,2; Thomas Ylioja³; Scott S. Lee^4,2; Esa M. Davis^5,6; Antoine B. Douaihy^5,6; Hilary A. Tindle^7,8

¹Massachusetts General Hospital, Boston, MA; ²Harvard Medical School, Boston, MA; ³National Jewish Health, Denver, CO; ⁴Brigham and Women's Hospital, Boston, MA; ⁵University of Pittsburgh School of Medicine, Pittsburgh, PA; ⁶UPMC, Pittsburgh, PA; ⁷Vanderbilt University, Nashville, TN; ⁸Veterans Affairs Tennessee Valley Healthcare System, Nashville, Nashville, TN. (Control ID #3872217)

BACKGROUND: Depression and anxiety symptoms are components of nicotine withdrawal that can undermine attempts to quit smoking. While evidence suggests that quitting smoking may improve mood symptoms, findings are limited by inadequate adjustment for potential confounders (e.g., substance use), which may worsen mood and hinder cessation efforts. In addition, anxiety and depression are common in hospitalized patients. Whether benefits of quitting on mood extends to this group is uncertain. We examined associations between smoking abstinence and depression and anxiety symptoms in hospitalized patients seeking to quit smoking.

METHODS: This was a secondary analysis of the 3-site Helping HAND 4 randomized clinical trial comparing the effectiveness of two interventions on smoking cessation post-hospital discharge. Primary outcomes were change in scores for depression (Patient Health Questionnaire (PHQ-8)) and anxiety (Generalized Anxiety Disorder Assessment (GAD-7)) from baseline to 6 months, with reduction indicating symptom improvement. Participants with primary outcomes available (n=986) were dichotomized as continuously abstinent (CA, self-reported abstinence at 1, 3, and 6 months) or not. Missing smoking status was considered as non-abstinent. Separate linear regression models were constructed for depression and anxiety outcomes. We controlled for baseline scores and other confounders, including alcohol, marijuana, and other drug use. Secondary analyses probed for the effects of duration of abstinence on mood.

RESULTS: Participants’ mean age was 52.3 (SD:12.2); 56.5% were female. Baseline mean cigarettes/day was 16.2 (SD:10.8). After adjusting for confounders, average improvements in mental health scores from baseline to 6 months were greater in the CA group compared to those not CA (difference-in-differences -2.55 for PHQ-8; 95% CI: -3.48 to -1.62 and -3.09 for GAD-7; 95% CI: - 3.98 to - 2.20). Abstaining longer resulted in greater benefits. Compared to individuals who did not abstain at all, reporting abstinence at 1, 2, or 3 time points corresponded to an additional mean reduction of PHQ-8 scores of 1.09 points (95% CI: -2.59 to 0.42), 1.10 points (95% CI: -2.88 to 0.68) and 2.73 points (95% CI: -3.68 to -1.78), respectively. The additional mean reduction in GAD-7 scores for abstaining at 1, 2, or 3 time points was 1.24 points (95% CI: -2.68 to 0.20), 0.48 points (95% CI: -2.15 to 1.20), and 3.24 points (95% CI: -4.15 to -2.34), respectively.

CONCLUSIONS: In recently hospitalized patients, continuous abstinence for 6 months post-discharge was associated with reductions in depression and anxiety symptoms after accounting for substance use. While shorter durations of abstinence may lower mood symptoms compared to continued smoking, abstaining longer resulted in the largest symptom reductions on the PHQ-8 and GAD-7. Clinicians counseling hospitalized patients who smoke can emphasize that sustaining abstinence after discharge may improve mood symptoms.

ASSOCIATION OF THE PATIENTS’ DIRECT ADDITION OF BUPRENORPHINE TO URINE SPECIMENS WITH CLINICAL FACTORS FROM A NATIONAL URINE DRUG TEST DATABASE Jarratt Pytell¹; Penn Whitley²; Steven Passik²; William L. Bundy²; Eric Dawson²

¹General Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ²Millennium Health, San Diego, CA. (Control ID #3873051)

BACKGROUND: Patients being treated for opioid use disorder (OUD) with buprenorphine may directly add their medication to urine drug test specimens to give results suggestive of adherence. Published studies describing this finding are limited to single sites and have not included clinically relevant information such as co-positivity of other substances or describe which settings this phenomenon might be more likely to occur. To address these gaps, we analyzed data from a national drug test database which included clinically relevant data and can therefore provide a more comprehensive description of the phenomenon.

METHODS: We conducted a cross-sectional study of urine drug tests results from 2017 to 2022 in Millennium Health’s proprietary urine drug test database. We included urine drug test results from patients receiving buprenorphine for the treatment of OUD and quantitative norbuprenorphine or buprenorphine urine concentrations were reported. Norbuprenorphine to buprenorphine concentration ratio of <0.02 was used to identify the possible direct addition of buprenorphine by a a patient to the urine specimen. The association of co-positive opioid or stimulant drug test, care setting, geographic region, participant age, participant gender, and year with possible add-in was calculated using general estimating equations which accounted for repeated measurements.

RESULTS: The study included 507,735 urine specimens from 58,476 patients. 261,210 (51.4%) were obtained from men with 137,254 (37.7%) from patients with ages 25-34 years. Overall, results from 9,546 (1.9%) were suggestive of the direct addition of buprenorphine and the annual prevalence decreased from

2.4% in 2017 to 1.2% in 2020. Opioid positive with (aOR 2.01, 95%CI 1.85-2.18) and without (aOR 2.02, 95%CI 1.81-2.26) stimulant positive specimens were associated with the direct addition of buprenorphine to specimens while opioid negative/stimulant positive specimens were negatively associated (aOR 0.78 95%CI 0.71-0.85). Specimens from primary care (aOR 1.60, 95%CI 1.44-1.79) and patient ages 35-44 years (aOR 1.59, 95%CI 1.34-1.90) associated with the direct addition of buprenorphine while private insurance (aOR 0.79, 95%CI 0.71-0.86) was negatively associated. Specimens from the South Atlantic census region had the highest association (aOR 1.4, 95%CI 1.25-1.56) and New England having the lowest association (aOR 0.54, 95%CI 0.46-0.65) with the direct addition of buprenorphine.

CONCLUSIONS: In this cross-sectional study, the direct addition of buprenorphine to urine specimens was associated with opioid positivity and primary-care settings and may becoming less prevalent over time. The direct addition of buprenorphine to urine is a clinically significant finding and best practices specific for this phenomenon are needed.

A SURVEY-BASED ASSESSMENT OF BARRIERS AND FACILITATORS TO RESIDENT-LED PRESCRIBING OF BUPRENORPHINE IN THE INPATIENT SETTING

David Chen¹; Leah Stinson¹; Michael A. Incze²; Carolyn Bell¹; Danielle Babbel¹

¹Internal Medicine, University of Utah Health, Salt Lake City, UT; ²Internal Medicine, University of Utah, Salt Lake City, UT. (Control ID #3877285)

BACKGROUND: Buprenorphine is an important treatment for opioid use disorder (OUD). However, it is underutilized in the inpatient setting. This study was part of a quality improvement initiative to increase resident-led prescribing of buprenorphine. Our objective was to determine the most significant barriers to as well as facilitators of inpatient buprenorphine prescribing, and to assess the potential impact of a buprenorphine orderset.

METHODS: Internal Medicine residents were invited to complete a Qualtrics-based survey. Residents were asked to gauge their comfort level (on a 0-5 Likert scale) with various aspects of prescribing buprenorphine. Residents were then asked to rank seven pre-specified barriers as well as eight facilitators in terms of their impact on prescribing buprenorphine in the inpatient setting. The mean ranking of each barrier and facilitator was used to determine an aggregate rank list. Finally, residents were asked to gauge (on a 0-5 Likert scale) if a proposed inpatient buprenorphine orderset (including standardized dosing, nursing orders, ancillary medications, and screening lab) would increase their comfort level with and likelihood of prescribing buprenorphine.

RESULTS: 20 residents evenly distributed through PGY-1 and PGY-3 training levels participated in our study. Most (14/20) residents only rarely or occasionally prescribed buprenorphine in the inpatient setting, and none were regular prescribers. Although almost all (16/17) residents somewhat or strongly agreed that buprenorphine is effective in reducing mortality from OUD, most felt uncomfortable dosing buprenorphine (13/17) or counseling patients on buprenorphine (15/17). Most residents (14/18) ranked lack of training and knowledge as the most significant barrier to prescribing buprenorphine, followed by insufficient time and concerns about transitions of care from the inpatient to outpatient setting. Special training was ranked as the highest facilitator, followed by previous experience prescribing buprenorphine and pharmacy assistance. All participants (17/17) agreed the proposed buprenorphine orderset would increase their comfort level at least moderately, and almost all (17/18) agreed it would increase their likelihood of prescribing buprenorphine at least moderately.

CONCLUSIONS: Our data suggest that, despite recognition for the lifesaving role of buprenorphine in OUD, there is a gap in resident training that needs to be addressed. It also suggests that a buprenorphine orderset would be beneficial in increasing comfort levels and the likelihood of prescribing buprenorphine in the inpatient setting.

ASYNCHRONOUS VERSUS SYNCHRONOUS SCREENING FOR DEPRESSION AND SUICIDALITY: EXPERIENCES IN A PRIMARY CARE HEALTH SYSTEM

Amelia Sattler¹; Julia Dunn³; Ana Calugar²; Marleni Albarran¹; Nadine Jawad¹; Mira Zein³; Mark McGovern³

¹Medicine, Stanford University School of Medicine, Stanford, CA; ²ambulatory quality , Stanford health care, Palo Alto , CA; ³Psychiatry, Stanford School of Medicine, Palo Alto, CA. (Control ID #3876960)

BACKGROUND: Primary care health systems (PCHS) can help prevent suicide by effectively screening and connecting patients with treatment for depression. Despite recommendations for universal depression screening, there are concerns about the need for immediate clinical response and possible liability in screening for suicidality. During the COVID-19 pandemic, patient care shifted radically from face-to-face to virtual. Our PCHS adapted our depression screening program to allow for both pre-visit virtual (asynchronous) and in-clinic (synchronous) visits. The objectives of this study were to describe and evaluate differences among patient characteristics and provider clinical responses for those who screened synchronously versus asynchronously.

METHODS: This quality improvement study was conducted in two PCHSs in Northern California. Our universal depression screening program launched with an automated electronic questionnaire workflow and clinical resources to help providers manage patients with depressive symptoms. Patients responding to the ninth question of the Patient Health Questionnaire (PHQ-9) pertaining to suicide with a score of one or higher in the first six months of the program were included in this analysis. Trained reviewers used reports and electronic medical records to determine clinical responses. Univariate logistic regressions were used to evaluate for differences in clinical response and patient characteristics.

RESULTS: In total, 1,683 patients screened positive on the ninth item of a PHQ-9. Hispanic and Latino patients were less likely than others to complete a PHQ-9 before a visit (OR: 0.6; 95% CI: 0.45-0.8; p<0.001). Patients with Medicare insurance were 0.64 times (95% CI: 0.51-0.79) less likely to complete a PHQ-9 before a visit than patients with private insurance. Those with moderate to severe depression were 1.61 times more likely (95% CI: 1.21-2.15; p=0.001) to complete screening before a visit than those with no or mild symptoms. Patients screened before a visit were twice as likely to complete a Columbia Suicide Severity Rating Scale than those who completed a PHQ-9 in clinic (OR: 2.41; 95% CI: 1.89-3.06; p<0.001). Additionally, patients screened asynchronously were less likely to receive a referral to psychiatry than those screened synchronously (OR: 0.23; 95% CI: 0.16-0.34; p<0.001). Those who reported suicidal thoughts “more than half the days” (OR: 1.62; 95% CI: 1.06-2.48) and “nearly every day” (OR=2.38; 95% CI: 1.38-4.12) were more likely to receive a referral to psychiatry, compared to those who reported thoughts “several days” (p=0.002).

CONCLUSIONS: Shifting depression screening from in-clinic to a pre-visit questionnaire led to a dramatic increase in our system’s ability to screen for depression while maintaining patient safety. Our findings suggest that virtual delivery of the depression screening program can increase self-reporting for patients and elicit more intentional clinical responses from providers.

BEFORE MEETING THE PRESCRIBER: ASSESSING STAFF STIGMA TOWARDS PEOPLE WITH SUBSTANCE USE DISORDERS

Priyal Gandhi¹; Jarratt Pytell²; Yea-Jen Hsu³; Alene Kennedy-Hendricks³; Colleen Barry⁵; Geetanjali Chander⁶; Megan Buresh⁴

¹Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; ²Medicine, Johns Hopkins University, Baltimore, MD; ³Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; ⁴Division of Chemical Dependence, Johns Hopkins School of Medicine, Baltimore, MD; ⁵Cornell Jeb E. Brooks School of Public Policy, Ithaca, NY; ⁶Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA. (Control ID #3876993)

BACKGROUND: There is great stigma towards people with substance use disorders (SUD), and particularly towards medications for opioid use disorder (OUD) including methadone and buprenorphine. This stigma has negative impact on access to treatment and provision of medical care.

Research assessing stigma towards people with SUD, OUD, and medications for OUD in the medical setting has largely focused on prescribers, with limited to no perspectives of non-prescriber staff, who are often front-line workers caring for people with SUD. Understanding attitudes of non-prescriber medical staff is critical to implementing anti-stigma education in healthcare.

METHODS: First, a draft survey instrument was developed based on literature review of surveys assessing stigma towards people with SUD, mental illness, and HIV. The draft instrument was distributed to a group of content and methods experts with revisions made to improve face and content validity. The revised instrument included questions assessing deservingness towards persons with drug addiction (6 items), stigma towards persons with drug addiction as measured by social distance measures (4 items), attitudes towards disease of opioid addiction (3 items), comfort providing services to people on medications for OUD (6 items), and attitudes and stigma towards opioid agonist medications (4 items). The survey was distributed to non-prescriber healthcare staff across inpatient and outpatient settings. Recruitment occurred by email over a six-month period and surveys were completed anonymously online.

RESULTS: The survey was distributed to 1497 healthcare staff, with 301 total responses for an approximate response rate of 20%. The most common profession identified among participants was nurse (23%), followed by pharmacist (15%) and pharmacy technician (12%). Most participants knew about buprenorphine (92%), methadone (90%), and injectable extended release naltrexone (67%). Participants responded positively to 8 out of 10 items on the deservingness and social distance scales. The majority (87%) of respondents agreed or strongly agreed that “people with drug addiction deserve the bad things that happen to them because of their addiction.” Most participants (74-89%) responded positively to questions assessing attitudes towards OUD as a treatable medical condition. Only thirty-four percent of respondents disagreed or strongly disagreed with the item “treating opioid addiction with methadone or buprenorphine is replacing one addiction with another.”

CONCLUSIONS: In this cross-sectional sample of non-prescribing healthcare staff, there was a generally low level of self-reported stigma towards people with SUD, OUD, and medications for OUD. Yet, the majority viewed SUD as a personal responsibility with opioid agonist treatments as another form of addiction. These results highlight the need for anti-stigma education among all healthcare workers as a first step to creating a welcoming place for people with SUD to obtain needed services.

COMORBIDITIES AND PATIENT-REPORTED STIGMA AMONG PATIENTS STARTING BUPRENORPHINE FOR OPIOID USE DISORDER IN THE EMERGENCY DEPARTMENT

Stephen G. Henry^1,2; Aimee K. Moulin^4,2; Dominique Ritley²; Sabrina F. Loureiro²; Julia E. Fleuret²; Iraklis E. Tseregounis^1,2; Elizabeth M. Magnan^3,2

¹Internal Medicine, University of California Davis, Sacramento, CA; ²Center for Healthcare Policy and Research, University of California Davis, Sacramento, CA; ³Family and Community Medicine, University of California Davis, Sacramento, CA; ⁴Emergency Medicine, University of California Davis, Sacramento, CA. (Control ID #3874354)

BACKGROUND: Diagnosing and starting treatment for opioid use disorder (OUD) in emergency departments (ED) is an effective strategy for reaching vulnerable patients and is recognized as best clinical practice. Little research has focused on factors associated with long-term treatment retention following ED- initiated treatment, including the role of comorbidities and patient-reported stigma in this difficult-to-study population. This study recruited patients starting buprenorphine for OUD in an academic emergency department to characterize their comorbidities and stigma experience, and to develop protocols to longitudinally follow them in subsequent studies.

METHODS: Potentially eligible adults were identified by ED clinicians, research coordinators who reviewed charts based on patents’ chief complaint, and ED counselors who assessed patients for OUD.

Research coordinators confirmed eligibility and enrolled patients either in the ED or by phone 1-2 days later. Enrolled patients completed phone surveys 1-2 days, 6 weeks, and 4 months after their ED visit. Surveys included use of opioids, alcohol, and other drugs; symptoms of anxiety (GAD-7), depression (PHQ-8), PTSD (PTSD-5), pain (brief pain inventory, BPI); and patient-reported OUD stigma (PROMIS stigma measure modified for OUD and substance use stigma mechanisms scale, SU-SMS).

RESULTS: Of 523 patients screened over 8 months, 60 (12%) were eligible. Of these 19 (32%) completed baseline surveys, 21 (35%) declined to enroll, and 10 (17%) and 11 (18%) could not be contacted to complete eligibility screening and baseline surveys, respectively, after their ED visit. So far, 10 and 5 patients have completed 6-week and 4-month surveys, respectively. Enrolled patients averaged 37 years old, were 41% male, 94% housed, 71% English-speaking, 37% White, 37% Hispanic, 11% Black, 16% Other. 56% reported using heroin in the past 30 days; 28% reported using opioids for nonmedical purpose. 93% used tobacco, 50%, cannabis, and 43%, methamphetamine. 22% and 53% had AUDIT-C and PTSD-5 scores >3, respectively. Mean GAD-7 and PHQ-8 scores were 13.9 (moderate anxiety) and 13.2 (moderate depression). Mean pain severity and intensity were 4.3 and 4.8, respectively on 0-10 scales. Mean PROMIS stigma and SU-SMS scores were 22.3 (SD 9.0) and 61.9 (SD 15.1), respectively.

CONCLUSIONS: Patients starting buprenorphine for OUD commonly use other substances and report significant mental health comorbidities. All patients reported some OUD stigma and stigma severity varied widely. Identifying, enrolling and following patients who start buprenorphine for OUD in the ED for research is challenging. Successful recruitment requires multiple, flexible strategies and substantial resources. Strategies should also take into account patients’ high rates of mental health and substance use comorbidities. Further research on the impact of patient-reported OUD stigma on treatment outcomes and research participation is needed.

DEPRESSION AND ANXIETY SYMPTOMS IN OLDER PRIMARY CARE ADULTS: 10-YEAR TRAJECTORIES AND THEIR DEMOGRAPHIC DETERMINANTS

Rebecca Lovett^1,2; Leah Welty^2,4; Andrea Russell³; Patrick Cecil³

¹Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ²Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL; ³Feinberg School of Medicine, General Internal Medicine, Northwestern University, Chicago, IL; ⁴Preventive Medicine (Biostatistics), Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #3876404)

BACKGROUND: Depression and anxiety are common mental health conditions among older adults in primary care settings. However, few studies have examined patterns of symptoms over time amongst this population. Improved understanding of symptom trajectories can help to identify subgroups of individuals for whom symptoms may be chronically high, increasing or relapse/remitting, which can help to optimize treatment efforts in time or resource-limited settings. The objective of this study was to determine depressive and anxiety symptom trajectories over 10 years among older, primary care adults and their demographic (gender, race, education) determinants.

METHODS: As part of the Literacy and Cognitive Function Among Older Adults (i.e., ‘LitCog’) cohort study, 900 community-dwelling adults aged 55-74 and without severe cognitive, visual, or hearing impairments at baseline were recruited from 5 primary care clinics across Chicago, IL from 2008 to 2013 and interviewed at 4 time points over a 10-year period. Mental health symptoms were assessed at each time point using the Patient-Reported Information Measurement System (PROMIS) depression and anxiety short-forms. Both depressive and anxiety symptom trajectories were estimated separately using group-based trajectory modeling (GBTM), assuming a censored normal distribution and including baseline demographic factors as time-stable covariates. Bayesian information criterion, entropy, and average posterior probabilities of group membership were used to identify optimal number of trajectory groups.

RESULTS: Criterion analysis indicated a three-group solution for both depression and anxiety. Most older adults exhibited minimal (47.2% and 22.8%) or normative (37.9% and 46.2%) levels of depressive or anxiety symptoms, respectively, and which declined slightly over the study period. A minority displayed chronically elevated depressive or anxiety symptoms (14.9% and 31.0%, respectively), which also slightly declined over time. For depression and compared to the minimal symptom group, being of a non-Black minority (aOR 3.43, 95% CI 1.35-8.74) and having less than a college degree (HS or less: aOR 6.52, 95% CI 2.84-14.9; Some college: aOR 3.42, 95% CI 1.41-8.30) were associated with chronic symptoms. For anxiety and compared to the minimal symptom group, female gender (aOR 1.76, 1.09-2.82) and a high school education or less (aOR 2.67, 1.37-5.22) were associated with chronic symptoms.

CONCLUSIONS: Most older, primary care adults have low mental health burden in older age, although a significant minority experience consistently elevated depressive or anxiety symptoms. Female gender, identifying as a non-Black minority, and having lower educational attainment tended to predict more adverse symptom trajectories over time. Findings can help to target screening and/or intervention efforts surrounding common mental health concerns among older adults in primary care.

DEVELOPING VETERAN NARRATIVES FOR DIRECT-TO-CONSUMER MARKETING MATERIALS ON MEDICATIONS FOR OPIOID USE DISORDER

Alicia Bergman¹; Rebecca Oberman²; Evelyn T. Chang³

¹CSHIIP, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Veterans Health Administration, Washington, DC; ³General Internal Medicine, VA- Greater Los Angeles, Los Angeles, CA. (Control ID #3868274)

BACKGROUND: VISN 22 conducted a quality improvement project to increase provider and patient awareness, uptake, and access to medications for opioid use disorder (MOUD) to decrease opioid-related overdoses and mortality. Patients have generally had favorable experiences with MOUD. Because sharing Veterans’ stories can be a compelling way to encourage other Veterans to seek treatment, we sought to develop truthful and impactful direct-to-consumer marketing materials that would feature Veteran testimonies.

METHODS: As part of an evaluation of the QUERI-funded initiative to improve access to MOUD in 5 medical centers in VISN 22, the qualitative lead and project director interviewed 17 patients who had been successfully treated with MOUD and were recruited by their addiction psychiatrists (FY18-21). Our implementation strategy included monthly cross-facility interdisciplinary collaborative meetings with 24 provider champions from primary care, addiction, pain, and pharmacy, and meetings within an Opioid Addiction and Recovery Veteran Engagement Board (OAR-VEB), consisting of 10 Veterans in recovery from OUD.

RESULTS: We identified six of the most impactful Veteran narratives about MOUD from the patient interviews and developed a one-paragraph blurb to follow each narrative on how veterans could seek treatment for OUD at their local facility and presented them at the cross-facility interdisciplinary collaborative meetings. Feedback from provider champions included recommendations to de-emphasize MOUD as treatment for pain (an off-label use for MOUD) and to avoid using overly positive quotes/narratives about MOUD. Next, we presented the four remaining quotes/narratives and revised blurb to Veterans during an OAR-VEB meeting. Veteran feedback included suggestions to avoid trigger words and stigmatizing language (e.g., “addiction”, “disorder”, crutch”), and to avoid overly positive language by making MOUD appear “too good to be true”. Next, we presented the 3 revised narratives and treatment blurb to the cross-facility interdisciplinary collaborative for review. Feedback included avoiding reference to a patient’s specific dosage and removing part of a quote that was not evidence-based. We then presented the narratives and treatment blurb to our VISN-level workgroup for final approval.

CONCLUSIONS: We effectively used key stakeholders to develop Veteran narratives about MOUD that would be evidence-based and compelling to Veterans. Veteran feedback focused on how to best appeal to Veterans and avoid stigmatizing language. Provider key stakeholder feedback was sensitive to the suggestions of Veterans but also ensured that the content was evidence-based. A similar multi-step process involving key stakeholders may be used to feature Veteran testimonies for direct-to-consumer marketing materials that is non-stigmatizing and evidence-based. These materials may be able to increase Veteran adoption of evidence- based treatment, such as that for OUD.

DEVELOPMENT AND VALIDATION OF AN EMR-BASED CASE IDENTIFICATION TOOL TO IDENTIFY HOSPITALIZED PERSONS WITH CHRONIC PAIN AND ELEVATED RISK OF OPIOID-RELATED HARM

Michele Buonora^1,2; Alexandra M. Hajduk¹; Adam Ackerman^4,1; Krishna R. Daggula⁶; William Becker^3,1; Sarwat Chaudhry¹; David A. Fiellin^1,5; Melissa B. Weimer^1,5

¹Department of Medicine, Yale University School of Medicine, New Haven, CT; ²Department of Medicine, VA Connecticut Healthcare System, West Haven, CT; ³VA Pain Research Informatics Multi-morbidities and Education Center, West Haven, CT; ⁴Medicine, Yale New Haven Hospital, Woodbridge, CT; ⁵Yale University School of Public Health, New Haven, CT; ⁶Joint Data Analytics Team, Yale New Haven Hospital, New Haven, CT. (Control ID #3874488)

BACKGROUND: Persons with comorbid chronic pain and elevated risk for opioid-related harm – defined as opioid use disorder (OUD), opioid misuse, or high risk for overdose or other opioid-related harm – are frequently hospitalized for general medical care. Little is known about the quality of hospital-based pain treatment, efforts to mitigate opioid-related harms, and/or OUD treatment for this group. There is an urgent need to study interventions addressing their complex needs. Currently, a major barrier to initiating this research is the inability to accurately identify this group in real time. We aimed to develop and validate an automated, rapid and feasible electronic medical record (EMR)-based tool using real-time data to identify hospitalized persons with comorbid chronic pain and elevated risk for opioid-related harm.

METHODS: We conducted a single-site development and validation study of an EMR-based case identification (ID) tool for adults (>18 years old) hospitalized at Yale New Haven Hospital. The tool comprised a discrete set of data elements grouped into four criteria informed by an exhaustive literature search, key stakeholders including persons with lived experience of chronic pain and/or OUD, and feasibility. The criteria included: (1) admission on a general medicine unit; (2) chronic pain; (3) elevated risk for opioid- related harm; and (4) opioid medication ordered during hospitalization. The medical records of 50 persons identified (“cases”), and 50 persons not identified (“non-cases”) by the tool, admitted on one calendar day, were independently reviewed by two physicians to evaluate for all four criteria. Differences were adjudicated by a third physician, and tool sensitivity and specificity calculated.

RESULTS: Data elements in the final case ID tool included a general medicine hospitalization; diagnosis code for low back pain, joint disorder, or headache (as indicator for chronic pain); diagnosis code for opioid poisoning, opioid withdrawal, adverse effect of opioid, OUD, and/or medication prescribed for OUD (as indicator for elevated risk for opioid-related harm); and an active opioid medication order. Cases had a mean age of 57.4 (±14.2) years, were 52% female, and 68% White, 24% Black, 6% Hispanic, and 2% American Indian or Alaskan Native. Sixty percent of cases had OUD, 4% opioid misuse, and 34% high risk for overdose or other opioid-related harm due to polypharmacy, high prescribed opioid dose, or lack of guideline-concordant care. On review, 48 of 50 cases met all four criteria, and 44 of 50 non-cases met three or fewer criteria, corresponding to a sensitivity of 88.9% and specificity of 95.7%.

CONCLUSIONS: It is feasible to develop an EMR-based tool to prospectively identify hospitalized persons with comorbid chronic pain and elevated risk for opioid-related harm. Future work should validate this tool in other hospital systems. It is imperative to develop and evaluate interventions for this group, many of whom have historically been excluded from this research.

DIMENSIONS OF HOMELESS EXPERIENCES ON SUBSTANCE USE AMONG A REPRESENTATIVE PROBABILITY SAMPLE OF ADULTS EXPERIENCING HOMELESSNESS IN CALIFORNIA

Ryan D. Assaf^1,2; Meghan Morris^3,1; Cheyenne Garcia^1,2; Eve Perry^1,2; Margot Kushel^1,2

¹Benioff Homelessness and Housing Initiative, University of California San Francisco, San Francisco, CA; ²Center for Vulnerable Populations, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA; ³Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA. (Control ID #3876557)

BACKGROUND: Approximately 170,000 people experience homelessness nightly in California (CA), representing one third of those in the US. Due to high rates of unsheltered homelessness, CA has half of the US unsheltered homeless population. Past experiences with homelessness increase the likelihood of illicit drug use. Most literature on homelessness comes from small non-representative samples, service provider samples, or is from areas with a right to shelter. In a representative study of adults experiencing homelessness in CA, we describe patterns of illicit drug use and assess the association between illicit drug use and homelessness age, duration, and shelter status.

METHODS: Using a venue-based sampling frame to create a representative sample of adults experiencing homelessness (PEH) in CA, we recruited homeless participants aged 18 and older in 8 counties between Oct. 2021 to Nov. 2022. Trained staff administered questionnaires. We used logistic regression analysis to assess dimensions of homelessness and any illicit drug (cocaine/crack, opioids/heroin, or meth/amphetamine) use in the past 6 months adjusting for demographics, socio-economic status, lifetime state jail/federal prison, and mental health six months before homeless experience.

RESULTS: Overall, 3,065 participants completed the survey. Among the weighted sample, the mean age was 46.6 years old (SD 72.3). Many participants were cisgender men (69.3%), Latinx (36.3%), non-Hispanic Black (23.8%) or non-Hispanic White (22.6%), with less than $10 in savings (85.3%). Approximately half were unsheltered (no vehicle) (49.8%), 20.9% unsheltered living in vehicles, and 29.3% sheltered. Half (53.8%) report having experienced homelessness more than once, and 73.0% experienced chronic homelessness. The median age of first homeless experience was 33 (IQR 21 - 45). Most reported lifetime use of any illicit drug (76.0%) with 50.3% reporting past 6-month use of any illicit drug (10.9% cocaine/crack, 17.1% opioid/heroin, 45.8% meth/amphetamine). Compared to those in shelters, those who were unsheltered (no vehicle) and those unsheltered in a vehicle had increased odds of any drug use in the past 6 months (adjusted odds ratio [AOR] 4.74, 95% confidence interval [CI] 4.56, 4.93; AOR 2.80, 95% CI 2.67, 2.93, respectively). Those experiencing chronic homelessness were at increased odds of drug use compared to those who were not (AOR 1.66, 95% CI 1.61, 1.72). Every 10-year increase in age of first homeless experience decreased the odds of any drug use (AOR 0.95, 95% CI 0.94, 0.96).

CONCLUSIONS: We found that the prevalence of cocaine/crack was lower (12.5-37.7%) whereas opioid/heroin (6.4-12.9%) and methamphetamine use (4.8-29%) were higher than prior literature among PEH; with similar associations with dimensions of homelessness. Housing first interventions successfully house those with substance use disorders and should be expanded to meet the need.

ENGAGING HEALTH CARE TEAMS TO INCREASE ACCESS TO MEDICATIONS FOR OPIOID USE DISORDER

Rebecca Oberman¹; Alexis Huynh¹; Adam Resnick¹; Kelsey Cummings¹; Stephanie L. Taylor²; Alicia Bergman³; Evelyn T. Chang⁴

¹Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Veterans Health Administration, Washington, DC; ²Health Services Research, VA, Los Angeles, CA; ³CSHIIP, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ⁴General Internal Medicine, VA- Greater Los Angeles, Los Angeles, CA. (Control ID #3868777)

BACKGROUND: Medications for opioid use disorder (MOUD) can effectively treat opioid use disorder (OUD) and decrease opioid-related overdoses and deaths. However, MOUD adoption has been slow, particularly in non-specialty settings (e.g., Primary Care, Mental Health), due to numerous implementation challenges. We sought to assess the use of Evidence-Based Quality Improvement (EBQI) as an implementation strategy to expand the use of MOUD within non-specialty settings.

METHODS: We used EBQI to sequentially engage seven facilities in VISN22 from April 2018 to December 2021. EBQI included multilevel stakeholder engagement, with external facilitators providing technical support, practice facilitation, and routine data feedback. We established an interdisciplinary quality improvement (QI) team at each facility (e.g., primary care, addiction, pain, pharmacy) and a monthly cross- facility interdisciplinary collaborative that allowed our QI teams to share tools, lessons learned, and experiences. Each facility identified multidisciplinary champions (e.g., primary care, mental health, pharmacy) who developed QI action plans and presented these plans to the collaborative, as well as to facility and VISN leadership. We also met monthly with VISN stakeholders to address implementation barriers and share progress.

Our primary outcome measure was the proportion of patients with OUD who received MOUD in the past year, a VHA performance measure. We used a stepped wedge design with repeated cross sections to accommodate the phased implementation of EBQI across the 7 facilities. We used aggregate facility-level data of OUD treatment from September 2015 – December 2021 and analyzed changes in patients receiving MOUD using hierarchical multiple logistic regression.

RESULTS: The proportion of patients with OUD receiving MOUD improved significantly over time for all facilities (OR: 1.027, 95% CI: 1.021,1.033). This represents a 2.7% increase in the odds of patients treated with MOUD for each quarter across facilities without EBQI. Facilities that engaged in EBQI had additional improvement in patients treated with MOUD (OR:1.194, 95% CI: (1.061,1.344) over time. Duration of EBQI implementation was unassociated with changes in patients receiving MOUD.

CONCLUSIONS: EBQI strategies used to engage health care teams within non-specialty settings were effective in expanding access to MOUD. QI teams used an assortment of QI interventions and developed action plans to improve access to MOUD at their facilities, resulting in an increase in patients receiving MOUD above and beyond those associated with temporal trends.

EVALUATING THE EFFICACY OF A MENTAL HEALTH TRIAGE PROGRAM AT A PRIMARY CARE CENTER FOR REFUGEE HEALTH

Uttara Gadde¹; Divya Saini²; Emily Rider-Longmaid¹; Rachael Truchil¹

¹Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; ²Medical School, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #3875983)

BACKGROUND: Refugees have a higher risk of depression, post-traumatic stress disorder (PTSD), and anxiety compared to the general population given exposures to war, torture, discrimination, and social alienation throughout the migration process. There have been recent efforts to integrate mental health services into primary care delivery to reduce barriers to care but the effectiveness of such integration for refugee populations is unknown given their unique language barriers, cultural differences, and other social determinants of health. This study aimed to highlight the burden of mental health disease amongst this patient population and evaluate the barriers to accessing care via an integrated mental health triage program. METHODS: A retrospective analysis was conducted at the refugee clinic at the Penn Center for Primary Care. A retrospective chart review identified patients referred to the integrated mental health services, Penn Integrated Care (PIC), between 2018-2021. PIC provides integrated care for patients with mild to moderate depression and anxiety, and coordinates linkage of care for patients with a higher level of need with community providers through an initial triage visit to determine eligibility. Demographic information and mental health diagnoses was collected from clinical visits and from PIC initial triage notes.

RESULTS: From 2018 to 2021, a total of 218 patients were seen, most commonly from Afghanistan, Ukraine, Nepal, Burma and Guatemala; of these patients, 37 (17%) screened positive for a mental health disorder, most commonly PTSD (7.8%) and depression (5.5%). Clinicians conducted assessments using standardized tools in 24% of patients. Of the 37 patients that screened positive, 22 (10%) were referred to PIC with barriers for referral including patient refusal or inability to perform full evaluation due to language barriers. Of the referred patients, triage was completed for 16 (73%).The most common barriers to completing triage included the inability to reach patients, insurance issues, language barrier, and patient refusal to participate. None of the patients were eligible to receive integrated services in the clinic due to higher level of need.

CONCLUSIONS: Screening for mental health disorders is an important component of providing comprehensive primary care for refugees. Despite the availability of integrated mental health services, there were significant barriers for refugee patients receiving this service, including barriers to placing referral, completing the assessment, as well as linkage with community services when integrated services were not feasible. To best serve this vulnerable population, more standardized assessment and referral tools must be utilized by providers as well as more streamlined processes (including potentially structural changes to the intake process and changes to the eligibility requirements in addition to the improved availability of interpretation services) for better linkage to care.

EVALUATION OF A NOVEL PRIMARY CARE-COLLABORATIVE CARE MODEL FOR ADULTS WITH COGNITIVE IMPAIRMENT AND NEUROPSYCHIATRIC SYMPTOMS

Daniel Y. Johnson¹; Erin Staab²; Peter Hahn¹; Carly Lusk²; Erin Zahradnik³; Neda Laiteerapong²

¹University of Chicago Pritzker School of Medicine, Chicago, IL; ²Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ³Psychiatry and Behavioral Neuroscience, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #3871946)

BACKGROUND: About 6 million Americans have dementia, and about 40% have neuropsychiatric symptoms (e.g., depression, anxiety, delirium). Ideally, these patients would be managed by a geriatrician, and if symptoms are moderate-severe, by a geriatric psychiatrist. However, there is a national shortage of geriatricians and geriatric psychiatrists. Another strategy is the Collaborative Care Model, which integrates primary care and behavioral health professionals to address mental health problems. This has been shown to be more effective than usual care for many mental health problems, but its effectiveness for patients with comorbid cognitive impairment is unknown. This study evaluates the clinical outcomes and implementation of collaborative care for adults with cognitive impairment and neuropsychiatric symptoms at a large urban academic medical center.

METHODS: This was a retrospective chart review of adults with cognitive impairment and neuropsychiatric symptoms enrolled in the Collaborative Care Service in the first year after launch (Nov 1, 2021-Oct 31, 2022). The service included biweekly telehealth visits with a social worker, care management, psychiatric consultation for diagnoses and medications, and/or brief therapy. The primary outcome was clinical effectiveness, defined as change in PHQ (Patient Health Questionnaire)-9 and GAD (Generalized Anxiety Disorder)-7 scores and assessed using paired t-tests. Secondary outcomes were the enrollment rate and the mean number of encounters with a social worker, assessments, and psychiatric case reviews per month. RESULTS: Twenty-five patients with cognitive impairment were enrolled in the service; all patients had depression and/or anxiety. The mean age was 71.4 ± 11.4 years old, 84% were female, 52% were Black, and 48% were White. Eight patients (32%) graduated: 7 for improved scores (88%) and 1 handed off to higher level of care (13%). Seven patients (28%) were discharged for lack of participation and 10 (40%) were still enrolled at the end of the study period. There were significant decreases in PHQ-9 scores among patients with depression (-5.3 ± 4.1, p < 0.01) and GAD-7 scores among patients with anxiety (-4.3 ± 4.4, p = 0.01). Each month, patients had an average of 2.4 ± 1.1 encounters, 1.4 ± 0.7 assessments, and 1.9 ± 0.8 case reviews.

CONCLUSIONS: In its first year, the Collaborative Care Service improved depression and anxiety symptoms among adults with cognitive impairment. Future work should explore primary care clinician, patient, and caregiver satisfaction with collaborative care. This service provides a framework for other behavioral health programs aiming to address neuropsychiatric symptoms among adults with cognitive impairment.

EXPLORATION OF HIV RISK BEHAVIORS AND ATTITUDES TOWARDS PREP AMONG PEOPLE WHO INJECT DRUGS BY GENDER AND SEXUAL ORIENTATION.

Elenore Bhatraju¹; Judith I. Tsui¹; Andrea Radick¹; Moonseong Heo⁶; Laksika Sivaraj⁶; Shruti Mehta⁴; Paula J. Lum⁷; Lynn E. Taylor⁸; Judith Feinberg⁹; Arthur Kim⁵; Brianna Norton²; irene pericot-tvalverde¹⁰; Kimberly Page³; Alain H. Litwin²

¹Medicine, University of Washington, Seattle, WA; ²Medicine, Albert Einstein College of Medicine, Bronx, NY; ³Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM; ⁴Epidemiology, Johns Hopkins, Johns Hopkins University, Baltimore, MD, US, academic, Baltimore, MD; ⁵Internal Medicine, Harvard Medical School, Boston, MA; ⁶Clemson University, Clemson, SC; ⁷Medicine, UCSF, San Francisco, CA; ⁸University of Rhode Island, Kingston, RI; ⁹West Virginia University School of Medicine, Morgantown, WV; ¹⁰Clemson University College of Behavioral Social and Health Sciences, Clemson, SC. (Control ID #3874584)

BACKGROUND: Decreasing new HIV infections in the US by 90% by 2030 is the goal of the federal Ending the HIV Epidemic initiative. People who inject drugs (PWID) are at increased risk for acquiring HIV, however uptake of Pre-Exposure Prophylaxis (PrEP) in this group has been extremely limited in the US and globally. This study evaluated interest and concerns around both oral and injectable PrEP among PWID across different gender and sexual orientations.

METHODS: Cross-sectional analysis of survey data from 8 different sites assessing attitudes and interest in PrEP were collected at a single post-treatment study visit during HERO, a pragmatic clinical trial of models of hepatitis C virus (HCV) treatment delivery among people who had injected drugs in the past 90 days. Demographics, HIV risk behaviors and attitudes towards PrEP are described overall as well as by the following self-identified gender and sexual orientation categories: heterosexual men, heterosexual women, men who have sex with men (MSM), women who have sex with women (WSW), transgender male to female (MtF); no female to male transgender participants enrolled. Interest in and barriers to PrEP were compared across categories using Chi-square tests.

RESULTS: 283 participants completed the survey between Sept 2016 and Aug 2018. The mean (±SD) age was 44 (±11) years. Gender and sexual orientation were reported as follows: heterosexual men 65%, heterosexual women 23%, MSM 4%, WSW 6%, and MtF 1%. 42% reported receptive injection equipment sharing and 41% had overlap of sex and injecting partners during the past 3 months. Self-perceived HIV risk scores (0-10) were low overall, mean (±SD) 2.3 (±2.0). Interest in injectable PrEP (49.6%) was substantially higher than interest in daily oral PrEP (19.6%). Interest in injectable PrEP was significantly different across the groups; heterosexual men reported the lowest interest (43.8%), compared to heterosexual women

(59.6%), MSM (58.3%), WSW (76.5%) and MtF (100%) (p=0.003 across groups). The most commonly cited concerns were medication side effects (52%) and interactions with other medications (39.4%). Perceived HIV risk and PrEP barriers were not significantly different among the gender/sexual orientation categories.

CONCLUSIONS: Despite ongoing risk factors for HIV, this cohort of PWID who had been treated for HCV had low self-perceived HIV risk. There was higher interest in injectable PrEP, and the top concerns about PrEP were related to side effects and medication interactions. These results suggest high acceptability of injectable PrEP among PWID, particularly among women and gender/sexual minority groups who may have overlapping sex and drug risk factors, and the need for education around PrEP candidacy and side effects.

FACTORS THAT FACILITATE THE PRESCRIBING AND ACCEPTANCE OF MEDICATIONS FOR OPIOID USE DISORDER IN VA: VETERAN AND PROVIDER PERSPECTIVES

Alicia Bergman¹; Rebecca Oberman²; Stephanie L. Taylor³; Evelyn T. Chang⁴

¹CSHIIP, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Veterans Health Administration, Washington, DC; ³Health Services Research, VA, Los Angeles, CA; ⁴General Internal Medicine, VA- Greater Los Angeles, Los Angeles, CA. (Control ID #3868251)

BACKGROUND: To address the overdoses and mortality associated with the opioid crisis, VISN 22 began a quality improvement project in 2018 to increase Veteran access to medications for opioid use disorder (MOUD) in non-addiction settings, such as primary care and mental health. MOUD, such as buprenorphine/naloxone, can effectively treat OUD and reduce opioid-related mortality. We sought to uncover the factors that can facilitate successful prescribing of MOUD and uptake/acceptance of MOUD by patients in non-addiction settings.

METHODS: Qualitative interviews were conducted with 18 Veteran patients with experience taking MOUD and 44 providers, most with MOUD experience or knowledge, including primary care providers, hospitalists, nurses, and addiction psychiatrists in five medical centers in VISN22. The interview guide was developed based on the Practical, Robust Implementation and Sustainability Model (PRISM) and included questions about Veterans’/providers experiences with MOUD. Interviews were recorded, transcribed, and analyzed to identify major themes regarding Veterans'/providers perspectives and barriers and facilitators to implementing MOUD.

RESULTS: Provider-reported MOUD prescribing facilitators included protected clinical time (e.g., having a 2-hour block to perform inductions, building in time to see patients more frequently), changes in scopes of practice for some healthcare staff (role definition for nursing and justifying nurse workload), understanding the rewards/benefits of MOUD prescribing, interdisciplinary mentorship and support (e.g., consulting with addition providers, partnering with psychology), ongoing training and education to increase comfort in prescribing MOUD, incentives, leadership buy-in, administrative staff understanding scheduling issues, and contingency for other prescribers to cover MOUD prescribing when they are not available. Veteran-reported facilitators to MOUD access/use included specific communication strategies like providers emphasizing MOUD as an alternative to traditional opioids for pain, providers timing conversations about MOUD correctly (e.g., at low point or during/post crisis), the provider sharing the science of MOUD and how it works, and providers emphasizing the satisfaction/positive experiences of other patients taking MOUD.

CONCLUSIONS: Providers identified numerous multi-level factors (e.g., clinic-, provider- and system-level support), that can facilitate Veterans’ successful uptake of and MOUD prescribing in non-addiction settings. Factors that facilitated patient acceptance of MOUD centered mostly around communication strategies. These findings can help VA providers across multiple settings and services develop communication strategies that can increase patient acceptance of MOUD. They also point to how interprofessional collaboration across VA services, and leadership support in making systems- and process-level adjustments, can facilitate MOUD prescribing for non-addiction providers.

FEASIBILITY AND ACCEPTABILITY OF A VIRTUAL GROUP INTERVENTION FOR RURAL VETERANS WITH CHRONIC PAIN

Joseph W. Frank^1,2; John S. Evans³; Rachael Kenney⁵; Evan Carey²; Anne Hale⁴

¹Medicine, University of Colorado School of Medicine, Aurora, CO; ²VA Eastern Colorado Health Care System, Aurora, CO; ³Research, Veterans Health Administration, Washington, DC; ⁴Research , Veterans Affairs, Denver, CO; ⁵Denver COIN, Veterans Health Administration, Aurora, CO. (Control ID #3876268)

BACKGROUND: Chronic pain is common among US Veterans, and barriers to in-person treatment and self-management resources can be especially challenging for rural Veterans. We developed and implemented a virtual group intervention to provide peer health coaching and self-management support for rural Veterans with chronic pain. We examined the feasibility and acceptability of the intervention and to assess changes in patient-reported outcomes from baseline to 6-month follow-up.

METHODS: We conducted an observational study of a weekly virtual group intervention for rural Veterans with chronic pain in a single VA healthcare system in the Mountain West. All sessions were facilitated by trained peers with lived experience with chronic pain. The intervention began in April 2022 with a 9-week curriculum on values clarification and goal setting, and the second phase (weeks 10-24) consisting of weekly mutual aid meetings. For feasibility, we tracked recruitment, enrollment, and retention at 6-month follow-up. For acceptability, we conducted semi-structured interviews (N=12), which were audio-recorded, transcribed and analyzed to explore the experience of participating and identify suggestions for program improvement. Participants and facilitators completed structured surveys at baseline (N=15) and 6-month follow-up (N=13) including a 3-item pain severity scale (PEG; range 0-10, higher=worse), a 3-item loneliness scale (UCLA; range 0-3, higher=worse) and a single-item global impression of change. We calculated t-tests and chi-square tests to assess changes in patient-reported outcomes.

RESULTS: We outreached 46 Veterans, and 16 Veterans enrolled in the group intervention (12 participants, 4 facilitators). This group was 75% male, 50% White, 87.5% rural). They reported an average pain duration of 22 years and baseline pain severity of 6.2/10. Fourteen individuals (88%) completed the initial session, and 9/16 individuals (56%) attended >50% of sessions at 6-month follow-up. Themes from semi-structured interviews included a strong sense of camaraderie; participants appreciated holding space with others who were living with chronic pain. Most participants preferred the mutual aid phase to the structured curriculum, and many described learning from the stories of other Veterans. There were no significant differences from baseline to 6-month follow-up for pain severity (mean PEG, 6.2/10 at baseline vs. 6.2/10 at follow-up) or loneliness (mean UCLA, 1.8/3 vs. 2.0/3). At 6-month follow-up, 42% (5/12) reported global improvement, and 25% (3/12) reported global worsening of pain symptoms.

CONCLUSIONS: A weekly virtual group intervention to provide peer health coaching and self-management support was feasible and acceptable for rural Veterans with chronic pain but did not demonstrate improved outcomes in its initial cohort. As the intervention expands to new sites, this evaluation will inform adaptations to improve the acceptability of the group, including adding a storytelling component to the mutual aid phase.

HARM REDUCTION IN THE HOSPITAL: OPPORTUNITIES TO IMPROVE ADDICTION CARE Leah Fraimow-Wong¹; Marlene Martin^1,2; Laura Thomas³; Ro Giuliano³; Oanh K. Nguyen^1,2; Kelly R. Knight^1,4; Leslie Suen^1,5

¹School of Medicine, University of California San Francisco, San Francisco, CA; ²Division of Hospital Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA; ³San Francisco AIDS Foundation, San Francisco, CA; ⁴Department of Humanities & Social Sciences, University of California San Francisco, San Francisco, CA; ⁵Division of General Internal Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA. (Control ID #3875443)

BACKGROUND: Harm reduction includes strategies developed by and for people who use drugs to promote health and reduce the negative impacts of substance use. Distributing harm reduction supplies in healthcare settings can be difficult due to varying regulations across states and historically, hospital-based harm reduction has been limited to naloxone. We partnered with hospital stakeholders and a local syringe service program to integrate harm reduction education and supplies (e.g., pipes, foil, syringes, fentanyl test strips, etc.) into an addiction consult team (ACT) at an urban, academic, safety-net hospital. We performed a qualitative evaluation to determine its impact on patients and staff.

METHODS: We conducted semi-structured interviews in English and Spanish with 9 patients who received harm reduction services, and 12 staff involved in their care (6 clinicians, 4 nurses, 2 patient navigators), including 5 ACT members. Interviews explored impacts, challenges, and opportunities related to hospital- based harm reduction interventions. We transcribed, coded, and analyzed interviews to identify themes using modified grounded theory methodologies.

RESULTS: Patients had a median age of 53, and 56% identified as male. Race/ethnicity was mixed (44% Black, 22% Latinx, 11% American Indian ,11% Asian Pacific Islander, 11% white), 77% spoke English and 22% Spanish, and primary substance use disorders (SUDs) were 44% opioids, 44% stimulants, and 11% alcohol. Patients reported the intervention made them feel deeply cared for, gave access to valuable resources, and created space for reflection on substance use goals, contrasting with prior stigmatizing hospital experiences. Staff reported personal fulfillment in better serving patients with SUDs and identified patients with stimulant use and those with limited English proficiency as less likely to have had prior exposure to harm reduction. All staff interviewed found value in providing supplies, but some reported hesitation about harm reduction frameworks, requesting education on its evidence basis, more training on SUDs broadly, and an on-site champion for support.

CONCLUSIONS: Hospital-based harm reduction efforts face regulatory and financial barriers in the US. However, our findings suggest it can be a powerful tool to engage populations missed by other interventions, counteract stigmatizing experiences with the healthcare system, and improve patient-staff relationships. Opportunities exist to improve care by expanding training on substance use and harm reduction across healthcare professions. As overdose deaths persist, incorporating harm reduction-based strategies may be critical for health systems, and policymakers should consider removing barriers to the distribution of harm reduction equipment in healthcare settings.

IDENTIFYING IMPLEMENTATION STRATEGIES TO INFORM IMPLEMENTATION OF A HOSPITAL-BASED OPIOID USE DISORDER (OUD) TREATMENT INTERVENTION ACROSS TWELVE HOSPITALS IN COLORADO

Susan Calcaterra, Crystal Natvig, Steven Lockhart, Susan Mikulich Gilbertson

Medicine, University of Colorado - Anschutz Medical Campus, Aurora, CO. (Control ID #3874575)

BACKGROUND: To inform implementation efforts of a healthcare system’s plan to expand hospital-based OUD treatment in 12 hospitals across Colorado, we conducted a formative evaluation of hospitalist physicians and advanced practice providers (APPs). We used the Consolidated Framework for Implementation Research (CFIR) to guide the formative evaluation to identify implementation strategies to maximize the intervention’s Reach, Adoption, and Implementation.

METHODS: We created a 37-item survey informed by practice recommendations for hospital-based buprenorphine or methadone initiation for OUD. Survey questions were grouped into 5 domains: (1) validity of the evidence supporting OUD treatment, (2) knowledge, attitudes, and beliefs about OUD treatment, (3) perception of how OUD treatment aligned within their clinical practice and within their hospital setting, (4) readiness to provide buprenorphine or methadone for OUD treatment, and (5) perceived hospital leadership support to provide OUD treatment. We collected responses on a 5-point Likert scale (score 1 = not ready, strongly disagree, etc.; score 5 = completely ready, strongly agree, etc.) and calculated summary scores for each domain. Next, we dichotomized responses to, “readiness to initiate buprenorphine or methadone” (not or slightly ready vs. somewhat, fairly, completely ready) and compared other domain summary scores by dichotomized “readiness” categories using independent t tests, Wilcoxon rank sum tests and chi square tests. Data collection occurred from June to August 2022.

RESULTS: Of the 160 respondents (60% response rate), mean age was 38.8 years, 59% were male (n = 93), 69% were physicians (n=111), 76% (n = 117) worked in metropolitan Denver, and 30% (n = 48) had an XDEA-waiver. Overall, respondents felt evidence supported the use of buprenorphine and methadone for OUD (mean summary score 4.19/5.00). Compared to respondents who were more ready to initiate buprenorphine (n = 72), respondents who were less ready (n = 88) were more likely to be unsure of (i) the legality of prescribing buprenorphine, (ii) did not know how, (iii) or have time, to initiate buprenorphine, (iv) did not feel their patients were interested in buprenorphine (v) nor could maintain recovery from opioids, and (vi) felt there was not a clear workflow to start buprenorphine and link patients to treatment after discharge (all p < 0.001). Similar findings were noted for respondents who were less likely (n = 105) vs. more ready (n = 55) to initiate methadone for OUD (p < 0.001).

CONCLUSIONS: Hospital-based clinicians support the use of buprenorphine and methadone to treat OUD. Implementation strategies will focus on providing OUD-based education, developing hospital-based pathways to initiate buprenorphine and methadone, and support social workers to identify referral networks for OUD treatment linkage following discharge.

IMPACT OF A BRIEF EDUCATIONAL INTERVENTION ON INDIVIDUAL PREFERENCES FOR MEDICATIONS FOR OPIOID USE DISORDER

Pooja A. Lagisetty^1,2; Adrianne R. Kehne²; Stephanie Slat¹; Colin macleod¹; Amy Bohnert^3,2

¹Internal Medicine, University of Michigan, Ann Arbor, MI; ²Ann Arbor VA, Veterans Health Administration, Ann Arbor, MI; ³Anesthesiology, University of Michigan, Ann Arbor, MI. (Control ID #3876454)

BACKGROUND: There is limited data around whether people of different racial/ethnic groups have different perceptions of medications for opioid use disorder (MOUD) versus non-medication treatment options. Improved community (e.g., family) perceptions of MOUD may improve the uptake of MOUD among people with OUD. This study aimed to assess baseline preferences for different OUD treatments across three racial/ethnic groups (non-Hispanic White, non-Hispanic Black, and Hispanic/Latinx) and assess whether a brief educational intervention could shift preferences for evidence-based medication.

METHODS: A racially stratified adult sample recruited from a national web-based survey platform were presented with a brief vignette about an individual with OUD followed by a brief educational intervention consisting of four one-minute videos on methadone, buprenorphine, naltrexone, and non-medication treatment. Respondents indicated their top treatment choice before and after the intervention. Descriptive statistics were calculated for preferences and respondent characteristics. Pre vs. post differences were analyzed using Bhapkar’s test and post hoc McNemar’s tests, and binary logistic generalized estimating equation (GEE) was used to identify predictors of treatment preferences.

RESULTS: 530 respondents (194 White, 173 Black, and 163 Latinx; 52% female) completed the intervention. Pre-intervention, methadone was the overall most preferred treatment option (40%), followed by non-medication treatment (26%) and buprenorphine (23%). Black and Latinx participants were somewhat less likely to pick medication treatments than White participants at baseline (Black: OR=0.74, p=0.18, Latinx: OR=0.62, p=0.05). In a binary test of changes in preferences between any of the three MOUDs vs. non-medication treatment, respondents were more likely (OR 4.95; p<0.001) to switch from non-medication to MOUD treatments than to make the opposite switch following the intervention. Respondents who changed their preferences disproportionately changed to selecting buprenorphine (OR=2.38; p<.001) and away from non-medication treatment (OR=0.20; p<.001). Personal or social exposure to MOUD (OR 3.99; p<.001) and nonmedical use of opioids (OR 3.02; p=.04) were associated with an increased likelihood of selecting MOUD.

CONCLUSIONS: These results indicate that brief educational videos can increase preference for MOUD versus non-medication treatments, particularly among individuals without prior opioid familiarity. Future studies should assess whether such interventions can improve favorable perceptions of MOUD among family and friends of people who use drugs and positively influence the uptake of MOUD in people with OUD.

IMPLEMENTATION OF UNIVERSAL DEPRESSION SCREENING AT A STUDENT-RUN FREE CLINIC: THE BRIDGE FROM PRIMARY TO PSYCHIATRIC CARE

Nana Park¹; Carson Gundlach¹; Tyler Judge¹; Elizabeth K. Benitez¹; Tiffany Merlinsky¹; Ashita S. Batavia²; Pamela Charney^1,2

¹WCCC, Weill Cornell Medicine, New York, NY; ²Medicine, Weill Cornell Medicine, New York, NY. (Control ID #3869003)

BACKGROUND: Depression is highly prevalent yet underrecognized in primary care settings, with up to 50% of cases going undetected. Moreover, there is scarce research on factors affecting delivery of mental health care among underserved populations. Here we report the utility of implementing a universal depression screening in an urban student-run free clinic (SRFC) to improve psychiatric care. We also examine differentiators between successfully and unsuccessfully referred patients.

METHODS: The SRFC provides free medical, psychiatric and gynecologic care to uninsured, low-income patients of New York City. Patients (n=224) seen by our free medicine and gynecology clinics between April 2017 and November 2022 were screened for depression in the patient’s primary language using a standardized Patient Health Questionnaire (PHQ-9). A PHQ-9 score greater or equal to 5 indicating at least mild depression prompted psychiatry referral. Retrospective chart review was conducted to determine clinical characteristics including age, gender, and medical comorbidities at time of referral. Student’s t-tests and Fisher’s exact tests were used to evaluate differences in continuous and categorical variables, respectively.

RESULTS: A total of 224 unique patients were administered PHQ-9 depression screens between April 2017 and November 2022. 83 out of 224 (37%) had a PHQ-9 score greater or equal to 5. Of the 83 with positive screenings, 77 were not existing patients of the SRFC's psychiatry clinic and were provided referrals. Among the 77 patients referred, 56 (73%) were female, the average age was 43.7 (SD=14.5), and the mean PHQ score was 10 (SD=5.13). 37 patients (48%) accepted the referral, while 40 (52%) declined or were lost to follow-up. There were no statistical differences in age or number of medical comorbidities between the two groups. Patients who accepted referrals were more likely to have higher PHQ-9 scores, psychiatric histories, and a history of trauma (Table 1). Females were more likely to accept referrals than males (p=0.043). Primary language was not a predictor of successful referral (p=0.944). There was no difference in the proportion of successful referrals pre-COVID (before March 2021) versus post-COVID pandemic (after March 2021).

CONCLUSIONS: Our implementation of a standardized screening tool reveals a significant rate of depressive symptoms among an uninsured primary care population. With a referral success rate of 48%, we demonstrate the feasibility of implementing universal screening and increasing delivery psychiatric care to underserved patients. Future studies may explore qualitative factors impacting referral status and evaluate the trajectory of mental health symptoms post-referral.

IMPLEMENTING POSTPARTUM DEPRESSION SCREENING FOR FATHERS IN A PRIMARY CARE SETTING

Samuel J. Wainwright^1,3; Rachel Caskey^1,3; Aida Rodriguez²; Abigail Holicky^1,6; Melissa Wagner- Schuman^7,5; Shreya Sarmah⁴; Anne E. Glassgow^1,3

¹Academic Internal Medicine, University of Illinois Chicago College of Medicine, Chicago, IL; ²Medicine, University of Illinois at Chicago, Chicago, IL; ³Pediatrics, University of Illinois Chicago College of Medicine, Chicago, IL; ⁴University of Illinois Chicago College of Medicine, Chicago, IL; ⁵Psychiatry, University of Illinois Chicago College of Medicine, Chicago, IL; ⁶School of Public Health, University of Illinois Chicago, Chicago, IL; ⁷Psychiatry, University of Cincinnati, Cincinnati, OH. (Control ID #3872148)

BACKGROUND: Postpartum depression (PPD) impacts fathers as well as mothers, and is estimated to affect between 8-13% of fathers. Paternal PPD is a risk factor for worsened quality of life, poor physical and mental health, and developmental and relational harms in the father-mother-child triad. However, there are no current recommendations for PPD screening among fathers. In order to assess acceptability of PPD screening to fathers and to assess the prevalence of PPD in a small cohort of fathers, paternal PPD screening was piloted in an intergenerational postpartum primary care clinic.

METHODS: Retrospective analysis was performed on fathers contacted during a paternal PPD screening pilot occurring between 10/5/2021 and 7/27/2022. The pilot was carried out in an intergenerational postpartum primary care clinic located at a Midwest urban academic safety net health system. Fathers actively involved in relationships with mothers receiving primary care in the clinic were approached with mothers’ consent. A novel survey instrument was used to collect information on mental health history and current stress; an Edinburgh Postnatal Depression Scale (EPDS), which has previously been validated in fathers, was also administered. Screenings were completed by clinical social workers; data were collected in REDCap and univariate statistics were calculated in Microsoft Excel.

RESULTS: Of the 29 fathers contacted, 89% agreed to screening (n=26) and 79% completed screening (n=23). Mean age was 31 years old (range 19-48). 86% identified as belonging to a racial or ethnic minority group. Fathers self-reported low rates of stress and preexisting mental health conditions, but 30% screened positive for PPD on EPDS (score of 8 or higher). Gaps in health care were found, as one-quarter (23%) of fathers were uninsured and half (52%) did not have a primary care provider. After screening, three fathers established primary care with a physician within the medical center, one followed up for social work and psychiatric care within the clinic, and one initiated immediate mental health care with Veterans Affairs system as a veteran.

CONCLUSIONS: Participation was high in a PPD screening pilot for fathers in a primary care setting. This demonstrates its acceptability to fathers and feasibility with dedicated outreach. Even a small cohort of fathers demonstrated significant peripartum mental health challenges unlikely to have been identified otherwise. For some of the participants, engaging in PPD screening was an effective tool to prompt their subsequent engagement with general health care. This pilot serves as an important step toward incorporating the health of fathers into our models for supporting the mental health of the entire family unit. Expanding evaluation for paternal PPD into routine primary care is necessary to reach more affected fathers.

IN-HOSPITAL METHADONE ENROLLMENT: A NOVEL PROGRAM TO FACILITATE LINKAGE FROM THE HOSPITAL TO THE OPIOID TREATMENT PROGRAM FOR MEDICALLY ILL AND VULNERABLE PATIENTS WITH OUD

Susan Calcaterra²; Eric Grimm¹; Angi Wold²; Angela Bonaguidi²; Emma J. Maki-Gianani²; Angela Keniston¹

¹Division of Hospital Medicine, University of Colorado, Aurora, CO; ²University of Colorado Denver Department of Medicine, Aurora, CO. (Control ID #3869196)

BACKGROUND: From 2000 to 2016 in the U.S., hospitalizations related to opioid use disorder (OUD) increased 219%, a 3-fold increase. Hospitalization provides an opportunity to initiate methadone for OUD; however legal restrictions prohibit methadone prescribing for OUD at hospital discharge. If a patient desires methadone for OUD treatment after hospital discharge, they must present to an Opioid Treatment Program (OTP) soon after discharge to avoid opioid withdrawal. Once at the OTP, they must complete a methadone enrollment before receiving their first methdaone dose. OTP linkage barriers include severe opioid withdrawal, unstable housing, lack of transportation, social support, or personal identification, and stigma.

METHODS: To reduce hospital to OTP linkage barriers, our Addiction Consultation Service partnered with a community OTP to launch IN-MEET, an in-hospital methadone enrollment program. IN-MEET includes an addiction-trained physician dually affiliated with a University Hospital and a community OTP, and an OTP- affiliated nurse. The IN-MEET physician and nurse meet with the patient in the hospital to compete a face-to- face medical examination and psychosocial assessment required for OTP enrollment, titrate the methadone dose, and provide active case management for hospital to OTP linkage. Upon linkage, patients meet with a clinician for ongoing methadone titration and are assigned a treatment counselor. We describe IN-MEET linkage and compare a subset of IN-MEET patients to patients who self-referred to the community OTP.

RESULTS: From April 2019 to October 2022, we completed 128 IN-MEET enrollments, of which 65% (n=83) resulted in hospital-to-OTP linkage. Next, we limited enrollments to the patient-level. Compared to patients who self-referred to the community OTP (n=2,374), IN-MEET patients (n=73) were older (mean age 39.7 years [standard deviation (SD) 11.2] vs. 35.7 years [SD 10.5]; p<0.004) and more likely to be male (69.9% vs. 56.7%, p=0.03). Compared to patient who self-referred to the community OTP, IN-MEET patients were more likely to be unhoused (58.9% vs. 12.2%), to have Medicaid (78.1% vs. 61.2%), to use heroin or fentanyl as their primary drug of choice (72.6% vs. 43.7%) and methamphetamine as their secondary drug of choice (37% vs. 23%), and to inject their primary drug of choice (63% vs. 31.7%). There were no differences in race or marital status between the two groups.

CONCLUSIONS: In-hospital methadone enrollment for OUD treatment linkage is feasible in the hospital setting and resulted in a high percentage of OTP linkage for patients who were older and more vulnerable compared to patients who self-referred to a community OTP. This model has potential to improve methadone access to patients who are medically ill and who may not otherwise seek out treatment.

INJECTION PRACTICE AND PERCEIVED RISK OF INFECTIVE ENDOCARDITIS

Carolyn A. Chan¹; Emma Biegacki²; Rebecca Minahan-Rowley²; Kimberly Sue²; Melissa B. Weimer²

¹General Internal Medicine, Yale School of Medicine, New Haven, CT; ²Program in Addiction Medicine, Yale School of Medicine, New Haven, CT. (Control ID #3873956)

BACKGROUND: Injection drug use-related infective endocarditis (IDU-IE) is a disease with high morbidity and mortality among people who inject drugs (PWID). Providing targeted information on best harm reduction practices for PWID is important, which may modify individual behavior to apply safer injection practices, allow for the creation of high-yield patient education materials, and prevent primary and tertiary IDU-IE. Clinicians have developed frameworks to help counsel patients on safer injection practices, yet little is known about how PWID perceive the risk of individual components of injection drug use practices and how it contributes to the risk of developing IDU-IE.

METHODS: A survey was administered to hospitalized patients at one hospital who inject substances, were identified by an addiction medicine consult service and had either a diagnosis of IDU-IE or another severe injection-related infection. Content experts reviewed the survey for face validity. The survey was anonymous and administered via an online QR code between November 2021- May 2022. PWID were asked how much they thought specific components of injection drug use contribute to the risk of developing IDU-IE, using a 4-point Likert scale: no risk, slight risk, moderate risk, or great risk. In addition, the survey asked what substances they inject, and what their personal barriers were to safer injection practices. Participants were compensated for their time.

RESULTS: A total of 15 individuals completed the voluntary survey; 53.3% were female with an average age of 42 years old, ages ranged from 28-61 years old. All participants reported injecting opioids (heroin or fentanyl) and 20% also injected cocaine. On average, participants reported injecting 2-3 times each day. Participants rated the following injection-related practices as no risk, slight risk, or moderate risk for developing IDU-IE: using tap or bottled water 71.4%, reusing a cooker 46.7%, not cleaning skin before injection 33%, licking the skin or needle prior to injection 33.3%, using spit to dissolve a substance 28.6%, reusing their own cotton 26.7%, sharing cottons with others 20.0%, sharing a cooker with others 13.3%, having an untreated abscess or skin infection 13.3%, reusing their own needle or syringe 13.3%, injecting cocaine 13.3%, and injection heroin/fentanyl 13.3%. Participants report running out of supplies and being in opioid withdrawal as common barriers to safe injection practice.

CONCLUSIONS: Significant knowledge gaps exist among PWID for the risks of injection-related practices to the development of IDU-IE. Future educational materials for patients with IUD-IE should focus on targeted knowledge gaps to intervene to prevent both primary and recurrent IDU-IE infections. These materials should emphasize the importance of skin cleaning prior to injection, not licking the skin or needle prior to injection, and using sterile water.

INTEGRATED OUTPATIENT TREATMENT OF OPIOID USE DISORDER AND INJECTION- RELATED INFECTIONS: PROGRESS AND PRELIMINARY OUTCOMES IN THE BUPRENORPHINE PLUS OUTPATIENT PARENTERAL ANTIBIOTIC THERAPY (B-OPAT) STUDY

Laura Fanucchi^1,2; Connor M. VanMeter²; James A. Grubbs¹; Sharon L. Walsh^2,3; Alice C. Thornton¹; Michelle Lofwall^2,3

¹Division of Infectious Diseases, University of Kentucky College of Medicine, Lexington, KY; ²Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY; ³Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY. (Control ID #3873906)

BACKGROUND: Hospitalizations for severe, injection-related infections (SIRI) are increasing with the opioid epidemic. Outpatient parenteral antibiotic therapy (OPAT) is often not offered to persons with opioid use disorder (OUD) and SIRI, though increasing evidence suggests it may be feasible and safe. This study evaluates the efficacy and cost-effectiveness of an integrated care model combining buprenorphine for OUD with OPAT for SIRI (B-OPAT) compared to treatment as usual (TAU) on key OUD, infectious disease, and economic outcomes. We present the current trial status and preliminary outcomes.

METHODS: B-OPAT is a randomized, 2-arm superiority trial recruiting a goal of 90 adults hospitalized with OUD and SIRI needing 2 or more weeks IV antibiotic therapy. Randomization is 1:1 to either discharge once medically stable to an integrated outpatient care model combining Buprenorphine and OPAT (B-OPAT) or to TAU. Stratification variables include the clinical SIRI subgroup, stimulant use disorder, and sex. The clinical SIRI stratification has 3 subgroups: 1) low risk endocarditis (IE) (tricuspid valve [TV] managed without surgery), 2) high risk IE (TV managed surgically, aortic valve, mitral valve, prosthetic valve), and 3) non-IE (e.g. osteomyelitis). The study intervention period is 12-weeks after hospital discharge followed by a 3-month safety follow-up window.

RESULTS: From Mar 2021 – Oct 2022, 200 persons were screened, 165 excluded (top barriers: distance/transportation 35, complex medical/psychiatric comorbidities 32, housing instability 18, patient- directed discharge 20), and 37 randomized (B-OPAT: 18, TAU: 19). To date, baseline characteristics appear similar (Table). Average hospital length of stay in B-OPAT is 23.4 days, and 31.9 days in TAU. B-OPAT subjects completed 19 days of OPAT versus 3.7 days in TAU.

In the 12-weeks post-discharge, B-OPAT had 7 serious adverse events (SAE) in 6 subjects: 1 overdose death, 5 hospitalizations (2 orthopedic surgery, 1 bacteremia, 1 COVID, 1 gastrointestinal bleeding), 1 non-fatal overdose. TAU had 11 SAEs in 5 subjects: 3 deaths (1 overdose, 1 SIRI complication, 1 myocardial infarction), 6 hospitalizations (2 pain related to SIRI, 1 bacteremia, 1 antibiotic intolerance, 1 valve replacement, 1 hemorrhagic stroke), and 2 non-fatal overdoses.

CONCLUSIONS: At ~40% target enrollment, emerging data suggest subjects receiving the outpatient care model combining OUD treatment with OPAT may have fewer SAEs than those in TAU and reduced length of stay. Continued study recruitment will help answer whether B-OPAT is clinically- and cost-effective relative to current practice and should be disseminated more broadly.

INTERNAL MEDICINE AND EMERGENCY MEDICINE PERSPECTIVES ON CARING FOR PEOPLE WHO INJECT DRUGS

Mackenzie L. Garcia^1,3; Lisa Raville⁴; Jason Hoppe²

¹Internal Medicine, Emory University School of Medicine, Atlanta, GA; ²Emergency Medicine, University of Colorado Medicine, Aurora, CO; ³University of Colorado Medicine, Aurora, CO; ⁴Harm Reduction Action Center, Denver, CO. (Control ID #3867827)

BACKGROUND: People who inject drugs (PWID) routinely face stigmatization when seeking healthcare. There is a critical need to understand provider attitudes towards PWID and towards harm reduction approaches to inform interventions to improve health outcomes for this marginalized population.

METHODS: We partnered with a local harm reduction agency to create a survey of emergency department (ED) and inpatient medicine (IM) providers to assess attitudes toward PWID and experiences related to implementing clinical harm reduction interventions. The survey included both Likert-scale questions and a modified version of the Medical Condition Regard Scale (MCRS), a validated 11-question tool that assesses attitudes towards specific health conditions¹. Possible modified MCRS scores ranged from 11 to 55, with higher scores indicating more positive attitudes towards PWID. Open-ended questions were included to capture additional barriers to providing care to PWID and implementing harm reduction. The survey was distributed through convenience sampling via institutional/professional listservs. The protocol was deemed exempt by the local IRB. Analysis included descriptive statistics conducted with Stata. Codes were inductively assigned to free text responses and thematically grouped.

RESULTS: 245 providers completed the survey, including physicians, advanced practice providers, nurses, ED technicians, social workers, and other staff. The average modified MCRS score among physicians was 42.8 (CI 41.2-44.4) compared to 33.4 (CI 30.9-35.9) among nurses and 44.5 (CI 42.3-46.7) among IM compared to 38.1 (CI 36.6-39.5) among ED providers. Among respondents, 89% of ED and 96% of IM physicians believe that providing clean needles to PWID does not increase substance use, and 92% of ED and 89% of IM physicians believe that it is their responsibility to ensure PWID are knowledgeable about harm reduction. Barriers to implementing harm reduction included prioritizing substance use treatment (34%), lacking harm reduction knowledge (34%), and time limitations (25%). Additional barriers identified through free-text responses included perceptions of PWID as adversarial, clinician feelings of helplessness, and lack of institutional processes.

CONCLUSIONS: While attitudes towards PWID vary by specialty and role, most providers support implementing harm reduction practices. This represents an opportunity to collaborate with harm reduction partners to enhance targeted training of clinicians regarding caring for PWID.

1. Christison G.W., Haviland M.G., Riggs M.L. The medical condition regard scale: measuring reactions to diagnoses, Acad Med 2002: 77: 257-262.

LIVING THROUGH AN ENCAMPMENT SWEEP: COMMUNITY AND UNCERTAINTY

Mike Mayer, Yesenia Mejia, Avik Chatterjee

Boston Medical Center, Boston, MA. (Control ID #3871899)

BACKGROUND: The number of people experiencing homelessness (PEH) in tent encampments has increased significantly in the past 20 years. Citing concerns over public health, safety, and increased substance use, many cities have taken steps to clear tent encampments in highly visible “sweeps.” In January

2022, nearly 200 PEH were displaced from a major urban encampment in New England. Some of these individuals were offered placement in “low-threshold” harm reduction shelters, while others were not. The impact of displacement from encampments on public health, safety, and substance use is not known.

METHODS: We conducted semi-structured interviews among participants recruited from a day center and the street near a large homeless shelter. Using NVivo software, we coded transcripts and applied the Borkan Immersion Crystallization method to identify recurring themes related to health, safety, and substance use before and after the sweep.

RESULTS: Among 20 participants, 11 identified as female, and 2 completed their interviews in Spanish. Five moved into low-threshold shelter or housing. Within the “health impact” theme, the sweep often led to health exacerbations for individuals who were not offered access to low-threshold shelters. Participants reported limited access to care, worsened sense of community, and frustration with insufficient access to basic resources. Within the “safety” theme, many individuals shared that the sweep had increased their safety concerns. This was largely attributed to the disruption of encampment social structure and an influx of new individuals. Safety concerns were most acute for women and gender-oppressed individuals. Within the “substance use” theme, the sweep had varied impacts. Individuals offered access to low-threshold shelters often reported improved health and recovery outcomes, while others reported no change or worsened outcomes. Additional themes identified included “uncertainty,” and “distrust.” Many respondents shared frustration with the lack of transparency related to the sweep, and many struggled with having no clear direction once their belongings were cleared: “[The aftermath of the sweep] was a lot more stressful. I already have anxiety and stuff, but it just made things ten times worse because on top of that, how am I going to get what I need and take a shower and do my normal routine now? It's like, ‘alright, where are we going to go?’” Others shared their frustrations with what felt like repeated disappointments while seeking assistance: “As somebody that is homeless, like chronically homeless and an addict, it's like being on a merry-go-round.”

CONCLUSIONS: Encampment sweeps may amplify the very health and safety concerns that city officials seek to address. Access to outreach-based medical care and low-threshold shelters appears to mitigate this. Future interventions should seek to improve access to basic resources and medical care including addiction treatment, preserve community social structures, and expand harm reduction shelter models.

LOW RISK PERCEPTION PRESENTS AN OPPORTUNITY FOR INTERVENTION AMONG HOSPITALIZED PATIENTS WHO SMOKE AND HAVE TOBACCO-RELATED DISEASE

Eden Y. Bernstein¹; Hilary A. Tindle³; Yuchiao Chang^1,4; Douglas E. Levy²; Travis P. Baggett^1,5; Nancy A. Rigotti^1,6

¹General Internal Medicine, Massachusetts General Hospital, Boston, MA; ²Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, MA; ³ViTAL, the Vanderbilt Center for Tobacco, Addiction and Lifestyle, Vanderbilt University Medical Center, Nashville, TN; ⁴Harvard Medical School, Boston, MA; ⁵Boston Health Care for the Homeless Program, Boston, MA; ⁶Tobacco Research and Treatment Center, MGH, Boston, MA. (Control ID #3869151)

BACKGROUND: Smoking is the leading cause of preventable death in the US. Hospitalization provides an opportunity for patients who smoke to initiate a quit attempt. We examined whether the presence of tobacco- related disease (TRD) and perceived risk (PR) regarding contribution of smoking to hospitalization, recovery, and future illness are associated with post-hospitalization smoking cessation.

METHODS: This was a secondary analysis of Helping HAND 4, a randomized multi-center trial which tested the effectiveness of 2 post-discharge tobacco cessation programs on smoking outcomes in hospitalized patients who desired to quit smoking. A baseline survey asked 3 questions on PR: How much (1) smoking contributed to the illness that caused hospitalization, (2) quitting smoking would speed recovery, (3) quitting smoking would help avoid future illness. PR was dichotomized to high (PR+) or low (PR-) relative to each question. Primary discharge diagnosis codes (ICD-10 from EHR) were used to categorize TRD as presence (TRD+) or absence (TRD-). Four patient groups were created based on TRD+/- and PR+/- relative to each question (Table). Logistic regression models examined the association of these groups with the primary outcome of self-reported 7-day tobacco abstinence at 6 months. Models adjusted for sociodemographics, smoking history, confidence in quitting, social support, site, study arm, quality of life, drug use, depression and anxiety.

RESULTS: Of 1,406 enrolled patients, the mean age was 52 years, 56% were females, 77% were white, and 31% had TRD. Low PR was common among patients with TRD (Table). For perception that smoking contributed to the illness that caused hospitalization, TRD was associated with cessation regardless of PR. For perceptions that smoking cessation will speed recovery and help avoid future illness, cessation was only more likely in the TRD+/PR+ groups.

CONCLUSIONS: Hospitalized patients with tobacco-related disease and high perceived risk across 3 measures were more likely to achieve 6-month smoking cessation, but many patients with tobacco-related disease inappropriately discounted the role of smoking in their illness. Addressing discordant risk perceptions in routine smoking cessation counseling of hospitalized patients with tobacco-related disease may increase post-discharge cessation.

MOBILE UNITS IMPROVE ACCESS TO MEDICATIONS FOR OPIOID USE DISORDER: A QUALITATIVE IMPLEMENTATION STUDY

Avik Chatterjee¹; Trevor Baker¹; Maria Rudorf¹; Galya Walt²; Caroline Stotz¹; Anna Martin¹; Elizabeth N. Kinnard¹; Ann S. McAlearney³; Julie Bosak¹; Bethany Medley⁴; Jeffrey H. Samet⁵; Karsten Lunze¹

¹ Internal Medicine, Boston University School of Medicine, Boston, MA; ²Harvard School of Public Health Aids Initiative, Boston, MA; ³Family and Community Medicine, The Ohio State University, Columbus, OH; ⁴Columbia School of Social Work, New York, NY; ⁵General Internal Medicine, Boston University School of Medicine, Boston, MA. (Control ID #3874902)

BACKGROUND: Medications for Opioid Use Disorder (MOUD) are lifesaving, but <10% of individuals who could benefit receive them. Barriers to MOUD include limited geographic availability, provider stigma, and lack of patient trust in healthcare. As part of the NIH- supported HEALing Communities Study (HCS), coalitions in several communities in Massachusetts, New York, and Ohio implemented mobile MOUD programs to overcome barriers to MOUD receipt. We defined mobile MOUD programs as mobile units that provide in-person or telehealth same-day access to an MOUD prescriber at an outreach site (e.g., homeless encampment, community center, public street).

METHODS: Program staff from five programs in two states (n=9) participated in semi-structured interviews exploring implementation of mobile MOUD units. Two authors developed a codebook based on the first two interview transcripts, which authors refined and applied to subsequent coding cycles.

RESULTS: Development and implementation of mobile MOUD units was driven by study goals including responding to community needs, improving immediate access to MOUD (“Our answer is pretty much always, ‘Yes, we'll get you started right here, right now,’"), advancing equity for marginalized individuals (“making sure that we have staff who speak other languages, who are on the unit and have some resources that are in different languages,”), and decreasing opioid overdose deaths.

Salient program characteristics included staff diversity, including linguistic diversity and staff with lived experience of substance use (“She just had that personal knowledge of where we should be going...She went to that homeless encampment and she was like, ‘Dude, you need a phone, you need this, you need that.’") Participants valued mobile units for also offering harm reduction services, broad medical services (e.g., wound care), connection to transportation programs, consistency in service provision, and telemedicine capabilities.

Implementation facilitators included trusting relationships with partner organizations and community members (“Anyone who's committed to addressing substance use like we are and serving the homeless population…[has] been wonderful and accepting and supportive,”), nuanced understanding of local politics, advertising, protocol flexibility, consistent staffing and hours, grant funding, training and technical assistance, and on-unit prescriber hours.

Barriers included onerous or unclear regulations around licensing, staffing shortages and competing priorities, reimbursement challenges due to unpredictable patient volumes (“On a busy day, we have six or seven…It's not really possible that billing in and of itself is going to be able to sustain it”), and community stigma toward mobile programming.

CONCLUSIONS: Despite organizational, community, and policy barriers, mobile MOUD units are an innovative and feasible way to expand access to life-saving medications, promote equity in MOUD treatment, and overcome stigma.

NATIONAL TRENDS IN METHAMPHETAMINE-RELATED PSYCHIATRIC HOSPITALIZATIONS IN THE UNITED STATES, 2015-2019

Susan Calcaterra¹; Aytha Swathi Pallavi¹; Daniel Ciccarone²; Brandon Del Pozo³; Jianing Wang⁴; joshua Barocas¹

¹Medicine, University of Colorado - Anschutz Medical Campus, Aurora, CO; ²University of California San Francisco School of Medicine, San Francisco, CA; ³Brown University, Providence, RI; ⁴Boston University, Boston, MA. (Control ID #3872156)

BACKGROUND: Harms related to methamphetamine (MAMP) use, including death and healthcare utilization, are at record highs. MAMP can precipitate psychosis. We aimed to measure and compare U.S. temporal trends in psychiatric hospitalizations with and without MAMP.

METHODS: We use data from the National Inpatient Sample to study patients 18 years and older with a psychiatric hospitalization from October 2015 to December 2019. The primary outcome was quarterly psychiatric hospitalization rates by substance use group. We classified substance use groups using ICD-10 codes which included: 1) MAMP alone (no cocaine, no opioid), 2) MAMP + cocaine (no opioid), 3) MAMP + any opioid (no cocaine), 4) MAMP + cocaine + any opioid, 5) any opioid or cocaine (without MAMP) relative to 6) psychiatric hospitalizations without cocaine, opioid, or MAMP. We used Joinpoint regression to identify time points in which MAMP-related psychiatric hospitalization trends changed significantly over the study period.

RESULTS: Our cohort included 6,573,198 total psychiatric hospitalizations. Psychiatric hospitalizations remained relatively unchanged from Q4 2015 to Q4 2019 (range 340,033 in Q4 2015 to 399,970 in Q4 2019). The rate of psychiatric hospitalizations increased by 58% from 1.23% (95% confidence interval [CI] 1.20, 1.27) to 1.94% (95% CI 1.90, 1.99) in the MAMP +/- other substances group, increased by 58% from 0.84% (95% CI 0.80, 0.87) to 1.33% (95% CI 1.29, 1.36) in the MAMP alone group, increased by 57% from 0.23% (95% CI 0.21, 0.24) to 0.36% (95% CI 0.35, 0.38) in the MAMP + opioids group, and decreased by 16% from 0.55% (95% CI 0.53, 0.58) to 0.46% (95% CI 0.35, 0.38) in the opioid and/or cocaine group. There was no change in the MAMP + cocaine or no substances groups. Joinpoint regression analysis did not identify time points in which MAMP-related psychiatric hospitalization trends changed significantly.

CONCLUSIONS: MAMP-related psychiatric hospitalizations increased from 2015 to 2019 while psychiatric hospitalizations without substances remained stable.

OFFERING BUPRENORPHINE IN MALE PRISONS INCREASED RECEIPT OF BUPRENORPHINE AFTER RELEASE IN MASSACHUSETTS: AN INTERRUPTED TIME SERIES ANALYSIS

Benjamin Bovell-Ammon⁷; Shapei Yan²; Devon Dunn³; Elizabeth Evans⁶; Peter D. Friedmann^4,5; Alexander Y. Walley¹; Marc LaRochelle¹

¹General Internal Medicine, Boston University School of Medicine, Boston, MA; ²General Internal Medicine, Boston Medical Center, Boston, MA; ³Massachusetts Department of Public Health, Boston, MA; ⁴Baystate Medical Center, Springfield, MA; ⁵University of Massachusetts Chan Medical School - Baystate Regional Campus, Springfield, MA; ⁶School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA; ⁷Boston Medical Center, Boston, MA. (Control ID #3870863)

BACKGROUND: Most prisons do not provide medications for opioid use disorder, despite a high risk of overdose after release. Massachusetts state prison system (Department of Correction, DOC), which had previously only offered pre-release naltrexone to patients with opioid use disorder, started also offering buprenorphine in April 2019. We hypothesized that this policy change would increase post-release buprenorphine receipt and not affect naltrexone receipt.

METHODS: We conducted an interrupted time series analysis of all 14,582 criminally sentenced men released from Massachusetts DOC from January 2014 through November 2020, using the Massachusetts Public Health Data Warehouse, a multi-sector data platform that individually links an all-payor claims database with over 20 other statewide databases. The outcomes were receipt of sublingual buprenorphine and injectable naltrexone, respectively, within 28 days after release. Aggregating data by calendar month of release, we used segmented linear regression to model the monthly proportion of released men who experienced each outcome over time, assessing for change in level and trend after the April 2019 DOC policy change and accounting for autocorrelation.

RESULTS: The policy change was associated with significant increases in the level (+2.5%; 95%CI 0.3, 4.6) and trend (+0.3%; 95%CI 0.1, 0.5) of buprenorphine receipt and with a significant decrease in the trend (-0.3%; 95%CI -0.5, -0.2) of naltrexone receipt (no significant level change in naltrexone: 0.8%; 95%CI -0.8, 2.5). By November 2020 (20 months after the policy change), the monthly proportion of recently released men receiving buprenorphine was 19.5% (95%CI 17.6, 21.3), an absolute difference of +8.8% (95%CI 6.5, 11.1) compared to what would have been predicted under pre-implementation trends; and the monthly proportion receiving naltrexone was 0.9% (CI -0.6, 2.3), an absolute difference of -5.9% (95%CI -7.8, -4.1) compared to baseline trends (Figure).

CONCLUSIONS: After buprenorphine became available to men in Massachusetts prisons, post-release buprenorphine receipt increased and naltrexone receipt decreased. This may reflect patient preferences for buprenorphine.

OUTPATIENT MENTAL HEALTH UTILIZATION BY ETHNICITY & PREFERRED LANGUAGE IN A NATIONAL COHORT OF COMMUNITY HEALTH CENTER PATIENTS

Elena Byhoff^1,2; Dang H. Dinh³; Jennifer A. Lucas³; Miguel Marino³; John Heintzman³

¹University of Massachusetts Chan Medical School, Worcester, MA; ²UMass Memorial Medical Center, Worcester, MA; ³Oregon Health & Science University, Portland, OR. (Control ID #3868653)

BACKGROUND: Disparities by race, ethnicity and language in access to mental and behavioral health (MHBH) specialty services is well documented. Hispanic populations experience similar or higher rates of mental health diagnoses (depression, anxiety, post-traumatic stress disorder) compared with non-Hispanic Whites, but are less likely to receive mental health treatment. Mental health treatment in particular relies on verbal communication so language barriers can present significant challenges for the diagnosis and treatment of mental health concerns. Among patients with access to care in Community Health Centers (CHCs), it is unknown how ethnicity and language are associated in differences in regular use of MHBH services. The objective of this study was to compare MHBH service use among Non-Hispanic White, Hispanic-English Preferring, and Hispanic-Spanish Preferring CHC patients

METHODS: Using Electronic Medical Record data, we conducted a retrospective data analysis of patients >18yo who received care at a national network of CHCs from 2012-2020. Demographic, health care utilization, comorbidity, and mental health variables were extracted from the EMR. The primary outcome was number of MHBH visits over time. Zero-Inflated Poisson regression models estimated odds of receiving MHBH specialty services and then compared expected annualized rates of MHBH services across racial/ethnic groups.

RESULTS: Of the 1,498,655 patients who received care at a CHC during the study period, 14% (215,098) received any specialty MHBH services. Hispanic English- and Spanish-Preferring patients had lower odds of ever having a MHBH visit (OR=0.69, 95%CI 0.62-0.78 and OR=0.68, 95%CI 0.56-0.82, respectively). Hispanic Spanish Preferred patients had an expected annualized rate of 0.61 MHBH visits for each expected annualized MHBH visit for Non-Hispanic White patients (95%CI 0.47-0.78).

CONCLUSIONS: Among patients who were likely to receive specialty MHBH services, Spanish-preferring patients had a significantly lower annualized rate of MHBH care. While overall access to care is improving with policy initiatives to integrate mental health care into primary care practices, and to remove insurance carve-outs to increase mental health service coverage, there is still unequal access to regular mental health care among non-English preferring patients in our sample.

PATIENT-CENTERED TELEHEALTH ACCESS TO OPIOID USE DISORDER HEALTH CARE – A QUALITATIVE ANALYSIS

Ximena A. Levander⁶; Jessica Couch⁶; Mackenzie Whitcomb⁶; Bradley Buchheit²; David Dorr¹; Darren Malinoski³; Philip T. Korthuis⁴; Sarah S. Ono⁵

¹Medical Informatics and Clinical Epidemiology, OHSU, Portland, OR; ²Family Medicine, Oregon Health & Science University, Portland, OR; ³Surgery, Oregon Health & Science University, Portland, OR; ⁴Medicine, Oregon Health & Science University, Portland, OR; ⁵Investigator, Center to Improve Veteran Involvement in Care (CIVIC) , VA Portland Health Care System, Portland, OR; ⁶Internal Medicine, Oregon Health & Science University, Portland, OR. (Control ID #3875252)

BACKGROUND: Regulatory changes at the start of the COVID-19 pandemic permitted buprenorphine initiation and continuation for opioid use disorder (OUD) via telehealth. These services were rapidly deployed to maintain, and potentially expand, OUD treatment access. However, how telehealth affected patient perceptions of access to OUD services, and approaches to improve patient-centeredness of telehealth for OUD, remain unknown.

METHODS: We conducted a qualitative analysis of patients who received OUD care at an academic center comprised of multiple primary care and addiction clinics in the Northwest US. We identified potential participants seen between March 2020 and December 2021 via electronic health record data who had 1) at least one telehealth visit for OUD and 2) at least one buprenorphine prescription, excluding for chronic pain alone. We conducted audio-recorded, individual phone interviews between October and December 2022. We used the Patient-centered Access to Health Care Framework to guide coding of professionally transcribed recorded data and generated themes from these codes using applied thematic analysis.

RESULTS: The 25 participants averaged 41 (range 20-61) years old; 52% were men. Geographically, 16% lived in rural areas; 28% were homeless in the prior six months. Six preliminary themes based on Patient- centered Access to Health Care Framework focused on accessibility of clinicians, clinics, and systems to deliver - and on patient-level ability to access - telehealth OUD care. (1) Lowered threshold to OUD care: Telehealth increased approachability and was ‘imperative’ to participants seeking out OUD treatment. (2) Adapted to required technology: Some participants needed more assistance than others in reaching services and to become ‘comfortable’ with technology. (3) Increased flexibility and availability of visits: Participants noted it was ‘way easier’ to reach their needed OUD care team with telehealth compared to in- person. (4) Reduced costs of the work of being an OUD patient: Participants highly valued no longer needing to drive, take time off work, or arrange childcare for a visit. (5) Depersonalized OUD Care: Participants noted telehealth visits being an ‘assembly line’, which was desirable for some but not for those wanting a ‘deep connection.’ (6) Preferred balance of in-person and telehealth visits: There was a wide range of preferences and reasons expressed by participants for visit type preferences.

CONCLUSIONS: Participants who received outpatient telehealth OUD treatment recognized and were grateful for the increased service accessibility and demonstrated determination in adapting to how they were delivered. Patient-centered telehealth for OUD will require flexibility in clinic and system protocols to accommodate patient preferences for receiving care.

PATIENT PERCEPTIONS OF STIGMA AND SOCIAL CONNECTEDNESS USING TELEHEALTH FOR OPIOID USE DISORDER TREATMENT: A QUALITATIVE ANALYSIS

Jessica Couch⁵; Mackenzie Whitcomb⁵; Bradley Buchheit²; David Dorr³; Darren Malinoski⁴; Philip T. Korthuis⁶; Sarah S. Ono⁷; Ximena A. Levander¹

¹Internal Medicine, Oregon Health & Science University, Portland, OR; ²Family Medicine, Oregon Health & Science University, Portland, OR; ³Medical Informatics and Clinical Epidemiology, OHSU, Portland, OR; ⁴Surgery, Oregon Health & Science University, Portland, OR; ⁵Oregon Health & Science University, Portland, OR; ⁶Medicine, Oregon Health & Science University, Portland, OR; ⁷Investigator, Center to Improve Veteran Involvement in Care (CIVIC) , VA Portland Health Care System, Portland, OR. (Control ID #3876911)

BACKGROUND: Stigma and social support are uniquely important factors in the treatment of individuals with opioid use disorder (OUD). Little research has assessed how the use of telehealth for OUD treatment can affect patients’ relationships with their communities and care teams, or how telehealth may interact with stigma to generate disparate patient experiences.

METHODS: In this qualitative study, we interviewed patients who had received outpatient OUD treatment at an academic medical center consisting of multiple primary care and addiction treatment clinics in the Northwest US. Participants were identified through their electronic health records as being eligible if they had 1) at least one virtual visit for OUD between March 2020 and December 2021, and 2) a prescription for buprenorphine that was not exclusively used to treat chronic pain. Interviews were conducted via phone

between October and December 2022, then recorded, transcribed, dual-coded, and analyzed using techniques from reflexive thematic analysis.

RESULTS: Of the 25 participants, the average age was 41 (range 20-61 years); 13 were cisgender men, 10 were cisgender women, 1 was a transgender man, two were non-binary. Participants were 84% White, 16% American Indian/Alaska Native, 12% Black, 12% Hispanic/LatinX and 4% Asian. Housing instability affected approximately one quarter of participants, with 28% having experienced homelessness in the prior six months. We generated five preliminary themes related to telehealth, including: (1) “A sense of social disconnect in the telehealth treatment experience,” which for some facilitated and for others hindered engagement in OUD care, depending on factors such as past experiences of stigma and difficulties with in- person interactions; (2) “Easing access to OUD treatment, at the cost of less holistic care,” with patients enjoying better appointment availability, but at the price of provider consistency and the interpersonal quality of visits; (3) “Challenges with building and maintaining mutual trust with providers,” with the physical distance of telehealth complicating this already difficult task; (4) “Changes to how patients engage within the recovery community,” with patients sharing diverse perspectives on how telehealth limited or facilitated this engagement; and, (5) “Control over the encounter environment affecting patient comfort during visits," with unique privacy concerns being described in both at-home and clinical environments, and potentially mediating patients’ willingness to engage in OUD care.

CONCLUSIONS: The use of telehealth for OUD treatment had layered and varied impacts on the nature of the patient-provider relationship, community support, and stigma. The potential for telehealth to play a protective role against stigma, particularly for patients from marginalized communities, has major implications for equity in OUD healthcare and is an important avenue for future research.

PEOPLE WHO USE DRUGS: TREATING BEYOND THE CONDITION

Frances Vernon¹; Megan Wade¹; Jessica Phan¹; Jennifer Adams²

¹Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²General Internal Medicine, University of Colorado, Denver, CO. (Control ID #3877242)

BACKGROUND: Stigma among healthcare providers towards people who use drugs (PWUD) is well documented, resulting in suboptimal care for the PWUD patient population. PWUD anticipate this stigma, which can result in delay of care or seeking healthcare elsewhere. In one report, PWUD cited judgment by providers as the biggest barrier to accessing care. However, there is limited research highlighting the experiences of PWUD in the healthcare system. The aim of this study was to characterize PWUD’s experiences with healthcare providers.

METHODS: A mixed-methods, cross-sectional survey was distributed at an urban community health and needle access (termed harm reduction) center between July and October 2022. 200 participants who self- identified as PWUD were recruited on a volunteer basis. Standardized surveys were verbally administered and electronically recorded. Data was analyzed using descriptive statistics.

RESULTS: Most participants (93%) had seen a healthcare provider in some capacity over the past 2 years and 70% reported that their provider knew about their drug use. When asked how often participants felt they could be open and honest with their healthcare providers, 55% responded always or most of the time. Forty- four percent of participants felt their providers’ attitudes changed negatively after learning they used drugs always or most of the time. When asked how often participants felt frustrated with their providers, 40% responded always or most of the time. When asked how often participants felt understood by their healthcare providers, 36% responded always or most of the time.

Fifty-three percent of participants felt that their healthcare providers rarely or never tried to understand how they see things before suggesting a new way of doing things in regards to their health. However, a majority of participants (55%) felt they received the healthcare they needed always or most of the time.

CONCLUSIONS: This study highlights the complicated nature of the relationship between healthcare providers and PWUD. Despite the majority of participants answering that they always told their providers about their drug use, fewer felt they could be open and honest with their provider about their drug use. While a majority of participants feel they have received the healthcare they need, a majority of participants also reported negative experiences of the healthcare system in their qualitative responses. The responses from study participants highlight a dichotomy between “transactional” (awareness of drug use, clear and precise information, received healthcare) versus “relational” aspects of the healthcare interaction (ability to be open and honest, changing attitudes, treated with kindness vs aggression).

Further studies should continue to explore the underlying causes of these provider-participant relations in order to determine how to improve the provider-patient care alliance.

PERCEPTIONS OF COMPLEMENTARY AND INTEGRATIVE HEALTH (CIH) AMONG PATIENTS WITH OPIOID USE DISORDER AND THEIR PROVIDERS

Evelyn T. Chang¹; Adam Resnick²; Rebecca Oberman³; Alicia Bergman⁴; Stephanie L. Taylor⁵

¹General Internal Medicine, VA- Greater Los Angeles, Los Angeles, CA; ²Los Angeles, US Department of Veterans Affairs, Washington, DC; ³Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Veterans Health Administration, Washington, DC; ⁴CSHIIP, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ⁵Health Services Research, VA, Los Angeles, CA. (Control ID #3874047)

BACKGROUND: The VA offers complementary and integrative health (CIH) therapies, such as acupuncture and chiropractic care, to patients with chronic pain and to those who have developed opioid use disorder (OUD) from long-term opioid therapy. While CIH has known benefits for chronic pain, less research exists on its use among patients with OUD. In this qualitative study, we aimed to assess provider and patient perceptions of CIH among Veterans with OUD.

METHODS: We interviewed 45 providers (from primary care, addiction, pain clinics) and 17 Veterans from 5 VAMCs in VISN 22 as part of a larger mixed-methods evaluation. Interviewees were identified through a snowball sampling strategy and interviewed one month prior to the implementation period. The interview guide used the Practical Robust Implementation and Sustainability Model (PRISM) to explore contextual factors influencing CIH adoption (i.e., patient perspectives, provider perspectives, external environment). Two reviewers analyzed the transcripts in Atlas.ti to identify themes and develop a codebook.

RESULTS: Most Veterans with OUD and providers were knowledgeable about CIH and had positive experiences towards CIH, particularly acupuncture and chiropractic care, as part of the treatment plan for chronic pain. Providers felt that it was important to offer non-pharmacologic options for chronic pain. Some providers, however, felt that Veterans with OUD may be less likely than those with chronic pain to consider CIH, because Veterans with OUD seemed fearful that opioids or other pain medications would be taken away.

CONCLUSIONS: Veterans with OUD and their providers were enthusiastic about integrating CIH into treatment plans as a non-pharmacologic option for chronic pain. Providers may have a misperception that Veterans with OUD are less likely to engage in CIH therapies due to patient concerns that CIH may be used to supplant pain medications. Providers may benefit from learning patient-centered approaches to offering CIH to Veterans with OUD as part of a comprehensive pain treatment plan.

PERIPARTUM MANAGEMENT OF OPIOID USE DISORDER AMONG PATIENTS HOSPITALIZED DURING PREGNANCY

Rebecca H. Lumsden¹; Shelby Powers²; Dana Clifton^1,3; Amy O'Regan⁴; Stephanie Poley⁵; Noel Ivey¹

¹Internal Medicine, Duke University School of Medicine, Durham, NC; ²Psychiatry, Duke University School of Medicine, Durham, NC; ³Pediatrics, Duke University School of Medicine, Durham, NC; ⁴Population Health, Duke University, Durham, NC; ⁵Duke Clinical Research Institute, Durham, NC. (Control ID #3874387)

BACKGROUND: Opioid use disorder (OUD) is rising among pregnant and postpartum patients; the peripartum period is a particularly high-risk time for relapse and fatal overdose. Medication for OUD (MOUD) is recommended in pregnancy to improve maternal and neonatal outcomes, yet little is known about peripartum management of hospitalized patients with OUD. We explored the burden of OUD among patients admitted to Duke Health system in pregnancy and described the peripartum trends in OUD management. METHODS: This retrospective cohort study included all patients with an ICD diagnosis of OUD admitted during pregnancy or up to 2 weeks postpartum to Duke University and Duke Regional Hospitals from May 2020 – Oct 2022. Demographic data, pregnancy outcomes, and healthcare utilization up to 3-months postpartum were collected. Timing of OUD diagnosis and rates of MOUD use in the peripartum period (during pregnancy, at delivery, at 3-months postpartum) were calculated using descriptive statistics.

RESULTS: There were 143 pregnancies complicated by OUD. The average age at delivery was 30.8 years (SD 5.2) with a median gravida of 4 (range 1-12). Nearly all (87.4%) had full Medicaid coverage, yet 31.5% had limited or no prenatal care. One-quarter (25.5%) had >1 hospital admission during pregnancy. Neonatal complications were common with 2.9% being stillborn, 28.7% preterm (<37 weeks gestational age), 29.8% low birthweight (<2500g), and 36.6% requiring neonatal ICU care.

While most (79.7%, n=114) were diagnosed with OUD prior to pregnancy, only 48.3% were prescribed MOUD prior to pregnancy. Active opioid misuse or relapse occurred in 35.0% of pregnancies, with intranasal (n=22) and intravenous (n=18) heroin and/or fentanyl most common. Of the 31 who initiated MOUD during pregnancy, only 3 received prescriptions from an OB provider.

Of the 136 who underwent labor and delivery, 77.9% (n=106) were prescribed MOUD during admission for delivery (34.9% methadone; 29.2% buprenorphine-naloxone; 35.8% buprenorphine). Only 22.7% were prescribed naloxone for overdose prevention at hospital discharge. After delivery, less than half (45.6%, n=62) had any routine postpartum follow-up care, and only 44 were known to remain on MOUD 3-months after delivery. There were 5 known OUD-related maternal deaths (3.5%) to date.

CONCLUSIONS: Inpatient admission during pregnancy is a critical opportunity for engagement in MOUD treatment. While MOUD use at delivery is high, significant gaps in OUD treatment exist after delivery with high rates of loss to follow up care by 3-months postpartum. Low rates of naloxone prescribing at discharge indicate a missed opportunity for harm reduction in this high-risk population. enhanced collaboration between OB and MOUD providers is needed to improve retention in postpartum OUD care. Further studies are needed to understand barriers to postpartum MOUD treatment to improve the health of this high-risk population.

REAL-WORLD ACCESS TO BUPRENORPHINE TREATMENT IN PHILADELPHIA: A SECRET SHOPPER STUDY

Margaret Lowenstein^1,2; M Holliday-Davis^1,2; Shoshana V. Aronowitz³; David Grande¹

¹Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA; ²Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA; ³School of Nursing, University of Pennsylvania, Philadelphia, PA. (Control ID #3874346)

BACKGROUND: Medications for opioid use disorder (OUD) like buprenorphine and methadone substantially improve outcomes, but there are many barriers to treatment. These include restrictive policies and practices not supported by evidence, such as delayed medication initiation, counseling requirements, or discharge for ongoing substance use. Our aims were: 1) to assess real-world access to buprenorphine treatment in Philadelphia and 2) to measure adoption of policies and practices that facilitate access to medication.

METHODS: We used an audit (“secret shopper”) design to survey all practices providing buprenorphine in Philadelphia, which has one of the highest overdose among US cities, from September-December 2022. We included all outpatient practices with one or more clinicians providing longitudinal buprenorphine treatment. First, we created a database of all potential programs and validated eligibility with a brief phone screen. Then, a research coordinator posing as a case manager called program front desk staff to inquire about appointment availability and specific policies and practices. These included same-day medication starts, counseling requirements, and tolerance of ongoing substance use. We analyzed data using descriptive statistics and assessed associations between program characteristics and adoption of restrictive practices.

RESULTS: After eligibility verification, our sample included 124 practices and we reached 100 (RR 81%). Overall, mean time to appointment for medication was 12.5 business days, with 16% of practices accepting walk-in visits. 52% of visits required two or more phone calls to schedule. 64% of practices accepted Medicaid, 49% accepted Medicare, 36% accepted commercial insurance, and 8% were self-pay only.

In terms of policies and practices, 46% of programs offered buprenorphine prescriptions at the first visit. 13% never provided medication at the first visit and 41% could not provide this information. 27% of practices mandated counseling to receive buprenorphine, 38% did not require counseling, and 35% could not provide this information prior to an initial visit. 20% of practices discharged or required inpatient treatment for patients with ongoing substance use, and 46% could not provide information about policies related to ongoing substance use.

We also compared policies for programs that accepted Medicaid with those that did not. Practices accepting Medicaid were more likely to provide medication on the first visit than those that did not (50% vs 22%, p=0.006), but also more likely to require counseling than those that did not (38% vs 8%, p<0.001). Tolerance of ongoing substance use did not differ by insurance status.

CONCLUSIONS: In this audit study of buprenorphine programs in Philadelphia, there was limited transparency and substantial variability in policies and practices that impact access to care. These findings can inform efforts to increase engagement and retention in treatment and better align care delivery with evidence.

SAFETY AND PRELIMINARY OUTCOMES OF SHORT-ACTING OPIOID AGONIST TREATMENT (SOAT) FOR HOSPITALIZED PATIENTS WITH OPIOID USE DISORDER

Ashish P. Thakrar^1,5; Tanya J. Uritsky^4,5; Cara Christopher⁴; Anna Winston²; Kaitlin Ronning³; Anna Lee Sigueza³; Anne L. Caputo³; Rachel McFadden^3,5; Jennifer Olenik²; Jeanmarie Perrone^6,5; M. K. Delgado^6,5; Margaret Lowenstein^2,5; Peggy Compton^3,5

¹National Clinician Scholars Program, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ³School of Nursing, University of Pennsylvania, Philadelphia, PA; ⁴Pharmacy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ⁵Center for Addiction Medicine and Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ⁶Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #3876177)

BACKGROUND: Patients with OUD frequently leave the hospital as patient directed discharges (PDDs) because of untreated withdrawal and pain. Short-acting opioids can complement methadone, buprenorphine, and non-opioid adjuvants for withdrawal and pain, however little evidence exists for this approach. This case series describes the safety and preliminary outcomes of a pilot intervention to offer short-acting opioid agonist treatment (sOAT) in addition to methadone and buprenorphine for hospitalized patients at an academic medical hospital in Philadelphia, PA.

METHODS: From August 2021 through March 2022, a pharmacist guided implementation of a pilot sOAT protocol consisting of escalating doses of oxycodone or oral hydromorphone scheduled every four hours, with additional doses of intravenous hydromorphone available as needed. Patients were also offered non- opioid adjuvants for withdrawal and pain and were encouraged to start methadone or buprenorphine treatment for OUD. We abstracted health records into a secure platform to describe the intervention and outcomes. The primary outcome was safety events: administration of naloxone, over-sedation, or a fall. Secondary outcomes were PDDs and respective length of stay (LOS), discharges on methadone or buprenorphine, and discharges with naloxone. We compared secondary outcomes to hospitalizations in the 12 month before index hospitalization among the same cohort.

RESULTS: Of the 23 cases, 13 (56.5%) were female, 19 (82.6%) were 40 years or younger, and 22 (95.7%) identified as White. Twenty-one (91.3%) regularly injected opioids and four (17.3%) were enrolled in methadone or buprenorphine prior to hospitalization. sOAT was administered at median doses of 200-320 morphine milligram equivalents per 24 hour period (equivalent to 20-35 milligrams of immediate-release oxycodoen every four hours). Naloxone administration was documented once in the operating room, over- sedation was documented once after unsanctioned opioid use, and there were no falls. Sixteen of the 23 index sOAT cases had a total of 42 admissions in the 12 months before index admission, none of which involved sOAT. The PDD rate for all 23 sOAT admissions was 44% with median LOS 5 days (compared to PDD rate 69% with median LOS 3 days for prior admissions), 65% of sOAT cases were discharged on buprenorphine or methadone (compared to 33% for prior admissions), and 65% of sOAT cases were discharged with naloxone (compared to 19% for prior admissions).

CONCLUSIONS: Pilot implementation of sOAT was safe using median doses of 200-320 morphine milligram equivalents per 24 hour period. Compared to prior hospitalizations among the same cohort, the PDD rate was lower, LOS for PDDs was longer, and more patients were discharged on buprenorphine or methadone maintenance and with naloxone, however efficacy for these secondary outcomes remains to be established.

SCREENING AND TREATMENT FOR UNHEALTHY ALCOHOL USE IN CENTRAL TEXAS FQHC

Mackenzie Franklin¹; Patrick Chang²; Nicole Kluz³; Jocelyn Labrada³; Karen Mendoza⁵; Eda Baykal- Caglar⁴; Mary Velasquez¹; Rebecca Nekolaichuk¹; Michael Pignone⁵

¹Internal Medicine, Dell Seton Medical Center at The University of Texas, Austin, TX; ²Population Health, The University of Texas at Austin Dell Medical School, Austin, TX; ³Internal Medicine, University of Texas at Austin, Austin, TX; ⁴Education and Research, CommUnityCare, Austin, TX; ⁵Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #3873486)

BACKGROUND: Several interventions have shown efficacy in managing unhealthy alcohol use, including screening, motivational interviewing to reduce consumption, and pharmacologic and behavioral interventions for alcohol use disorder (AUD). However, these interventions have not been widely implemented in primary care settings. We aim to reduce unhealthy drinking through implementation of a screening and brief telephone-based intervention program in a Central Texas Federally Qualified Health Centers (FQHC).

METHODS: We developed a quality improvement-based screening and intervention protocol in which patients (age 18+) within a Central Texas FQHC system answer an initial screener, with positive results triggering full AUDIT administration to guide further intervention. Patients with moderate scores (AUDIT 4-12) were offered evidence-based, two-session phone-based brief intervention (BI) with a social work- trained interventionist; those with higher scores could also be referred for pharmacotherapy where warranted. The counseling used motivational interviewing and education around effects of unhealthy alcohol use. Subsequent to intervention, we contacted participants in a 3-6 month window after initial counseling and administered repeat AUDIT in order to assess change in alcohol use.

RESULTS: Starting in March 2021, 5243 patients were screened using the AUDIT-C, with 328 (6.3%) screening positive. Of these, 208(63.4%) were contacted and successfully administered a full AUDIT. Within this population, the mean age was 46 years [IQR 36, 58 years]; 28% identified as female and 83% identified as Hispanic/Latino; 61% were insured through the county-based Medical Access Program (MAP), while 5.8% were insured through Medicaid, 7.7% through commercially obtained insurance and 4.3% through Medicare. Initial AUDIT scores were: 0-4 (n=17, 8.2%), 4-12 (n=116, 55.8%), and > 12 (n=75, 36.1%).

We obtained follow-up AUDIT for 128 of 208 participants (62%). Individuals aged 50 or older or Hispanic/Latino or Non-Hispanic white were more likely to complete 3-6 month follow-up than counterparts. For patients who agreed to complete 3-6 month follow-up, 101 (79%) showed a reduction in AUDIT score, with a mean AUDIT score change of -3.1, 95% CI (-3.7, -2.4).

CONCLUSIONS: Screening and brief telephone-based intervention is associated with reduced risky drinking behaviors in diverse adult FQHC patients. Screening and brief intervention provides an opportunity for primary care providers to effectively address risky drinking behaviors in FQHC patients.

SUBOPTIMAL SCREENING RATES OF ANXIETY AND DEPRESSION FOR INPATIENTS WITH INFLAMMATORY BOWEL DISEASE

Ariel Jordan¹; Mehwish Ahmed²; Queen Saunyama²; Jami Kinnucan³; Megan Riehl²; Jeffrey Berinstein²

¹Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI; ²Gastroenterology, University of Michigan Michigan Medicine, Ann Arbor, MI; ³Gastroenterology, Mayo Clinic in Florida, Jacksonville, FL. (Control ID #3863650)

BACKGROUND: Patients with inflammatory bowel disease (IBD) are at increased risk for anxiety and depression, which has been associated with elevated risk for clinical relapse, hospitalization, need for treatment escalation, and decreased likelihood to achieve sustained remission. While mental health management is clearly an important aspect of IBD care, we suspect that patients with IBD are not adequately screened on admission by their treatment team. We aim to assess patient perceptions regarding the evaluation of these important mental health metrics during hospitalization.

METHODS: This was a prospective survey study in adult patients with IBD hospitalized at a single tertiary center for the indication of IBD-related complication between December 2021- November 2022. Patients completed a survey focused on screening for anxiety and depression, including the Hospital Depression and Anxiety Scale [HADS] (category subscore >8 considered abnormal), inpatient interventions, and outpatient follow-up plan. Descriptive statistics were reported as means and standard deviations (SD) for continuous variables and as frequency and percentages for categorical variables.

RESULTS: Among the 40 respondents, 57.5% were female with mean age of 45.2 (SD 17.1). The majority were Caucasian (95.0%), IBD diagnosis (60% Crohn’s disease, 37.5% ulcerative colitis, 2.5% indeterminate colitis), with mean age of diagnosis of 32.2y (SD 20.0y). 67.5% were on an immunosuppressive agent, 52.5% had extraintestinal manifestations, and 67.6% required steroids during this admission. Prior to admission,

52.5% had a diagnosis of anxiety, depression, or both. 52.9% report being on a selective serotonin reuptake inhibitor at home. 62.5% of all respondents reported not being given a survey asking about anxiety or depression during their admission. The majority (77.5%) noted no discussion of anxiety or depression during admission. The mean HADS anxiety subscore was 9 and mean HADS depression subscore was 4. 37.8% of respondents did not feel an adequate plan was developed for their depression and/or anxiety prior to discharge.

CONCLUSIONS: Our data shows that inpatient screening and management for anxiety and depression among inpatients with IBD was suboptimal. In our population, many patients had a previous diagnosis of anxiety or depression. Despite this, most patients did not have a discussion of anxiety or depression during their admission. Additionally, the abnormal HADS anxiety subscore further demonstrates that anxiety remains an undertreated aspect of IBD care. To our knowledge, this is one of the first studies to evaluate inpatient patients with IBD for mental health disorders. This data highlights the importance of provider education as well as implementation of protocols to assess all hospitalized patients with IBD for anxiety and depression.

TELEHEALTH DURING THE COVID-19 PANDEMIC: IMPACT AND IMPLICATIONS FOR DEPRESSION SCREENING

Maria E. Garcia¹; Ladson Hinton²; Jennifer Livaudais-Toman³; Mitchell D. Feldman⁴; Leah S. Karliner⁵

¹General Internal Medicine, University of California, San Francisco, San Francisco, CA; ²Psychiatry, UC Davis, Sacramento, CA; ³Division of General Internal Medicine, University of California, San Francisco, Greenwich, CT; ⁴Medicine, University of California San Francisco, San Francisco, CA; ⁵Medicine, UCSF, San Francisco, CA. (Control ID #3877050)

BACKGROUND: During the COVID-19 pandemic, much of routine preventative care was put on hold. While depressive symptoms increased dramatically with the pandemic, it is unclear whether primary care practices continued routine depression screening, and whether this differed with the rapid shift to telehealth or return to in-person office visits. Our study objective was to assess depression screening rates over the first 18 months of the pandemic and to investigate differences by visit type and patient demographics.

METHODS: We examined electronic health record data for adult patients at 6 University of California San Francisco, primary care practices to assess depression screening rates using the Patient Health Questionnaire-2 at eligible visits from January 2020 to September 2021. Visits were excluded if patients had depression screening in the preceding year, or had a baseline diagnosis of depression, bipolar disorder, schizophrenia, schizoaffective disorder, or dementia. We further compared depression screening rates over time by visit type (in person, video, or telephone). In multivariable analysis, we evaluated the likelihood of being screened using logistic regression models, examining visit type, age, gender, race/ethnicity, language preference, and comorbidities, accounting for multiple visits per patient and adjusting for primary care site.

RESULTS: There were 68,412 depression-screening-eligible visits for 40,989 unique patients during the study period (60% female, mean age 49.9 [SD = 17.5], 43% English-speaking White, 26% English- speaking Asian, 9% English-speaking Latino, 7% English-speaking Black, and 5% patients with non-English language preference). Depression screening decreased sharply at the beginning of the pandemic, largely recovered after three months, but never reached pre-pandemic rates. Telephone and video visits had low screening rates throughout the study period. In multivariable analysis, patients with video and telephone visits had a lower likelihood of being screened compared to those with office visits (OR 0.28, 95% CI 0.27-0.30, and OR 0.24, 95% CI 0.20-0.27, respectively). Patients with non-English language preference were less likely to be screened than those with English language preference (Chinese OR 0.74, 95% CI 0.63-0.86; Spanish OR 0.58, 95% CI 0.43-0.78; other languages OR 0.70, 95% CI 0.59-0.85). There was no difference in screening by gender or age, except among those older than 75 years (OR 0.79, 95% CI 0.68-0.92 compared to 18–30- year-olds).

CONCLUSIONS: Depression screening rates fell precipitously in the early months of the pandemic, recovering quickly, but not completely, over the subsequent months. Much of this recovery was during in-person office visits, with persistently low rates of depression screening during both telephone and video visits. Telehealth is here to stay; to avoid disparities in depression screening, and thus diagnosis, primary care must develop systems to incorporate routine depression screening into telehealth visits.

THE ASSOCIATION BETWEEN INFLAMMATORY BOWEL DISEASE AND EXPOSURE TO TOBACCO SMOKING

Bushra M. Abdallah, Mariah Arif, Maryam Al-Malki, Razan Hourani, Tamader Al-Maadeed, Nidal Khodr, Ghaith Al-Kuwari, Mashael Al-Siddiqi, Tanya Kane, Tawanda Chivese

College of Medicine, Qatar University College of Medicine, Doha, Ad Dawhah, Qatar. (Control ID #3868660)

BACKGROUND: There is still some uncertainty about the association between tobacco smoking exposure and the risk of inflammatory bowel disease (IBD) and this association is under-researched in the Middle East and North Africa region. This research investigated the association between childhood and adulthood exposure to tobacco smoking with ulcerative colitis (UC) and Crohn’s disease (CD) in an Arabic population in the Middle East and North Africa region.

METHODS: This is a matched case-control study using data from the national biobank. Cases were individuals who were diagnosed with CD or UC. Controls were individuals who did not have CD, UC, irritable bowel syndrome or indeterminate colitis, and were matched to cases using age and sex. The exposures of interest were childhood second-hand passive smoking and adulthood smoking. The association between UC and CD and smoking was assessed using conditional multivariable logistic regression, after adjusting for confounders.

RESULTS: A total of 89 CD and 362 UC cases and equal numbers of controls were included. The median age of CD cases was 37 years (IQR 29-47), and the median age of UC cases was 35 years (IQR 28-44). After multivariable logistic regression, CD was associated with higher odds of being a current smoker (OR 2.51, 95%CI 0.85-7.37, p=0.095), although with weak evidence against the model hypothesis at the study’s sample size. There were, however, no significant differences in childhood passive smoking exposure between CD cases and their controls. Further, there were no significant differences in both childhood passive smoking and adulthood smoking exposure between UC cases and their controls.

CONCLUSIONS: In this setting, adulthood tobacco smoking appears to increase the odds of having CD while there seems to be no association between either childhood or adulthood tobacco smoking exposure and the odds of having UC. These findings, together with the existing literature, suggest the need for smoking cessation initiatives in populations at high risk of CD in the region, where smoking is highly prevalent.

THE ASSOCIATIONS OF PAIN SEVERITY AND CANNABIS USE WITH CIGARETTE USE IN PATIENTS WITH CHRONIC PAIN

Gayatri Nangia¹; Chenshu Zhang¹; Deepika Slawek²; Julia Arnsten³; Joanna L. Starrels⁴

¹Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY; ²Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY; ³Medicine, Albert Einstein College of Medicine/Montefiore Medicine, Bronx, NY; ⁴Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #3875207)

BACKGROUND: Cigarette use, a leading cause of preventable death, is disproportionately high in individuals with chronic pain. Prior studies showed that unregulated cannabis use was associated with increased cigarette use, and medical cannabis use was associated with decreased cigarette use. These studies focused on inhaled cannabis and were limited by methodology. With the expansion of medical cannabis for pain, we sought to answer (1) whether overall cannabis use is associated with increased cigarette use, (2) whether this relationship differs by cannabis use characteristics (inhaled or not, medical or not) and (3) whether pain severity potentiates the relationship between cannabis use and cigarette use.

METHODS: We performed a secondary analysis of a longitudinal cohort study of 225 adults with chronic or severe pain who were newly certified in New York state for medical cannabis use. The current analyses were restricted to participants who smoked cigarettes at baseline. To examine question one, we conducted linear mixed effects models with repeated measures at months 0, 3, 6, and 9. The main independent variable was days of overall cannabis use in the past 30 days (0-30). The dependent variable was average number of cigarettes per day in the past 30 days. To address question two, we repeated two similar models; one included three independent variables corresponding to days of use of different types of cannabis (unregulated, medical, or both) and the other included two independent variables corresponding to days of use by different modes (inhaled [smoked or vaporized] or non-inhaled [any other method of use]). To address question three, interaction analyses were conducted by including pain severity (Brief Pain Inventory, 0 to 10) and its interaction terms in the overall cannabis use model.

RESULTS: Of 225 participants, 75 (33%) reported any cigarette use at baseline, mean age was 54 years, and 55% identified as male. Regarding questions one and two, the frequency of cannabis use was not associated with cigarettes per day for any of the cannabis use variables. However, when adjusting for pain severity and its interaction with overall cannabis use, overall cannabis use was positively associated with cigarette use (b=0.34; p=0.010) and this relationship was attenuated by pain severity (β for pain*cannabis use= -0.05; p<0.01).

CONCLUSIONS: In this cohort, cannabis use was not associated with cigarette use but when accounting for pain severity, pain severity attenuated the positive relationship between cannabis use and cigarette use. This finding could indicate that having more pain is protective against increased cigarette use when using cannabis. Further research should examine the motivations and effects driving the complex relationships between pain severity and cigarette use in individuals certified for medical cannabis.

THE DEVELOPMENT OF A PUBLICLY AVAILABLE STATE-WIDE TOOL SUMMARIZING REFERRAL AND TREATMENT OPTIONS FOR PERSONS WITH UNHEALTHY ALCOHOL USE: RESULTS FROM STAKEHOLDER INTERVIEWS

Sean Riley¹; Mary C. Wirtz²; Daniel E. Jonas²

¹Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²Internal Medicine, The Ohio State University, Columbus, OH. (Control ID #3874545)

BACKGROUND: Finding appropriate treatment and referral options for persons with unhealthy alcohol use is sometimes challenging for primary care clinicians. Details about available treatment options and referral resources are often scattered and outdated. Therefore, many clinicians are unfamiliar with the range of available options for their patients with unhealthy alcohol use. The purpose of this project is to gather qualitative information that will inform the development and dissemination of a publicly available, interactive, online tool providing a comprehensive set of referral resources for clinicians caring for patients with unhealthy alcohol use. The tool will allow clinicians to search different levels of care and services provided within specific geographic regions based on proximity to the patient’s places of residence.

METHODS: Semi-structured interviews were conducted with six clinicians and administrators at a multidisciplinary academic health center to gather insight into the process for developing the tool and assessing project feasibility and potential utility. Two researchers were present for all interviews and utilized a grounded theory approach to inductively identify themes and codes.

RESULTS: Stakeholders expressed general support regarding the feasibility and utility of the project. Three major themes emerged on the development and implementation of the tool: 1. The tool may have the greatest value for clinicians who are not affiliated with a large health system, as those in large health systems often have internal resources and options built into their workflows (e.g., via EHR referral preferences). 2. Careful consideration must be made to provide information relevant to marginalized populations, for example, including the provision of transportation or childcare. 3. Addiction-care resources are constantly changing, and a systematic process for updating the information will be needed in order to best serve patients and clinicians. Thematic saturation was reached with six interviews, but ongoing stakeholder interviews will likely take place in the continuing development of the tool.

CONCLUSIONS: A publicly available online tool comprising state-wide resources for unhealthy alcohol use has the potential to provide clinicians and administrators with a valuable instrument to use to help bridge gaps in care for patients with unhealthy alcohol use. The results of these stakeholder interviews will directly inform the design and implementation of the tool by providing a means of creating comprehensive, up-to- date, and localized information on resources relevant to all patient populations.

THE EFFECT OF PRACTICE FACILITATION ON KEY DRIVERS OF IMPLEMENTATION FOR SCREENING AND MANAGEMENT OF UNHEALTHY ALCOHOL USE IN THE STOP UNHEALTHY (STUN) ALCOHOL USE NOW TRIAL

Colleen Barclay¹; Sean Riley¹; Darren Dewalt²; Debbie Grammer³; John C. Weathington³; Daniel E. Jonas¹

¹Division of General Internal Medicine and Geriatrics, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH; ²Division of General Internal Medicine and Clinical Epidemiology, Department of Medicine, The University of North Carolina at Chapel Hill Department of Medicine, Chapel Hill, NC; ³North Carolina Area Health Education Centers Program, Chapel Hill, NC. (Control ID #3876197)

BACKGROUND: Unhealthy alcohol use is a leading cause of preventable mortality, yet many primary care practices do not have systems to screen for and manage unhealthy alcohol use (UAU). We are evaluating the effect of practice facilitation on implementation of practice and system changes to improve evidence-based

screening and intervention for UAU.

METHODS: We enrolled small- to medium-sized primary care practices, which received a practice facilitation intervention aiming to increase screening and brief counseling for UAU, and referral and pharmacotherapy for patients with an alcohol use disorder. The 12-month intervention included quality improvement (QI) coaching, electronic health record support, practice support materials, training, and expert consultation. We used the Key Drivers of Implementation Scale (KDIS), a facilitator-assessed, behaviorally- anchored ordinal scale, to evaluate monthly progress on 10 domains that affect uptake of the project’s change package. For each domain, KDIS scores range from 0 to 3 or 0 to 5. Here we report preliminary results for improvement in KDIS domains for participating practices. We categorized practices as having improved in a domain if there was at least a 0.5 point improvement.

RESULTS: Preliminary results were available for all 20 practices that remained in the trial. To date, the mean number of months with KDIS data during the intervention phase of the trial is 10.6 (range 2-12; 15 practices have completed reporting for all 12 months of the intervention and all but 1 practice has reported at least 6 months). Ratings in some of the 10 KDIS domains improved over time for all practices, with a mean of 4.1 domains per practice showing improvement (range 0-9 domains), and the mean number of practices showing improvement for each domain was 8.2 (range 3-17). The mean magnitude of improvement across domains (for all practices showing improvement) was 1.96 (range of means: 1 to 2.29). Figure 1 shows changes in KDIS ratings over time, by domain. This is preliminary data; some practices are still undergoing the trial intervention.

CONCLUSIONS: Practice facilitation improved some key drivers of implementation for screening and management of unhealthy alcohol use for most practices in this preliminary assessment.

TREATMENT GAPS AND DISPARITIES AMONG MEDICARE BENEFICIARIES HOSPITALIZED WITH ALCOHOL USE DISORDER

Eden Y. Bernstein¹; Travis P. Baggett^1,3; Shrunjal Trivedi²; Shoshana J. Herzig²; Timothy Anderson²

¹General Internal Medicine, Massachusetts General Hospital, Boston, MA; ²Medicine, Beth Israel Deaconess Medical Center, Brookline, MA; ³Boston Health Care for the Homeless Program, Boston, MA. (Control ID #3874195)

BACKGROUND: Alcohol use disorder (AUD) is common among Medicare beneficiaries. Treatment includes behavioral interventions and/or pharmacotherapy. Hospitalization may provide an opportunity for initiation of AUD treatment and coordination of follow-up care, but the extent to which this occurs is unknown.

METHODS: This was a retrospective cohort study of the 20% national sample of Medicare Part D beneficiaries hospitalized in 2016 with a primary or secondary discharge diagnosis of AUD. The primary outcome was initiation of medications for AUD (MAUD) within 7 days of discharge. MAUD included naltrexone, acamprosate, or disulfiram. The secondary outcome was having an outpatient mental health or primary care visit within 30 days of discharge. For the MAUD analysis, patients with MAUD fills 3 months prior to hospitalization and those with both liver and renal disease, which are contraindications for naltrexone and acamprosate, were excluded. Mixed effect logistic regression models were constructed to control for age, sex, race, comorbidities, prior MAUD use, and hospital care by addiction medicine or psychiatry as well as clustering of repeat hospitalizations within each patient.

RESULTS: The cohort included 29,797 AUD hospitalizations (44% age over 65, 29% female, 72% white, 17% Black, 35% dual-eligible for Medicaid, and 11% with a primary AUD diagnosis). After excluding 1,188 hospitalizations with MAUD contraindications or recent use, there were 244 (0.9%) MAUD fills within 7 days of discharge. By comparison, there were 1,547 (5.4%) discharge benzodiazepine fills. Factors associated with a reduced likelihood of MAUD initiation included male sex (aOR 0.69 [95% CI 0.50-0.95]) and Black race (aOR 0.57 [95% CI 0.34-0.94] vs. White). Remote use of MAUD prior to hospitalization (aOR 12.24 [95% CI 5.97-25.11]) and involvement of an addiction specialist during hospitalization (aOR 4.95 [95% CI 3.41-7.19]) were associated with a greater likelihood of MAUD initiation. Forty-eight percent (n=14,413) of AUD hospitalizations were followed by an outpatient appointment within 30 days of discharge. Black race (aOR 0.56 [95% CI 0.50-0.64] vs. White), Hispanic ethnicity (aOR 0.80 [95% CI 0.67-0.95] vs White), and Medicaid eligibility (aOR 0.51 [95% CI 0.46-0.57]) were associated with reduced odds of outpatient follow- up, while MAUD receipt on discharge was associated with a greater likelihood of follow-up (aOR 2.13 [95% CI 1.45-3.13]).

CONCLUSIONS: In this national sample of patients hospitalized with AUD, MAUD initiation was very rare but associated with greater likelihood of outpatient follow-up. Clinicians, health systems, and policymakers must urgently align efforts to address care gaps and disparities in hospital-initiated AUD treatment.

TRENDS IN ALCOHOL AND MARIJUANA USE BY SMOKING STATUS IN THE UNITED STATES: AN ANALYSIS OF THE 2010-2020 NSDUH

Jacob J. Rich²; Thanh C. Bui⁴; Eden Y. Bernstein³; Phuc H. Le¹

¹Center for Value-based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH; ²Center for Value-Base Care Research, Cleveland Clinic, Cleveland, OH; ³General Internal Medicine, Massachusetts General Hospital, Boston, MA; ⁴College of Medicine, Department of Family and Preventive Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK. (Control ID #3876816)

BACKGROUND: In addition to illicit drugs, alcohol and marijuana contribute to the majority of addiction and substance-related mortality in the US. People who smoke tend to use other substances including alcohol and marijuana concurrently, increasing the risk of adverse health outcomes. Understanding the population- level pattern of polysubstance use could be helpful in designing prevention efforts. We assessed trends in alcohol and marijuana use by smoking status in US adults and associated risk factors.

METHODS: We conducted a cross-sectional analysis of the National Survey on Drug Use and Health data from 2010-2020. We included adults aged ≥18 years and categorized them into 3 subgroups: current smoker (had smoked within the last 30 days), former smoker (had not smoked within the last 30 days, but has had over 100 cigarettes during their lifetime), and never smoker (had fewer than 100 cigarettes during their lifetime). We estimated the annual prevalence of past-month marijuana use, unhealthy alcohol use (>1 drink/day for women or >2 drinks/day for men), or both across the 3 smoking subgroups. In addition, we used logistic regressions to examine determinants of concurrent use among current smokers. All analyses applied weights to account for the complex survey design.

RESULTS: The final sample included 436,691 persons. One-fourth were current smokers, 15% past smokers, and 60% never smokers. Overall, 8.5% of the sample practiced unhealthy alcohol use, while 13.1% had consumed marijuana within the last 30 days. The prevalence of unhealthy alcohol and marijuana use were higher in current smokers compared to former and never smokers. From 2010-2020, while the prevalence of unhealthy alcohol use remained overly stable, that of marijuana use increased significantly in all smoking subgroups regardless of age, sex or race/ethnicity. In multivariable models, current smokers who were older than 25 years (vs. 18-25 years) and Hispanic (vs. White) were less likely to use marijuana, while those with more than a high-school degree (vs. less than high-school) and government insurance (vs. private insurance) were more likely. People with an income of >$50,000/year who currently smoked had increased odds of unhealthy alcohol use. Finally, current smokers aged >25 years were less likely while those with no insurance were more likely to use both alcohol and marijuana than people of 18-25 years and those with private insurance, respectively.

CONCLUSIONS: Despite much public health success in reducing tobacco use, marijuana use is rising among all smoking subgroups in the US, including never smokers. Additionally, unhealthy alcohol use has remained overly stable. In addition to tobacco control efforts, public health strategies targeting especially young adults will be needed to reduce the use of alcohol and marijuana and prevent adverse health outcomes.

TRENDS IN USE AND COSTS OF PRESUMPTIVE AND CONFIRMATORY URINE DRUG TESTS FOR PATIENTS RECEIVING BUPRENORPHINE FOR OPIOID USE DISORDER

Ricardo Cruz, Marc LaRochelle

General Internal Medicine, Boston University School of Medicine, Boston, MA. (Control ID #3876355)

BACKGROUND: Guidelines recommend urine drug testing (UDT) as a monitoring and risk reduction tool for patients prescribed medications for opioid use disorder (OUD). Little is known about the relative use and cost of presumptive UDT, and comparably more specific and expensive, definitive UDT.

METHODS: We conducted a repeated cross-sectional study using Truven Health Analytics MarketScan® Commercial Claims Database for calendar years 2011-2020. For each year, we identified enrollees with one or more pharmacy claims for buprenorphine for OUD. Within this cohort, we identified all medical claims for presumptive and definitive UDT using Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS). We report temporal trends in use and total and out-of-pocket costs of UDT per person-year of enrollment.

RESULTS: From 2011 to 2020 there were 453,098 unique individuals with one or more buprenorphine for OUD prescription, contributing 387,197 person-years of enrollment. Over the 10-year time period, we identified 1,476,181 presumptive UDT and 1,029,758 definitive UDT costing a total of $225,235,545 and $298,382,709 respectively. The mean number of presumptive and definitive UDT per person year increased from 2.8 and 1.4 respectively in 2011 to a peak of 4.6 and 3.6 in 2016 before declining to a mean of 3.0 for presumptive and 2.0 for definitive tests in 2019. The average total cost per UDT mirrored the trends in use of UDT, peaking at $197 for presumptive and $448 for definitive UDT in 2016 before declining to $79 and $144 respectively in 2019. The mean out-of-pocket cost was $258 per person-year over the 10-year period, and peaked at $429 per person-year in 2016.

CONCLUSIONS: In a cohort of patients receiving buprenorphine for OUD, we identified an increasing trend in use and cost of presumptive and definitive UDT from 2011-2016, followed by a decline in both the use and cost of UDT through 2019. We are not aware of changes to clinical guidance in use of UDT over this timeframe, raising the question of profit driving observed trends. While UDT are recommended by clinical guidelines largely based on expert opinion, more evidence is needed to support the use and frequency of UDT for this indication.

TWO SIDES OF THE AISLE AND TWO MODELS OF OPIOID USE DISORDER: EXPLORING THE MODERATING EFFECT OF POLITICAL AFFILIATION ON POLICY SUPPORT WHEN EXPOSED TO A SURVIVORSHIP VERSUS CHRONIC DISEASE MODEL OF OUD

Joshua Ho²; Ashish P. Thakrar³; Geetanjali Chander⁴; Jarratt Pytell¹

¹Medicine, Johns Hopkins University, Baltimore, MD; ²Internal Medicine, University of Colorado, Denver, CO; ³Internal Medicine, University of Pennsylvania, Philadelphia, PA; ⁴University of Washington School of Medicine, Seattle, WA. (Control ID #3870603)

BACKGROUND: Low public support for opioid use disorder (OUD)-related policies directly contributes to mortality. In a prior study, exposure to a survivorship model of OUD relative to a chronic disease model failed to increase support of OUD-related policies. We conducted a secondary analysis to explore if the impact of OUD model exposure on policy support differed by political affiliation.

METHODS: General public participants read vignettes depicting individuals in sustained remission from OUD. The experiment varied gender, race, and disease model: Chronic Disease “like diabetes, which requires ongoing work or treatment” or Survivorship “like some cancers, which can be treated and not come back for the rest of their life”.

Support for policies (Figure) were measured on a Likert scale and dichotomized as support (4-5) versus no support/indifferent (1-3). Multivariate logistic regression models included an interaction of disease model exposure with self-reported political affiliation while adjusting for covariates. Adjusted predicted probability of support are presented.

RESULTS: There were 1,440 participants: 447 Democrats, 370 Independents, and 355 Republicans.

Democrat, Independent, and Republican average ages were 46, 42, and 48, respectively (p<0.01). Democrats and Independents were less likely to be White (74% and 78%) compared to Republicans (94%, p<0.01). Significant differences in employment, highest level of education, and income, and no differences in self- reported gender were observed.

We did not detect a difference in support for policies by political affiliation depending on disease model exposure (Figure). Democrats were significantly more likely to support policies.

CONCLUSIONS: Political affiliation did not moderate the effect of disease model exposure on policy support. Exposure to a disease model might evoke different conceptions of disease treatability and societal responsibility. Understanding these conceptions could tailor public messaging and improve support for evidence-based OUD-related policies.

VALUE AND PERCEPTIONS OF MENTAL HEALTH TRAINING: A SURVEY OF PRIMARY CARE RESIDENCY ALUMNI

Lisa Ochoa-Frongia¹; Cristina Calderon^1,2

¹Medicine, University of California San Francisco, San Francisco, CA; ²Psychiatry, University of California San Francisco, San Francisco, CA. (Control ID #3877394)

BACKGROUND: Mental health conditions including depression, anxiety and PTSD are among leading causes of disability and loss of quality of life in the United States. Up to 70% of primary care visits are driven by mental health conditions. Most patients seek mental health care from their primary care provider (PCP) alone, but primary care physicians often leave training without the knowledge and skills to appropriately treat common mental health conditions. To inform an enhanced mental health curriculum in our primary care residency program, we surveyed program alumni on their practices and values around PCP care for common mental health conditions and mental health training.

METHODS: In 2022, we surveyed alumni of the San Francisco General Hospital-based Primary Care Track of the University of California San Francisco Internal Medicine residency program (SFPC). An invitation to a Qualtrics survey was E-mailed to 168 SFPC alumni from all graduation years (1985 to 2021).

RESULTS: Sixty-five respondents (39%) completed the survey. Respondents were more likely to be recent graduates. Most (52%) practice in an academic environment. Over 85% of respondents manage anxiety, depression, insomnia and sleep disorders, and SI/suicide risk in their current practice. A majority manage conditions related to interpersonal violence (IPV, 71%) and trauma/PTSD (63%). Fewer manage ADHD (43%), bipolar disorder (46%), personality disorders (49%), and psychotic disorders (42%).

Over 70% of respondents agree PCPs should have the ability to screen for all mental health conditions in the survey. Over 90% feel PCPs should be able to diagnose and manage anxiety, depression, insomnia, SI/suicide risk and trauma/PTSD. For IPV, >90% of respondents feel PCPs should be able to diagnose, but 74% felt the PCP should manage this condition. Respondents find it less appropriate for PCPs to diagnose and manage ADHD and bipolar, personality and psychotic disorders.

Sixty percent or more would have wanted more training in adult ADHD, bipolar disorder, trauma/PTSD, personal wellbeing, insomnia/sleep disorders, IPV and psychotic disorders, and 50-55%, more on referral to mental health colleagues, personality disorders, and anxiety. Most (≥60%) would have wanted the same amount of training on depression and SI/suicide risk assessment. On no topic did more than 3% of respondents feel they would have wanted less training.

CONCLUSIONS: Alumni of a primary care residency training program manage many mental health conditions in their practice and feel PCPs should be able to screen for, diagnose and manage multiple mental health conditions. While they feel it is less appropriate for PCPs to diagnose and manage ADHD, and bipolar, personality and psychotic disorders, they would have wanted more training on these conditions in residency. This may reflect a pragmatic approach toward the challenge of managing such conditions given limited

access to mental health specialists. We will modulate our enhanced curriculum to incorporate these values.

WHICH POSITIVE CHILDHOOD EXPERIENCES (PCES) IMPROVE ADULT MENTAL HEALTH IN THE FACE OF ADVERSE CHILDHOOD EXPERIENCES (ACES): A NATIONALLY REPRESENTATIVE STUDY

Jaime La Charite^1,3; Mariam Khan²; Cher X. Huang⁵; Yvonne Lei²; Teryl K. Nuckols³; Narayan Sastry⁶; Rebecca Dudovitz^4,7; Adam Schickedanz⁷

¹Department of General Internal Medicine, University of California Los Angeles, Los Angeles, CA; ²Medical School, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ³Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; ⁴University of California, Los Angeles, Los Angeles, CA; ⁵Massachusetts General Hospital, Boston, MA; ⁶University of Michigan, Ann Arbor, MI; ⁷Pediatrics, University of California Los Angeles, Los Angeles, CA. (Control ID #3874599)

BACKGROUND: Although mounting evidence supports a dose-response relationship between adverse childhood experiences (ACEs) and many poor health outcomes, less is understood regarding the impact of positive childhood experiences (PCEs) on health. PCEs are supportive relationships and positive community experiences that promote health. Higher PCE count scores are associated with improved health. After accounting for ACE exposure, it is unknown if certain PCEs are more protective against developing adult mental health conditions. This information is critical for intervention development to improve lifetime health.

METHODS: We analyzed data from the nationally representative, longitudinal Panel Study of income Dynamics. We drew PCE and ACE measures from its 2014 Childhood Retrospective Circumstances Study and adult health outcomes and covariates from its 2017 core survey. We used factor analysis to identify the survey items and latent domains underlying the PCE construct. Item responses within each domain were averaged on a scale from 0 to 4, with four indicating max PCE exposure. Weighted logistic regressions tested associations between each domain average and lifetime diagnosis of depression, controlling for ACE exposure and adult individual-level covariates. Secondary outcomes included lifetime anxiety diagnosis and current symptoms of psychological distress during adulthood. We also tested interactions between PCE domains and ACE score.

RESULTS: 7,422 adults completed the 2014 and 2017 surveys and were included in our sample; average age was 50 years. The average PCE score across all domains was 3.3. Factor analysis divided PCEs into five domains: (i) peer support and healthy school climate, (ii) neighborhood safety, (iii) neighborhood support, and supportive and close relationship with (iv) maternal figure and (v) paternal figure. Higher scores on the PCE domain, "peer support and healhy school climate," had the most consistent protective relationships with the mental health outcomes tested. "Peer support and healthy school climate" was the only domain that demonstrated a significant reduction in the likelihood of reporting a lifetime diagnosis of depression (aOR 0.51, 95% CI: 0.39, 0.66) and/or anxiety (aOR 0.58, 95% CI: 0.43, 0.79). Higher scores on the domains (i) peer support and healthy school climate (aOR 0.59; 95% CI: 0.42-0.83), (ii) neighborhood safety (aOR 0.53, 95% 0.38-0.73), and (iii) neighborhood support (aOR 0.69, 95% CI: 0.50-0.96) showed significant reductions in the likelihood of reporting symptoms of psychological distress as adults. Generally, the relationships between the PCE domains and mental health outcomes were attenuated, but not moderated by ACE exposure.

CONCLUSIONS: The PCE domain “peer support and healthy school climate” appears protective against symptoms and conditions of mental illness assessed during adulthood including for ACE exposed individuals. Interventions that promote PCEs may yield lifetime mental health benefits and population health gains.

XYLAZINE WOUNDS, WITHDRAWAL, AND CLINICAL OUTCOMES FOR HOSPITALIZED PATIENTS WITH DETECTABLE VS. UNDETECTABLE URINE XYLAZINE: A RETROSPECTIVE COHORT STUDY

Ashish P. Thakrar^1,2; Miles Black³; Tony Spadaro^4,2; Thuan Le³; Jeanmarie Perrone^4,2; Margaret Lowenstein^1,2

¹National Clinician Scholars Program, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²Center for Addiction Medicine & Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ³Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; ⁴Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #3875996)

BACKGROUND: Xylazine, an alpha₂-agonist veterinary tranquilizer, is found in more than 90% of illicit opioid (heroin or “dope”) samples in Philadelphia and is rapidly spreading across the Northeast United States. In March 2022, our health system implemented a urine test to detect xylazine using gas chromatography – mass spectrometry (GC-MS). Anecdotal reports indicate that xylazine is associated with severe injection- related wounds and a withdrawal syndrome when abruptly discontinued, however, to our knowledge, only a single case report has described the hospital course of patients with xylazine exposure.

METHODS: We conducted a retrospective cohort study of all Emergency Department (ED) and admitted hospitalized patients with urine xylazine test ordered by treating clinicians at an academic hospital system in Philadelphia, PA. We used data from the electronic health record (Epic) to describe demographic characteristics for the entire cohort and to compare patients with detectable vs. undetectable urine xylazine for the following outcomes: urine drug test results; severity of opioid withdrawal and possible manifestations of xylazine withdrawal (Clinical Opiate Withdrawal Scale (COWS), peak systolic blood pressure, and peak heart-rate); wound-related ED chief complaint and need for surgical wound debridement; and discharge disposition.

RESULTS: Of 87 GC-MS urine xylazine tests performed between January and October 2022, 46 (52.9%) detected xylazine. Twenty-four (27.6%) of patients with xylazine testing performed identified as female; 56 (64.4%) as White, 28 (31.2%) as Black; and 4 (4.6%) as Hispanic/Latinx. 39 (84.8%) xylazine positive patients vs. 26 (63.4%) xylazine negative patients were co-positive for fentanyl (difference, 21.4%; p=0.02). Initial median COWS score was higher among xylazine positive vs. negative patients (6 (IQR 2-10.3) vs. 4 (IQR 2-7)). Twelve (26.1%) patients with detectable xylazine vs. 1 (2.4%) with undetectable xylazine presented to the emergency department for wound related issues (difference, 23.7%, p=0.02). Among xylazine positive patients, 4 (8.7%) vs. 2 (4.9%) died while admitted (difference, 3.8%, p=0.48) and 16 (34.8%) vs. 7 (17.0%) left as patient-directed (against medical advice or “AMA”) discharges (difference, 17.8%, p=0.06). Analyses of urine fentanyl concentrations, systolic blood pressure, heart-rate, and surgical debridement outcomes are ongoing.

CONCLUSIONS: Compared to those with undetectable urine xylazine, patients with detecetable urine xylazine were more likely to have detectable urine fentanyl, had more severe opioid withdrawal, and more frequently presented for wound-related concerns. The proportion of xylazine positive patients with in- hospital mortality and patient-directed (AMA) discharges were higher, however these did not reach statistical significance. Results from ongoing analyses will further elucidate the unique clinical characteristics of patients with xylazine exposure, an emerging clinical concern.

Scientific Abstract - Quality Improvement and Patient Safety

BRIEF EDUCATION SESSIONS INCREASE PPI DEPRESCRIBING IN A RESIDENT PRIMARY CARE CLINIC

Jenny Zhang¹; Maria R. Bellantoni²; Rachel Kruzan¹; Leonard S. Feldman³

¹Internal Medicine, Johns Hopkins Medicine, Baltimore, MD; ²Indian Health Service, Rockville, MD; ³IM and Peds, Johns Hopkins, Baltimore, MD. (Control ID #3874115)

BACKGROUND: Deprescribing is an important part of clinical practice, but often not formally taught in internal medicine residency training. The goal of this quality improvement (QI) project was to encourage deprescribing among residents through annual, brief education sessions focused on deprescribing non- indicated proton pump inhibitors (PPIs), a common medication that can be associated with adverse effects when taken long-term.

METHODS: Our resident-led, IRB-approved QI project was launched in September 2021 at a federally qualified health center that also is the continuity clinic site for over 44 internal medicine residents. To adapt to evolving COVID precautions, the 15-minute education session was delivered virtually to all residents over a video conference platform in fall 2021, then transitioned to in-person, resident-to-resident teaching in fall 2022. Pre- and post-education surveys assessed baseline and retention of knowledge as well as resident comfort around prescribing and deprescribing as measured on a 10-point Likert scale. Data on PPI utilization were collected from our electronic medical record.

RESULTS: At baseline, residents were more comfortable prescribing as opposed to deprescribing PPIs (mean 6.9 vs 5.8 out of 10 which indicated most comfortable) and medications (6.8 vs 5.9). Education increased comfort around deprescribing PPIs (5.8 pre-education vs 7.6 post) and medications overall (5.9 vs 7.9). Both virtual and in-person teaching improved resident knowledge of PPI side effects (mean 38% correct on pre-education quiz vs 89% post), indications for long-term PPI use (18% vs 56%), and time to reassessment of PPI use in GERD (38% vs 89%). PPI utilization decreased by 22% from September 2021 through December 2022. Virtual education in 2021 led to an initial 6% decrease in PPI use; this trend continued until fall 2022, when in-person education resulted in an additional 9% reduction.

CONCLUSIONS: Deprescribing can be effectively taught in residency training through brief virtual or in- person education. An increase in resident knowledge and comfort around deprescribing PPIs led to reductions in use, which can translate into lower cost, less polypharmacy, fewer adverse effects, and better patient outcomes. Residency programs would benefit from incorporating deprescribing into their curriculum in a longitudinal manner.

ADDITION OF ACTION-ITEM LIST TO INTERNAL MEDICINE DISCHARGE SUMMARY TEMPLATE IMPROVES PHYSICIAN CONFIDENCE AND SATISFACTION WITH TRANSITION OF CARE

Margo Tanner, Rebecca Clemo

Internal Medicine, University of Virginia, Charlottesville, VA. (Control ID #3875497)

BACKGROUND: Transitions of care at hospital discharge have consistently been identified as an area for improvement across medical specialties. The discharge summary is the primary tool used to communicate follow-up recommendations from inpatient to outpatient teams. In surveying providers assessing for satisfaction with the standard discharge summary template, a common response was that follow-up “action items” are often nonspecific or difficult to identify in cumbersome hospital course narratives. This has numerous clinical care implications which can include inefficient use of clinician time, medication management errors, or missed incidental imaging findings. The goal of this project was to improve satisfaction with the IM discharge summary and improve patient care through better communication between inpatient teams and primary care physicians (PCP).

METHODS: Our group developed a template titled “PCP Action Items/Follow-Up Recommendations” to address these concerns and highlight care elements requiring direct action at hospital follow-up in a designated section of the discharge summary. The template was divided into subcategories using provider feedback and review of existing discharge summaries for areas of common mistakes and omissions in documentation. Subcategories include medication to-do items (which is specified to include any active medication changes/titrations to be completed by the PCP), new central venous line access and management plan, code status change, and follow-up of specific labs, imaging findings, and specialty appointments. The template was added to all IM discharge summaries within EPIC. Provider satisfaction was assessed via pre- and post-intervention surveys.

RESULTS: PCP satisfaction and confidence in the IM discharge summary improved following this intervention. Positive responses for overall satisfaction increased by 29.8% (51.5% pre-intervention to 81.3% post-intervention, p = 0.010) and confidence in identifying important follow-up items for receiving PCPs increased by 31% (40% pre-intervention to 71% post-intervention, p = 0.012). This intervention allowed for the average percentage of PCPs completing discharge summary review in under 10 minutes to increase by 9.5% (68.6% pre-intervention to 78.1% post-intervention), reducing provider preparation time for these encounters. Burden to recipients and discharge summary writers was also considered, with 90.6% of physicians from both groups reporting that this intervention does not negatively impact their workflow. The majority of receiving PCPs and discharge summary writers felt that this tool positively impacted patient care and improved communication between phases of patient care (93.5% recipient PCPs, 96.9% discharge summary writers).

CONCLUSIONS: Overall, we assert that this tool has improved provider satisfaction and confidence in our IM discharge summary communication, without negatively impacting provider workflow or productivity.

ADDRESSING NOTE BLOAT: AN NYU GRADING INTERVENTION ON INTERNAL MEDICINE PROGRESS NOTE DOCUMENTATION

Jahnavi Udaikumar¹; Katherine A. Hochman¹; Jonah Feldman¹; Adam J. Goodman^2,1

¹Internal Medicine, NYU Langone Health, New York, NY; ²Medicine, NYU Langone Health, New York, NY. (Control ID #3876882)

BACKGROUND: The electronic health record (EHR) is the primary medium by which physicians can communicate a patient’s medical management and plan of care. There are certain drawbacks to the EHR technology, however, that lead to the perpetuation of outdated and inconsistent patient information in progress notes. This phenomenon, known as “note bloat”, could be contributing to medical error and poor patient outcomes. Our pilot study examines the effectiveness of a newly created grading intervention in addressing “note bloat” and auditing documentation quality.

METHODS: This is a large-scale, quality improvement study conducted by a multidisciplinary task force on the Inpatient General Internal Medicine service across three hospital campuses in the New York University (NYU) Langone Health System. The project began by developing a set of “Best Documentation Standards” aimed to discourage inconsistencies in copy-forwarding of notes that contribute to “note bloat”. A note template that aligned with these guidelines and promoted cognitive synthesis of data was then developed for the EHR. Additionally, a standardized scoring tool was formulated to measure note quality. This tool, termed the “5 C’s”, was derived from aspects of the PDQI-9, but, was more efficient to implement into practice. This new audit tool was then used by physicians to score 45 Internal Medicine progress notes during the pre- and post- progress note template intervention period. A rubric was also created to improve inter-rater reliability. These results were then statistically analyzed and applied to an artificial intelligence machine learning model. Multiple notes were then graded and an effort to expand this quality improvement was made.

RESULTS: In approximately three months, the template utilization rate was 75% for History and Physical notes, 66% for General Internal Medicine progress notes, and 33% for inpatient General Internal Medicine consult notes. Additionally, there was a 31%, 45%, and 45% reduction of note length, respectively. Using the “5 C’s” grading model, the total score given by the first group of physicians was 6.2 in the pre-template intervention period. The total score given by the second group of physicians was 7.17. In the post- template intervention period, the total score using this same rubric was 7.4 and 8.76, by the first and second group of physicians, respectively. Inter-rater reliability also showed comparable readability scores, especially when using the “5 C’s” scoring tool in post-template intervention period.

CONCLUSIONS: Although the power and generalizability of the results are limited to General Internal Medicine in the NYU Langone Health system network, the adoption of a new note template and "5 C's" grading rubric did indicate improvement in note quality. We believe our intervention can be expanded to other hospital services, applied to artificial intelligence learning models, and disseminated to improve documentation standards, quality, and thereby medical management.

AN INTERVENTION TO ENSURE PROPER STATIN DOSING IN PATIENTS WITH CLINICAL ATHEROSCLEROTIC CARDIOVASCULAR DISEASE (ASCVD)

Wafa Nabi¹; Danish Zaidi¹; Angel Guan³; Julia Joseph¹; Jody Sharninghausen¹; Alex Heard¹; Danielle Wojtaszek²; Matthew H. Zegarek³; Rebecca Brienza³

¹Internal Medicine, Yale New Haven Hospital, New Haven, CT; ²Pharmacy, VA Connecticut Healthcare System, West Haven, CT; ³Internal Medicine, VA Connecticut Healthcare System, West Haven, CT. (Control ID #3858654)

BACKGROUND: Landmark clinical trials have demonstrated the impact of statin therapy on reducing morbidity and mortality in patients suffering from ASCVD. Recent literature suggests that many patients are not appropriately dosed.

METHODS: We aimed to assess the appropriateness of statin dosing among patients with clinical ASCVD within a primary care clinic panel at a New England VA Hospital and increase the percentage of patients on optimal statin dosing by 20% within 1 year. Inclusion criteria was determined by medical indication for statin use per AHA/ACC guidelines for either primary or secondary prevention, identified using patient diagnostic codes, medication lists and refill history, and laboratory values (hemoglobin A1c, LDL). Root cause analysis was performed to address barriers to optimal dosing and patient adherence. Subsequent interventions included telephone calls and letters to patients by clinic staff.

RESULTS: 214 patients were included in this study, 98.6% of whom were male, which is consistent with the general patient population of the Veterans Affairs healthcare system. Of these 214 patients, 92 patients (43%) had a history of clinical ASCVD (mean age 71 years ± 10.4). 81.5% of all patients with clinical ASCVD were appropriately dosed on a moderate-to-high intensity statin. Possible causes of inappropriate dosing in the remaining patients included providers’ concerns (of side effects), patients’ concerns (of minimizing polypharmacy), providers’ environmental conditions (time constraints, provider burnout, lack of clinical reminders) and patients’ environmental conditions (lack of discharge medication list, pillbox, or social support). Successful adjustment of statin dose was accomplished in 57% of inappropriately-dosed patients. Factors that precluded intervention in the remaining patients included a history of side effects (58%), provider concern for minimal benefit given comorbidities (17%), or management of the statin by another provider (25%).

CONCLUSIONS: In conclusion, these results support the utility of quality improvement measures to optimize statin dosage in patients with ASCVD. This analysis also sheds light on the effectiveness of the interventions used as well as barriers to dose adjustment.

ANTICIPATORY GUIDANCE AND PATIENT SELF-MANAGEMENT AT DISCHARGE: A PROVIDER SURVEY

Jenna Carson²; Jessica Donato¹

¹Hospital Medicine, Cleveland Clinic, Cleveland, OH; ²Internal Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #3867875)

BACKGROUND: One of the tools providers use in the discharge process to promote a safe transition of care is the written discharge instructions. Optimization of these instructions has been identified by physicians as a potential strategy to prevent readmissions. Our survey aimed to assess knowledge, attitudes, and self-reported practices of providers related to anticipatory guidance and patient self-management in the discharge process.

METHODS: An anonymous web-based survey was sent to hospital-based internal medicine providers at a large academic medical center, which included resident physicians, attending physicians, and advanced practice providers (APPs).

RESULTS: Of the 87 survey respondents, 69% were trainees, 26% were attendings, and 5% were APPs.

66% of respondents were familiar with the terms “anticipatory guidance and patient self-management,” and a majority were able to identify specific components (84-94%). However, only 33% of providers endorsed that these concepts were part of their discharge practice (28% of trainees and 44% of licensed independent practitioners, LIPs). 100% of respondents agreed or strongly agreed that providing patients information about what to expect after discharge and how to manage anticipated problems is valuable and could contribute to safer discharges, and 91% of providers agreed or strongly agreed that they had the knowledge and skills to provide patients with anticipatory guidance (87% of trainees and 100% of LIPs).

CONCLUSIONS: Our survey shows that hospital-based providers are familiar with the concepts of anticipatory guidance and patient-self management and find value in providing this information to patients to improve discharge safety. However, only a minority of providers incorporate these important concepts into their discharge practice. This represents an important opportunity for quality improvement. Improvement efforts should consider this opportunity is not unique to trainees and does not seem to be related to a lack of awareness or skill to provide this information to patients.

A QUALITATIVE EVALUATION OF A UNIVERSAL HEPATITIS B SCREENING ELECTRONIC MEDICAL RECORD REMINDER TOOL AT AN ACADEMIC PRIMARY CARE NETWORK

Sai Sarnala^3,2; Richie V. Chu^3,4; Thanh V. Doan^3,5; Armaan Jamal^3,5; Anuradha Phadke⁶; Hang Pham⁷; Richard So⁸; Robert Huang^3,9; Gloria S. Kim^3,10; Latha Palaniappan^3,10; Karina Kim³; Malathi Srinivasan^3,1

¹Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA; ²Department of Chemistry, University of Pennsylvania School of Arts and Sciences, Philadelphia, PA; ³Center for Asian Health Research and Education, Stanford Medicine, Stanford, CA; ⁴Department of Community Health Sciences, University of California Los Angeles, Los Angeles, CA; ⁵Department of Biology, Johns Hopkins University, Baltimore, MD; ⁶Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA; ⁷Department of Surgery, Stanford University School of Medicine, Stanford, CA; ⁸San Francisco Hepatitis B Free - Bay Area, San Francisco, CA; ⁹Department of Gastroenterology, Stanford University School of Medicine, Stanford, CA; ¹⁰Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA. (Control ID #3875091)

BACKGROUND: An estimated 862,000 to 2.4 million Americans have chronic hepatitis B infection (CHB), yet diagnosis rates remain low as 67% of persons living with hepatitis B are unaware of their infection. The CDC is considering guidelines for one-time universal screening for CHB to improve diagnosis rates and treatment outcomes. Current risk-based screening approaches pose a barrier to CHB patient screening. In April 2022, Stanford Primary Care Clinics implemented a universal CHB health maintenance alert in the electronic medical record (EMR), with a one-click ordering feature, for previously unscreened patients. Here, we assess the feasibility and acceptability of implementing a universal CHB alert by seeking stakeholders’ perspectives through surveys and qualitative interviews.

METHODS: At 8 academic and community-affiliated clinics in Northern California, in August – September 2022, 125 primary care providers at Stanford and university health associates (UHA) primary care clinics were surveyed about their experiences and perceptions of an EMR reminder system for CHB screening. The online survey included 34 questions about provider perceptions of universal CHB screening, CHB EMR workflow and utility, patient perspectives, and future directions. Semi-structured interviews with PCPs and medical assistants (MAs) explored viewpoints around the universal EMR alert implementation, and CHB universal versus risk-based screening.

RESULTS: 69 of 125 (55.2%) PCPs responded to the survey. The majority of respondents (n=41, 59.4%) reported that the universal screening would identify more patients with hepatitis B. Most respondents (n=50, 88%) reported ordering 0-5 hepatitis B screenings per month prior to the universal screening, while 46 (80.7%) ordered more than 6 screenings per week since rollout. 43 providers (62.3%) shared that universal screening removed stigma around asking about high-risk behaviors (sexual and IV drug habits), country of origin, and prior parental infection. We interviewed providers (15) and MAs (5) until thematic saturation. Five positive themes regarding CHB universal screening were identified: 1) Baseline under-screening of at- risk groups; 2) Patient acceptance of universal screening; 3) One-click ordering feature convenience; 4) Generally seamless integration to existing workflow; 5) Ease of physician decision-making. Three issues to implementation were identified: 1) Additional burden on medical assistants to adapt to new workflows; 2) Opportunities to improve patient discussions about hepatitis B; 3) Providers’ hesitancy to use the tool due to the Medicaid ICD-10 coding of “risky lifestyle”.

CONCLUSIONS: Implementing universal chronic hepatitis B screening in academic and community primary care clinics in Northern California was feasible, acceptable to providers and patients, and improved primary care workflows. Next steps include assessing the magnitude of new CHB patient identification through universal screening.

ASSESSING BURNOUT IN HEALTHCARE TEAMS IMPACTED BY THE COVID PANDEMIC: A WELLNESS QUALITY IMPROVEMENT PROJECT

Jodi-Ann Smith, Alexandra Gottdiener, Ahmad Alqam, Michael Basir

Internal Medicine, Englewood Health, Englewood, NJ. (Control ID #3872411)

BACKGROUND: Burnout is a syndrome characterized by three dimensions: emotional exhaustion, depersonalization, and low sense of accomplishment from work. Long work hours, sleep deprivation and loss of autonomy all contribute to higher prevalence of burnout in medical providers_1. Organizations are increasingly being encouraged to routinely measure burnout in their providers and implement strategies to mitigate the effects of stress. Additionally, the ACGME has added Professionalism 4: Knowledge of Systemic and Individual Factors of Well Being to residents’ milestones. Despite these calls, only a few organizations routinely measure burnout and incorporate such metrics into organizational quality dashboards.

METHODS: The Well-being Index (WBI), developed at the Mayo Clinic is a well-validated self-assessment screening tool that measures six dimensions of distress. “At risk,” individuals who score above a given threshold are at greater risk for adverse outcomes, including but not limited to burnout, severe fatigue, and suicidal ideation. In November 2021, the survey was administered to providers at our hospital that we believed were most susceptible to burnout secondary to the COVID pandemic: providers in the emergency department, intensive care unit, hospitalists, and internal medicine (IM) residents. The WBI was also administered prior to implementation of a Wellness curriculum for the IM residents.

RESULTS: Surprisingly, the pre-intervention survey demonstrated that all physician and physician assistants scored well below the national average with only 25% of responders “at risk” compared to over 40% found to be at risk in the national data₂. In contrast, the IM residents scored well above the national average₃, with women and PGY2/3s found to be at highest risk. Given these results, our QI team focused efforts on the residents. In collaboration with clinical social workers, we conducted a series of focus groups to identify factors contributing to those questions on the survey that were answered positively, indicating higher measure of distress, and then created qualitative reports that were shared with program leadership. During this time, the piloted wellness curriculum was delivered to all residents. Our residents continued to take part in events organized by the resident-lead wellness committee including, birthday celebrations and holiday parties. The WBI was administered again to just the residents in April 2022. The post-intervention survey found that the WBI score improved from 3.80 to 2.85, with a statistically significant p-value of 0.03 (p ≤ 0.05). Additionally, the number of residents “at risk” decreased by 50%, from 40% at baseline to 20%.

CONCLUSIONS: Burnout is a major problem facing healthcare systems with negative consequences not only for healthcare providers but also their patients. Residency programs should routinely screen for distress among their trainees and implement strategies to mitigate the effects of work-place stress.

ASSESSING THE IMPACT OF SHORT-TERM THERAPY IN HIGH RISK AND HIGH UTILIZING POPULATIONS

Paige Dobalian¹; Elizabeth K. Asfaw²; William J. Carroll³; Kathryn Osher⁴; Sun Yoo⁴

¹Internal Medicine, UCLA, University of California Los Angeles, Los Angeles, CA, US, academic, Los Angeles, CA; ²Internal Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ³Internal Medicine, University of California Los Angeles, Los Angeles, CA; ⁴Department of Medicine, UCLA, Santa Monica, CA. (Control ID #3875331)

BACKGROUND: The UCLA Extensivist Program is a primary care program for medically complex patients with frequent hospitalizations (2 or more hospitalizations or 4 or more ED visits in the last year). UCLA's highest risk patients, who have an increase in co-morbid mental health illnesses, are the recipients of this comprehensive and holstic care program. These patients are at already at high risk of adverse health outcomes, particularly when timely access to psychiatric care is challenging to receive. Randomized controlled studies have previously demonstrated that the addition of psychiatric care into primary care medical homes can increase quality of life and decrease healthcare costs. This quality improvement (QI) project tries to assess the impact of short-term behavioral health therapy embedded into the UCLA Extensivist Program.

METHODS: Extensivist physicians referred participants to therapy sessions with a licensed clinical social worker integrated in their Extensivist team. Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder 7 (GAD-7) scores were used to measure depression and anxiety levels. Inclusion criteria included Extensivist patients who participated in short-term therapy (30 or less sessions) with recorded PHQ-9 and GAD-7 scores at both initial and concluding sessions. Patients who participated in more than 30 sessions and those with incomplete data were excluded. Excel was then used for data analysis of average, minimum, maximum, and standard deviation.

RESULTS: Between 9/6/2019-11/15/2022, 125 participants were treated with short-term therapy. 57 were excluded due to inadequate data points which left 68 participants. Mean age was 58.9 years (range 22-108 years). 60.3% were female. 80.9% had public insurance (13.2% Medicaid, 67.6% Medicare, 69.1% Dual Eligible). After an average of 13.4 therapy sessions, 73.5% and 69.1% of patients had a decrease in their PHQ-9 and GAD-7 scores, respectively. Mean PHQ-9 scores decreased by 4.2 points (34.7% reduction), and mean GAD-7 scores decreased by 4.2 points (36.4% reduction).

CONCLUSIONS: This QI project reveals the benefit of incorporating behavioral health into primary care medical homes as an effective strategy to address psychiatric health outcomes, particularly with high risk patients who often have psychosocial barriers that contribute to their inadequate care and adverse health outcomes. There was a considerate average decrease of 4.2 points in both depression and anxiety measures after an average of 13.4 sessions. Despite lack of adherence to therapy as a common factor in mental health, only 30.9% discontinued therapy prematurely in this study. This demonstrates good compliance with these high risk patients in this primary care system integrated with behavioral health.

Limitations to this study include low sample size which can be addressed in the future when additional patients have met inclusion criteria. Future directions of this study include analyzing the intervention’s effect on healthcare utilization.

ASSESSMENT OF A NOVEL, RURAL TELE-DIABETES PROGRAM ON GLYCEMIC CONTROL AND DIABETES DISTRESS IN VETERANS

Adnan Syed^2,1; Cynthia Schihl³; Janee L. Lai³; Darren L. Kristofic³; Ashlyn N. Smith³; Peter D. Reaven³; Gauri Behari³

¹Medicine, University of Colorado, Aurora, CO; ²Research, VA Eastern Colorado Health Care System, Aurora, CO; ³Endocrinology, Phoenix VA Health Care System, Phoenix, AZ. (Control ID #3873790)

BACKGROUND: Many rural Veterans with diabetes lack adequate specialized, timely, efficient, effective, equitable and patient-centered care within the Veterans Health Administration (VHA) Veterans Integrated Services Network (VISN) 22 catchment area. The VA Rural Telediabetes Program (VA-RTP) was officially implemented in August 2020 at two VHA sites (Northern AZ and Phoenix, AZ) to provide diabetes management care through virtual visits and quarterly face to face visits with an interdisciplinary team of physicians, specialty advanced practice providers, nurses, dieticians, a psychologist and medical administrative staff. A key component of the program is each Veteran is screened for diabetes distress (DD), feelings of frustration or being overwhelmed by one’s diabetes, which helps identify and address this issue in the Veterans’ care plans early. The objectives of this study were to assess the change in hemoglobin A1c (HbA1c) and DD over time of Veterans in this program.

METHODS: This is a retrospective cohort study of patients enrolled in the VA-RTP. Patients were eligible for enrollment if 1) primary residence address was in the Northern Arizona VAMC or Phoenix VAMC catchment area; 2) had an HbA1c level of ≥ 8.5%; 3) located in a rural or highly rural area; and 4) had at least one appointment with the VA-RTP from September 1, 2020, to June 30, 2021. The primary outcomes were change in HbA1c level and DD score (≤2 [normal DD], 3-4 [mild-moderate DD] and >4 [moderate-severe DD]). We conducted in-depth, retrospective electronic chart reviews of a random sample of patients fitting these criteria to assess our outcomes. Assessments were performed at 3-month intervals for 15 months for HbA1c and DD. Linear mixed models and chi-square analyses were used to assess HbA1c and DD over time by comparing baseline vs 3-, 6-, 9-, 12- and 15-months.

RESULTS: Of the 290 eligible patients, 156 patient charts were reviewed, and 85 unique patients had baseline data for HbA1c, DD, or both. The mean age (mean [SD]) was 68.5 [9.5], 74% were white and 94% had Type 2 Diabetes. Baseline HbA1c (mean [SD]) was 9.82% (2.04) and 56.9% of Veterans had a DD score ≤2. We found improvement of HbA1c levels from baseline to 3-months (-1.04% [0.37], p = .006, 6-months (-1.96% [0.33], p < .001), 9-months (-1.68% [0.31], p < .001), 12-months (-1.67% [0.48], p < .001) and 15- months (-1.67% [0.62], p = .012). We also found improvement in DD from baseline to 15-months: 56.9% vs. 84.4% with score ≤2, 23.5% vs. 11.1% with a score of 3-4 and 19.6% vs. 0.04% with a score >4, X² (2, N = 51) = 9.08, p = .011.

CONCLUSIONS: Patients in the VA-RTP demonstrated sustained improvements over 15 months in HbA1c levels and DD scores of individuals among rural and highly rural Veterans. These results support the feasibility and potential value of providing virtual diabetes care to rural and highly rural Veterans.

BLOOD PRESSURE CONTROL FLUCTUATION AND QUALITY STANDARDS

Stacy Tsai, Nikita Barai, Kyle Koster, Mary Fishman, Kelsey B. Bryant

Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY. (Control ID #3856851)

BACKGROUND: Nearly half of adults in the United States have hypertension (HTN), however only about 1 in 4 adults with HTN have their condition under control. HTN is an important standard in quality care metrics. The metric for HTN is met if the most recent blood pressure in the electronic health record (EHR) is less than 140/90 mmHg. However, because blood pressure is dynamic this leads to fluctuating control rates that may not be reflective of true clinical status and cardiovascular risk to the patient.

METHODS: Data reported from an urban hospital based academic practice from September-October 2022 were reviewed to assess frequencies of patients who lost control by the last blood pressure <140/90 mmHg standard. Encounters were reviewed to identify the setting of out-of-range measurement (PCP office, specialist office, urgent visit, remote monitoring), if follow-up plan was made, and if present, a repeat measurement was controlled.

RESULTS: A total of 8363 patients had a diagnosis of HTN in October 2022. The HTN control rate declined from 69.3% in September to 68.3% in October. In this one-month period, 642 patients lost their controlled status, and 555 patients gained blood pressure control. Of patients who lost control, a subset of 360

encounters were reviewed. The mean BP of those who lost their control status was 150/83mmHg. 73.9% of these BP readings occurred outside of the PCP office. Of those that occurred in a PCP office, 89.4% addressed BP during the visit. Of the charts reviewed, 245 patients had a subsequent BP recorded; 57.6% of these repeat BP readings were at goal.

CONCLUSIONS: The majority of uncontrolled BP readings were obtained at specialist office visits rather than PCP visits. These data suggest that improving hypertension management will require addressing blood pressure at all points of contact within the healthcare system. Collaboration with subspecialists may improve overall HTN control; for example, performing repeat BP readings in the office or in creating a follow-up plan with PCP. In addition, over half of patients who lost control with a single uncontrolled BP reading had a repeat reading that was controlled, suggesting that the one-time reading may not be representative of the patient’s overall BP control and cardiovascular risk. Single readings are subject to issues that can transiently raise blood pressure, such as pain or anxiety, and may not be reflective of true control status. Although average BP may be more reflective of overall cardiovascular risk, institutions are held to the assessment of the most recent individual reading. Improving collaboration between specialties may improve overall control and decrease the likelihood of elevated readings outside of PCP visits. While any elevated reading should raise concern for control status, ensuring accuracy of measurement and maintaining a treatment plan at all visits, not just those of the PCP, is key to improving hypertension management.

CAN THE MICHIGAN PICC-DVT RISK SCORE PREDICT MIDLINE-DVT?

David Paje²; Megan O'Malley²; Elizabeth McLaughlin²; Jennifer K. Horowitz²; Steven J. Bernstein¹; Scott

Flanders²; Scott Kaatz³; Vineet Chopra⁴

¹Internal Medicine, University of Michigan, Ann Arbor, MI; ²Department of Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI; ³Henry Ford Health System, Detroit, MI; ⁴Department of Internal Medicine, University of Colorado Health, Aurora, CO. (Control ID #3861029)

BACKGROUND: The Michigan PICC-DVT Risk Score (MRS) identified five predictors for deep venous thrombosis (DVT) associated with peripherally inserted central catheters (PICCs): presence of another central venous catheter (CVC), elevated white blood cell (WBC) count, active cancer, multiple catheter lumens, and history of venous thromboembolism (VTE). We sought to determine if these risk factors can also predict DVT in patients receiving midlines, which are shorter peripherally inserted devices associated with a similar risk of DVT as PICCs.

METHODS: From 12/2016 to 07/2022, trained abstractors collected demographic and clinical data on patients receiving midlines at 64 hospitals participating in the Michigan Hospital Medicine Safety Consortium, a collaborative quality initiative funded by Blue Cross Blue Shield of Michigan. Patients were followed until midline removal, death, or 30 days post device insertion, whichever came first. The primary outcome was image-confirmed symptomatic upper extremity DVT (UE-DVT). Patient and device characteristics of midline placements with a UE-DVT were compared to those without a UE-DVT. All comparisons used Chi-square tests for categorical variables and t-tests and Wilcoxon rank-sum tests for continuous variables. We evaluated the association between MRS predictors and DVT in midline recipients using a mixed-effects logistic regression model that accounted for hospital-level clustering. Model discrimination was assessed through area under the curve (AUC) receiver operating characteristic analysis.

RESULTS: A total of 19,334 midlines were included. UE-DVT occurred in 218 (1.13%). All MRS predictors were more common in midlines with a UE-DVT than those without: presence of another CVC (19.7% vs 10.4%; p<0.01), elevated WBC count (38.0% vs 29.0%; p<0.01), active cancer (9.2% vs 5.7%; p=0.026), double-lumen midline (11.9% vs 8.2%; p<0.01), and history of VTE (24.8% vs 18.9%; p=0.03). After multivariable adjustment and accounting for hospital-level clustering, only two MRS predictors for

PICC-DVT were found to be predictive of DVT in midlines: presence of another CVC (odds ratio [OR] 1.85; 95% CI: 1.28-2.69) and WBC >12 k/microliter at time of insertion (OR 1.44; 95% CI: 1.06-1.94). Model calibration was driven by hospital-level variation more than predictor variables. The AUC was 0.732 when the predicted probability of an event included the random-effects for hospitals, but only 0.599 when hospital- level effects were removed.

CONCLUSIONS: The MRS provides low predictive power for midline-associated DVT. Based on the low rate of midline-associated DVT in our sample, the poor predictive power could be a result of infrequent outcome, or it could be an indication of other patient and device characteristics driving DVT events in the midline population. A larger sample size may be necessary to develop an independent risk score for determining predictors of midline-associated DVT.

CATALYZING SYSTEM CHANGE: 100 QUALITY IMPROVEMENT PROJECTS IN 1000 DAYS Amelia Sattler¹; Anuradha Phadke²; Malathi Srinivasan¹; Jake Mickelsen³; Davis Chhoa¹

¹Medicine, Stanford University School of Medicine, Stanford, CA; ²Medicine, Stanford University School if Medicine, Palo Alto , CA; ³Department of Medicine, Ambulatory Quality, Palo Alto, CA. (Control ID #3877174)

BACKGROUND: Health systems improvement requires quality improvement (QI) infrastructure that empowers

patient-facing staff to address important issues that impact their practice, thereby creating sustaining innovations. We created a scalable 8-week rapid-cycle QI training program, open to all primary care frontline staff (providers, nurses, medical assistants, medical learners), offered quarterly. The Primary Care – Project Engagement Platform (PC-PEP) program architecture includes a custom curriculum, QI coaching, institutional support, and participation incentives to promote participation and to catalyze change. At three years, we conducted a program evaluation to understand PC-PEP program impact around National Academy of Medicine (NAM) Quintuple Aim outcomes and around participant QI self-efficacy.

METHODS: From 2018-2021, PC-PEP projects were categorized using the NAM Quintuple Aim framework: 1) better health, 2) better patient experience, 3) lower cost of care, 4) better care team experience and 5) improved equity and inclusion. We assessed projects on a rubric informed by The Ottawa Hospital (TOH) Innovation Framework: Step 1 (identified problem root causes), Step 2 (designed and tested interventions), Step 3 (assessed project goal outcome), Step 4 (project goal with target group), Step 5A (intervention(s) spread within clinic), Step 5B (intervention(s) spread to different settings). Participants rated change in their QI skills and self-efficacy due to program participation through an online survey in summer 2021.

RESULTS: In the first 1000 days, 105 PC-PEP projects were completed by 172 unique participants, including clinicians (primary care physicians and mid-level providers n=55), staff (n=99) and medical learners (medical students and residents, n=18). Most projects aimed to improve patient health (55%) or care team experience (23%). 9% of projects reached TOH Step 1, 8% Step 2, 16% Step 3, 26% Step 4, 21% Step

5A and 20% Step 5B. Learner involvement increased likelihood of publication and presentation (47% vs 10%). 98% of participants reported improvement in QI self-efficacy. Compared with physicians, medical assistants felt that participation improved the system’s acknowledgement of their QI work (100% vs 61%).

CONCLUSIONS: With appropriate improvement infrastructure, all clinic team members can offer invaluable perspective, energy, and leadership in addressing microsystem care delivery challenges. Scalable QI training models like PC-PEP can empower practicing providers and staff to create meaningful change within their workplace, in all NAM Quintuple Aim domains. Program success depends on creating an improvement mindset and having institutional support for these innovations.

COMPARING PICC PLACEMENT BY VASCULAR ACCESS NURSES VERSUS INTERVENTIONAL RADIOLOGISTS

David Paje¹; Megan O'Malley¹; Steven J. Bernstein¹; Elizabeth McLaughlin¹; Jennifer K. Horowitz¹; Martha Quinn²; Scott Kaatz⁴; Scott Flanders¹; Vineet Chopra³

¹Internal Medicine, University of Michigan, Ann Arbor, MI; ²School of Public Health, University of Michigan, Ann Arbor, MI; ³University of Colorado Health, Aurora, CO; ⁴Henry Ford Health System, Detroit, MI. (Control ID #3868625)

BACKGROUND: The placement of peripherally inserted central catheters (PICCs) is increasingly performed primarily by vascular access nurses (VAN) in United States hospitals. Despite the increased use of these specially trained clinicians, little is known about the patient and device characteristics of the PICCs they placed compared to those placed by interventional radiology (IR) providers. While there is some evidence that VAN device placements are associated with low device-related complication rates, comparison to IR specialists cannot be made without accounting for likely differences in patient and device selection. In this study, we describe the patient and device characteristics of PICC placements by these two groups.

METHODS: From January 2013 to November 2022, trained abstractors collected data on patients receiving PICCs while hospitalized at 13 hospitals participating in the Michigan Hospital Medicine Safety Consortium. At these hospitals PICCs are routinely placed by both VAN and IR providers. Patient and device characteristics of PICC placements by VAN were compared to those placed by IR. Device selection measures included preference for single-lumen devices, avoidance of short dwell times (less than 5 days), and avoidance of PICCs in patients with eGFR <45 ml/min/1.73m². Patients were followed until PICC removal, for 30 days following PICC placement or death, whichever occurred first. Chi-square tests were used to compare categorical variables and t-tests and Wilcoxon rank-sum tests for continuous variables. Associations between patient characteristics and placements by VAN or IR were also assessed using mixed-effects logistic regression models, accounting for hospital-level clustering.

RESULTS: A total of 25,276 PICCs placements were analyzed. Of these, 17,963 (71.1%) were placed by VAN and 7,314 (28.9%) by IR. Patient characteristics varied greatly across provider types. Compared to PICCs placed by VAN, those placed by IR were more likely to be in patients with renal failure (34.1% vs 31.5%; p<0.01), paralysis (6.4% vs. 3.9%; p<0.01), a history of breast cancer (4.1% vs. 2.4%; p<0.01) and another central venous catheter already in place (13.2% vs. 10.4%; p<0.01). IR-placed PICCs were less likely to be single-lumen devices (37.3% vs. 51.2%; p<0.01), were more frequently removed within 5 days (21.2% vs. 17.0%; p<0.01) and had a higher proportion of patients with eGFR <45 ml/min/1.73m2 (16.6% vs 11.0%; p<0.01).

CONCLUSIONS: We found significant differences in patient and device characteristics when comparing vascular access nurse and interventional radiologist PICC placements. Because of these differences in patient and device selection and their established correlation with PICC-related outcomes, methods such as target- trial emulation are needed to evaluate the true association between catheter outcomes and these two provider types.

COST-EFFECTIVENESS OF IMPROVING APPROPRIATE USE OF PERIPHERALLY INSERTED CENTRAL CATHETERS

Megan O'Malley²; David Paje²; Steven J. Bernstein²; Elizabeth McLaughlin²; Jennifer K. Horowitz¹; Amy McKenzie⁴; Thomas D. Leyden⁴; Scott Flanders²; Vineet Chopra³

¹Department of Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI; ²Internal Medicine, University of Michigan, Ann Arbor, MI; ³University of Colorado Health, Aurora, CO; ⁴Blue Cross Blue Shield of Michigan, Detroit, MI. (Control ID #3868642)

BACKGROUND: Improving the appropriate use of peripherally inserted central catheters (PICC) has been shown to reduce the rates of PICC-associated complications. However, quality improvement (QI) programs promoting appropriate PICC use may require significant financial investment. We evaluated the cost- effectiveness of a physician-led, performance-incentivized, quality improvement intervention to improve appropriate use of peripherally inserted central catheters at hospitals participating in a state-wide collaborative funded by Blue Cross Blue Shield of Michigan and Blue Care Network (BCBSM/BCN).

METHODS: We analyzed data from patient-level chart abstraction and semi-annual surveys at 35 hospitals participating in the PICC QI initiative of the Michigan Hospital Medicine Safety Consortium from 01/2015 to 12/2021. The pre-intervention phase was from 01/2015 to 12/2016 and the intervention phase from 01/2017 to 12/2021. Following evidence-based guidelines, the initiative focused on increasing the proportion of single-lumen PICCs, decreasing short-term PICCs (≤5 days), and avoiding PICCs in patients with advanced chronic kidney disease (CKD). Improvement strategies included benchmarked hospital data, support from physician champions, and a toolkit to guide hospitals through the QI process. Adherence to QI measures was reported quarterly and incentivized through a pay-for-performance scorecard. Costs for the QI intervention were assessed using recognized frameworks for economic evaluations. These included payments to data abstractors, QI staff salaries, incentive payments, costs for quarterly meetings and hospital site-visits. Effectiveness was calculated from propensity score matched data across the pre-intervention and intervention time periods for complications (i.e., venous thromboembolism [VTE], central line-associated blood stream infection [CLABSI], and catheter occlusion). Cost-effectiveness was presented as costs per averted complication during the 60-month intervention period.

RESULTS: There were 17,418 PICCs placed in the pre-intervention period and 26,004 PICCs in the intervention period. From pre-intervention to intervention period, single-lumen PICC use increased (38.7% vs 59.3%, p<0.1), short-term PICCs decreased (29.9% vs. 15.0%, p<.01), and use of PICCs in patients with CKD decreased (32.0% vs. 23.3%, P<.01). The estimated number of complications prevented during the post-intervention period was 871 CLABSIs, 2,535 VTEs, and 8,743 catheter occlusions. The total cost of the QI project was $31.8 million. The total cost-offset of avoiding the cost of complications was $64.4 million. The savings per complication averted was $2,614 (95% CI: $2,314-$3,003) and the return on investment was $103 per each $100 spent.

CONCLUSIONS: We found that a large-scale, multi-hospital QI intervention to improve appropriate PICC use can be cost-effective over long observation periods. These results may provide evidence to policymakers who wish to implement similar QI initiatives.

DEVELOPMENT OF MULTIDISCIPLINARY TEAM COMMUNICATION INTERVENTIONS TO IMPROVE PRIMARY CARE OF COMPLEX PATIENTS

Amy Hooberman¹; Jessica Ameling¹; Jasmine Oesch¹; Meredith Eis¹; Milisa Manojlovich³; Jeremy B. Sussman^1,2

¹Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; ²Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI; ³University of Michigan School of Nursing, Ann Arbor, MI. (Control ID #3872163)

BACKGROUND: Without effective interprofessional communication, medically or socially complex patients may receive suboptimal care in busy clinics due to multiple disciplines failing to align their skills and the patients’ needs. Here we describe our use of qualitative methods to plan a pilot intervention of a team- based quality improvement initiative to identify better care practices for communication.

METHODS: Investigators trained in qualitative research methods interviewed 17 multidisciplinary staff (e.g., Physicians, RNs, LPNs, Social Workers) at a primary care clinic to assess their beliefs about 1) current communication practices, and 2) potential changes to practices from which complex patients would most benefit. Data were coded for themes using rapid qualitative analysis.

RESULTS: Our interviews identified five key barriers to optimal team-based communication in complex patients, described in the Table. Interviewees expressed support for regular, formal, multidisciplinary meetings to discuss complex patients. They preferred bi-weekly or monthly meetings and suggested that meetings be used for updates and to ensure goals of care are aligned among team members.

CONCLUSIONS: We identified gaps in team communication and targets for improvement. We used interview themes to develop a crossover trial in a single clinic with two interventions and a concurrent control group of a different clinic, which is ongoing. The two interventions are: 1) A single multidisciplinary meeting of clinic providers and staff to clarify roles to improve communication and 2) Multidisciplinary huddles held multiple times per month to discuss medically or socially complex patients.

DIAGNOSTIC DISCORDANCE OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) IN VETERANS AT THE WEST PALM BEACH VETERANS AFFAIRS MEDICAL CENTER

Patton Adderley^2,1; Srividya Kakulavarapu^2,1; Anatoliy Korzhuk¹; Sidney Braman¹

¹VA West Palm Beach Medical Center, West Palm Beach, FL; ²Internal Medicine, University of Miami School of Medicine, Miami, FL. (Control ID #3876952)

BACKGROUND: Chronic obstructive pulmonary disease (COPD) affects over 250 million people and is the third leading cause of death worldwide. As such, it carries both a significant clinical and economic burden globally. The diagnosis of COPD is made using a combination of medical history - ascertaining typical clinical symptoms and risk factors - and demonstrating persistent airflow obstruction. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) states that spirometry is the most reproducible, and objective measurement of airflow limitation in the diagnosis and assessment of COPD. However, spirometry has been reported to be underused by medical practitioners, leading to COPD misdiagnosis. This study evaluates the frequency of spirometry use in the diagnosis of COPD among patients at the West Palm Beach Veterans Affairs Medical Center as well as the concordance between physician-diagnosed COPD and confirmatory spirometric findings.

METHODS: We conducted a single-center retrospective cohort review of 634 patients with a physician- coded diagnosis of COPD between the years 2020 and 2022. The presence of spirometry and spirometry results were analyzed after extraction from the electronic medical record (EMR) at the West Palm Beach Veterans Affairs Medical Center.

RESULTS: Of the 634 patients with a physician-labeled diagnosis of COPD, 424 (66.88%) had spirometry performed. Of these 424 patients, 284 (66.98%) had spirometry-confirmed COPD, with a post-bronchodilator FEV1/FVC < 0.70. 44.79% of the 634 patients with physician-labeled COPD had spirometry-confirmed COPD.

CONCLUSIONS: This study describes a concerning deviation from the diagnostic standard of COPD, where less than half of the patients with physician-labeled COPD had spirometry-confirmed disease. This high proportion of misdiagnosis occurred in a setting with readily accessible pulmonary function testing. Physicians must maintain a high level of scrutiny of EMR problem lists and available diagnostic studies to guide diagnosis, select correct treatment, and save healthcare costs. Implementing an electronic checkpoint that generates a diagnostic checklist whenever COPD is coded as a problem in the EMR may mitigate this problem moving forward.

DOES A CATHETER-TO-VEIN RATIO >45% INCREASE PICC-RELATED VENOUS THROMBOEMBOLISM?

David Paje¹; Megan O'Malley¹; Steven J. Bernstein¹; Elizabeth McLaughlin¹; Jennifer K. Horowitz¹; Scott Kaatz³; Scott Flanders¹; Vineet Chopra²

¹Department of Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI; ²University of Colorado Health, Aurora, CO; ³Henry Ford Health System, Detroit, MI. (Control ID #3868201)

BACKGROUND: Practice guidelines recommend a catheter-to-vein ratio (CVR) of less than 45% to reduce the risk of peripherally inserted central catheter (PICC) associated venous thromboembolism (VTE). We evaluated whether a CVR of >45% increases the risk of VTE and catheter occlusion in patients receiving PICCs.

METHODS: From August 2020 to April 2022, trained abstractors collected demographic and clinical data on patients receiving PICCs while admitted at 52 hospitals participating in the Michigan Hospital Medicine Safety Consortium. Patients were followed until PICC removal, death, or 30 days following placement, whichever came first. Primary outcomes included image confirmed symptomatic VTE (including upper extremity deep venous thrombosis and pulmonary embolism) and catheter occlusion. PICC placements with CVR >45% were compared to those with CVR ≤45%. The association between CVR >45% and primary outcomes was also assessed after PICC placements were stratified according to catheter thickness. Comparisons used Chi-square tests for categorical variables and t-tests and Wilcoxon rank-sum tests for continuous variables.

RESULTS: A total of 6,630 PICCs with documented CVR and catheter size were included in the analysis. Of these, 470 (7.1%) had CVR >45% and 6,160 (92.9%) had CVR ≤45%. The PICC catheter sizes were mostly 4-French (66.5%; N=4,406) and 5-French (32.6%; N=2,163); and median dwell time was 25 days (interquartile range, 9 to 30 days). Overall, catheter occlusion occurred in 433 (6.5%) PICCs and VTE in 120 (1.8%). PICCs with CVR>45% had similar rates of complications when compared to CVR ≤45%: catheter occlusion, 7.7% vs 6.4% (p=0.304); and VTE, 1.9% vs 1.8% (p=0.860). When stratified by catheter thickness, the rates of both complications were also similar between both groups. Overall, 5-French compared to 4-French catheters had higher rates of catheter occlusion, 11.0% vs 4.2% (p<.001) and VTE, 3.1% vs 1.2% (p<.001).

CONCLUSIONS: In our analysis, CVR of >45% was not associated with PICC-related VTE or catheter occlusion. However, increasing catheter thickness was associated with a higher risk of VTE and catheter occlusion. Further studies are needed to identify the optimal catheter-to-vein ratio to predict PICC-related complications, and to assess the effect of catheter thickness on such association.

DOES GENDER OR ETHNICITY PLAY A ROLE IN ACHIEVING ROSC?

Hiral Amin^1,2; Rohan Umrani³; Ashley Pinckney^1,2; Darlene Mata¹; Bhavana Kadiyala^3,2

¹Internal Medicine, Rowan University, Glassboro, NJ; ²Thomas Jefferson University, Stratford, NJ; ³Internal Medicine, Rowan University School of Osteopathic Medicine, Stratford, NJ. (Control ID #3877077)

BACKGROUND: There are many factors that can affect the likelihood of achieving ROSC (Return of Spontaneous Circulation). A prospective study once found no difference in gender in achieving ROSC amongst inpatients despite women generally having deeper chest compressions than men. Another study looking at racial disparities had identified Black/African American individuals to be at a higher risk of not achieving ROSC. The purpose of this study is to determine if gender or ethnicity affect the likelihood of achieving ROSC.

METHODS: We performed a retrospective chart review of cardiac arrests among a large multi-hospital system from April 17, 2017 to August 1, 2022. We excluded those individuals who were younger than 18 years of age. We collected data pertaining to age, ethnicity, race, duration of code, initial rhythm during cardiac arrest, achievement of ROSC, and disposition.

RESULTS: 2992 charts met criteria for our analysis. The odds ratio of achieving ROSC amongst men was 0.98 (95% CI 0.74 - 1.29) while the odds ratio of achieving ROSC amongst women was 1.04 (95% CI 0.79 -

1.37). When looking at ethnicity, Hispanic (OR 2.25; 95% CI 1.06 - 4.7) individuals were more likely to achieve ROSC than those who identified as Black/African American (OR 1.21; 95% CI 0.90 - 1.61) or White (OR 0.85; 95% CI 0.65 - 1.12). Average code blue time was 3 minutes longer for Hispanic (95% CI 1.06 - 4.70) and 7 minutes longer for Black/African American (95% CI 0.90 - 1.61) populations when compared to those identifying as White (average code blue time: 37 min 23 seconds; 95% CI 0.65 - 1.12). It is crucial to note that the number of Hispanic individuals in this study were only 115 and 897 individuals were Black/African Americans while 1642 were identified as White.

CONCLUSIONS: Our study concluded that gender did not affect the likelihood of achieving ROSC but ethnicity did play a role in achieving ROSC. Our data is limited by the low population size in ethnicities other than White. 338 individuals did not have ethnicity related information and this could have been the patient’s personal choice or incomplete acquisition of data on part of the hospital staff. Despite the differences in code time among the different ethnicities, our data does not provide a cause for the differences in likelihood of achieving ROSC among the different ethnicities. Further studies can shine light into this issue. We should also account for other factors such as family withdrawal of care or even medical futility.

DOES PATIENT LANGUAGE PREFERENCE AFFECT HOSPITAL LENGTH OF STAY AND READMISSION RATES?

Brandon Wilson¹; Andrew Chandler¹; Alexandra Young¹; Rebecca Deng¹; Wazim Narain¹; Megan C. Buckley¹; Rahul Kurapati¹; Vladimir Ornstein²

¹Internal Medicine, Lenox Hill Hospital, New York, NY; ²Medicine, Northwell Health, New Hyde Park, NY. (Control ID #3876445)

BACKGROUND: Readmission to the hospital within 7 or 30 days is associated with increased morbidity and mortality. Prior studies have found that readmission rates of racial minorities are higher than those of white patients, contributing to health inequities. Increased readmission rates among racial minorities may in part be due to barriers in communication. In the United States, more than 25.9 million people have limited English proficiency (LEP). The Joint Commission recommends the use of professional medical interpreters for LEP patients but notes an underutilization among providers. For this reason, we examined the impact of patient language preference on hospital length of stay and readmission rates at our urban academic community hospital.

METHODS: We conducted a retrospective cohort study at a diverse 600-bed teaching hospital using the electronic health record. We identified adults who were 18 years or older and discharged from the internal medicine service between January 2021 and October 2022, to investigate the effect of language preference on length of stay and readmission rates. To control for confounders, we also collected information on patient characteristics associated with rehospitalizations such as age, length of stay, Charlson Comorbidity Index, and Lace Score. Primary outcomes were 7-day and 30-day all cause readmission to discharging hospital.

RESULTS: Of the 10,559 patients meeting inclusion criteria, 9,979 patients listed English as their primary language, and 580 patients listed other languages as their language of preference. English Speakers had a 30- day readmission rate of 13.11% and a 7-day readmission rate of 4.13% whereas Patients with Non-English Language Preference had a 30-day readmission rate of 12.93% and 7-day readmission rate of 4.08%. Length of stay was 4.504 for English Speakers and 4.651 for Patients with Non-English Language Preference.

Average Lace Score which predicts risk of rehospitalization was 9.767 for English Speakers and 9.212 for Patients with Non-English Language Preference.

CONCLUSIONS: No statistically significant differences were identified in hospital readmission rates between English Speakers and Patients with Non-English Language Preference. This suggests language translation services at the time of discharge and providing discharge documents in each patient’s language of preference help prevent readmissions. In the future, we could explore whether there are differences in quality metrics, such as patient experience or sub-group level evaluations, between English Speakers and Patients with Non-English Language Preference.

DON’T STRESS IT- A QUALITY IMPROVEMENT PROJECT TO REDUCE UNNECESSARY PROTON PUMP INHIBITOR USE IN A PUBLIC HOSPITAL’S MEDICAL INTENSIVE CARE UNIT

Judah Kupferman^1,2; Nuzhat Batool^1,2; Mike Gnoinski¹; Joshua Aron^4,2; Alfredo Astua^5,2; Jennifer Pintiliano^3,2; Mona Krouss^6,2

¹Medicine, NYC Health and Hospitals Elmhurst, Elmhurst, NY; ²Icahn School of Medicine at Mount Sinai, New York, NY; ³Pediatrics, NYC Health and Hospitals Elmhurst, Elmhurst, NY; ⁴Gastroenterology, NYC Health and Hospitals Elmhurst, Elmhurst, NY; ⁵Critical Care Medicine, NYC Health and Hospitals Elmhurst, Elmhurst, NY; ⁶Quality and Safety, New York City Health and Hospitals Corporation, New York, NY. (Control ID #3871956)

BACKGROUND: Stress ulcers are superficial lesions of the stomach that appear after major physiologic stress. Within the setting of an intensive care unit (ICU), up to a quarter of patients develop overt gastrointestinal (GI) bleed, and up to 3.5% demonstrate clinically important bleeding. Critically ill patients with coagulopathies or prolonged mechanical ventilation often warrant pharmacologic stress ulcer prophylaxis (SUP). Due to gaps in knowledge, many clinicians often inappropriately prescribe patients with proton pump inhibitors (PPI) for SUP, and subsequently discharge them from the hospital with the medication. Some falsely assume that PPIs have benign adverse effects, although prolonged use has been shown to increase the risk of Clostridioides difficile infections and other costly complications.

METHODS: We initiated a Quality Improvement project to reduce unnecessary PPI use within the medical ICU at a public hospital in Queens, New York by 30% within 4 months. Residents were educated using an algorithm for SUP use that was adapted for an affiliated public hospital in New York, and a pharmacist worked with physicians in the ICU to confirm appropriateness of PPI use. If SUP was indicated, we recommended the use of famotidine over pantoprazole due to fewer side effects. Administrations per 1,000 patient care-days (PCD) for famotidine and pantoprazole were collected, beginning from 3 months prior to the first intervention and continuing until 6 months afterward.

RESULTS: Pre-intervention (3/1/2022 to 5/31/2022), there were 59.21 administrations for pantoprazole per 1,000 PCDs, and post-intervention (6/1//2022 to 1/31/2023) there were 31.03 administrations per 1,000 PCDs (47.5% reduction). For famotidine, 15.35 administrations per 1,000 PCDs were administered during the pre- intervention period, and 6.01 doses per 1,000 PCDs were administered in the post-intervention period (60.8% reduction). Based on the medium of administration, the amount of money saved from reduction in PPI use was $52.36 to $269.64 per 1,000 PCD.

CONCLUSIONS: By the second PDSA cycle of our Quality Improvement study, PPI use was reduced to about half, and famotidine use was reduced by almost two-thirds. We encouraged clinicians to rely on enteral feeds rather than pharmacologic SUP when possible. We developed SUP use guidelines for our hospital. Future steps include providing continued education on a regular basis, and maintaining integration of the ICU pharmacist to check SUP indications.

Citations:

1. ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. Am J Health-Syst Pharm. 1999; 56:347-79.

2. Ye Z, Reintam Blaser A, Lytvyn L, et al. Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline. BMJ 2020;368:l6722.

3. Hong MT, Monye LC, Seifert CF. Acid Suppressive Therapy for Stress Ulcer Prophylaxis in Noncritically Ill Patients. Ann Pharmacother 2015;49(9):1004-8.

4. Barletta JF, Bruno JJ, Buckley MS, Cook DJ. Stress Ulcer Prophylaxis. Crit Care Med 2016;44(7):1395-405.

DO RESIDENT PHYSICIANS HAVE WORSE PATIENT OUTCOMES? INVESTIGATION OF DIAGNOSTIC ERRORS SECONDARY TO FAILURE TO CLOSE THE LOOP IN AN ACADEMIC PRIMARY CARE SETTING

Maelys Amat¹; Timothy Anderson¹; Kelly Graham¹; Scot B. Sternberg³; Mark D. Aronson¹; Russell Phillips²

¹Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Center for Primary Care, Harvard Medical School, Boston, MA; ³Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #3869620)

BACKGROUND: Diagnostic errors in primary care often occur due to failure to follow up on diagnostic tests and specialty referrals- (diagnostic loops). Failure to close the loop may be particularly challenging in a resident practice where physicians graduate each year, and rates of patient loss after these physicians transition is high, likely leading to more opportunities for such failures. Our aim was to determine the prevalence of failure of loop closure for tests and referrals ordered by resident physicians compared to attending physicians.

METHODS: Retrospective cohort study evaluating all clinic visits from 1/1/2018-12/31/2021 at an urban hospital-based primary care clinic and an affiliated community health center. Our primary outcome was the prevalence of failure to close diagnostic loops, including (1) dermatology referrals for suspicious skin lesions, (2) colonoscopy referrals and (3) cardiac stress tests. Our primary predictor was resident vs faculty status of the ordering clinician. We adjusted for patient characteristics, comorbidities and markers of patient engagement. We then performed statistical mediation analyses, adding each set of patient factors sequentially to multivariable logistic regression models, to determine mediators of the relationship between primary care physician-type and loop closure.

RESULTS: We identified a total of 12,282 referrals, including 10,128 colonoscopies, 1,029 dermatology referrals and 1,125 stress tests, of which 1,929 (15.7%) were in the resident practice. Of the 1,929 referrals in the resident practice, 1,021 (52.9%) were completed within the designated time vs 58.4% (6,044 out of 10,353) of referrals in the attending practice. Prior to adjusting for the variables included in our analysis, resident patients were less likely to close the loop on all referrals (OR 0.80, p=0.00) (Table 4). In our mediation analysis, patient portal use, visit type and location were the most powerful drivers of loop closure (OR increase from 0.84 to 0.88). In our adjusted analysis, residents were less likely to close the loop on referrals for all test types (OR 0.88, p=0.02).

CONCLUSIONS: In conclusion, rates of diagnostic test and referral completion were very low for all provider types and patient groups at two primary care sites, and slightly but significantly lower for residents than attending physicians. Our results point to patient engagement as a partial explanation for these differences, however, unmeasured factors related to the complex system in which resident physicians practice primary care are also likely contributing.

EDUCATING PATIENTS AT DISCHARGE: PERCEIVED RESPONSIBILITIES AMONG NURSES AND RESIDENTS AT AN ACADEMIC MEDICAL CENTER

Annie Yang¹; Rongzi Shan¹; Hunter Launer¹; Jiwen Li²; Yuliya A. Zektser¹; Eve Emmanouilidou³; Dhwani Krishnan⁴; Anna Dermenchyan⁴; Wendy Simon¹; Linda Czypinski¹

¹Medicine, University of California Los Angeles, Los Angeles, CA; ²Cardiovascular Medicine, Stanford University, Stanford, CA; ³University of Illinois Urbana-Champaign Carle Illinois College of Medicine, Champaign, IL; ⁴THINQ Collaborative, University of California Los Angeles, Los Angeles, CA. (Control ID #3871763)

BACKGROUND: A safe discharge requires significant coordination across interdisciplinary providers. Multiple team members are involved in patient education on the day of discharge, which contributes to complexity, inefficiency, and confusion among clinical teams and patients. Due to the lack of clarity regarding the specific roles and responsibilities related to discharge education, our study sought to better understand and compare the perceptions of nurses (RNs) and resident physicians (MDs) during the patient discharge education process.

METHODS: We surveyed RNs (March-April 2022) and MDs (June 2022) at an urban academic medical center regarding perceived responsibilities (physician, nursing, shared) for nine key elements of discharge education, including explaining diagnoses, pointing out signs that may prompt care, symptom management, self-care instructions (e.g. diet, wounds), medication teaching and changes, follow up appointments, and contact information. We also asked MDs who they felt to be primarily and ideally responsible for patient education (nurse, intern, resident, attending). We performed summary statistics and compared perceptions between RNs and MDs using chi-square tests.

RESULTS: In total 105 RNs and 82 MDs completed the survey. Overall, there were no differences in RN and MD perception of responsibility for many elements of discharge education. The majority identified explaining diagnoses as primarily an MD responsibility (60%) and the following as shared responsibilities: communicating appointment times (68%), self-care instructions (58%), medication teaching (55%), medication changes (52%). Self-care (33%) and medication teaching (41%) were more commonly felt to be RN responsibilities while medication changes was commonly attributed to MDs (41%). However, we did find an association between provider type and perceived responsibility for three items (p<0.001). More RNs than MDs felt that pointing out signs that may prompt care (75% vs 54%), symptom management (75% vs 49%), and explaining the reason for appointments (52% vs 35%) were shared responsibilities, while MDs thought these to be more in their purview. Among MDs, there was no clarity as to who they felt to be primarily responsible for education. Most PGY1s (54%) were unsure, but more PGY2/3s (46%) felt residents to be primarily responsible. The senior resident was felt to be best suited for educating patients by MDs (44%) with the next best person being the attending (27%).

CONCLUSIONS: Both RNs and MDs concurred that most of the key elements in discharge education were a shared responsibility. When there were perceived differences, more nurses felt these tasks to be shared compared to MDs. There also needs to be better consensus among MDs on who should be leading education efforts from the MD side. These areas highlight the need for improved interdisciplinary communication and clarification of responsibilities to create a more streamlined and safer experience for patients during discharge.

EFFECT OF FOLLOW-UP APPOINTMENTS ON UNPLANNED 30-DAY READMISSIONS, A RETROSPECTIVE OBSERVATIONAL COHORT STUDY

Nai Chien Yeat¹; Vladimir Ornstein¹; Rahul Kurapati¹; James M. Capon¹; Andrew Price¹; Nazish Ilyas¹; John Hon²; Lucrezia Renzetti¹

¹Internal Medicine, Lenox Hill Hospital, New York, NY; ²Northwell Health, New Hyde Park, NY. (Control ID #3872220)

BACKGROUND: The 30-day readmission rate is a key performance indicator for hospitals. Studies have reported a correlation between scheduling follow-up appointments and lower readmission rates in specific populations (e.g. Heart Failure, COPD). However, evidence regarding the effectiveness of scheduling post- discharge appointments in general medicine patients has been mixed.

METHODS: We conducted a retrospective cohort study of adults discharged from the hospitalist service at an academic medical center between July 1st, 2021, and June 30th, 2022 to investigate the effect of scheduled follow-up appointments on the rate of unplanned readmission. To control for confounders, we also collected information on other variables predictive of rehospitalization risk (e.g., length of stay, LACE).

RESULTS: Of the 3624 patients meeting inclusion criteria (discharged to home, not against medical advice), 50.2% (1819 of 3624) had an appointment with either a PCP or specialist documented at discharge; 12.2% (441 of 3624) were readmitted within 30 days of discharge.

Patients with an appointment documented in their discharge instructions had a paradoxically higher readmission rate (14.5%; 263 of 1819 discharges) than patients discharged without an appointment (9.86%; 178 of 1805 discharges), Odds Ratio 1.54 (OR 95% CI 1.26 - 1.89, P < 0.01). This difference persisted even after stratification by Length of Stay (LOS): In patients with LOS > 5 days, and patients with LOS ≤ 5 days alike, a documented follow-up appointment was associated with a higher readmission rate, OR 1.73 (CI 1.09 - 2.72, p= 0.019) and OR 1.39 (CI 1.11-1.76, p= 0.005) respectively.

However, stratifying patients by LACE score attenuates this effect. A documented follow-up appointment was not associated with a higher risk of readmission in either patients with high LACE (LACE > 10) (OR 95% CI 0.97 - 1.66; P=0.08) or in patients with intermediate LACE (LACE 5-10) (OR 95% CI 0.95 - 1.86; P=0.10).

This may be because providers prioritize appointments for patients with a higher perceived risk of readmission (using a binary logistic regression model, each unit increase in LACE increases odds of having a follow-up appointment by 1.10-fold [CI 1.07-1.11]). This results in a higher mean LACE for patients with follow up appointments (mean LACE of 10 vs. 8.8, t-test P < 0.01). Higher LACE scores in turn confer a higher risk of readmission (using a binary logistic regression model, OR for LACE was 1.20 [95% CI 1.16 -1.23], i.e., a unit increase in LACE increases odds of readmission 1.2-fold)

CONCLUSIONS: Stratifying by LACE, a scheduled follow-up appointment does not affect the readmission rate of either high LACE, or intermediate LACE patients. Therefore, the paradoxical association between scheduling follow-up appointments and an increased risk of readmission in the general patient population may be due to the confounding effect of provider teams preferentially making appointments for patients with a higher perceived risk of readmission.

EFFECTS OF A GENDER-REBALANCING STRATEGY ON RESIDENT PATIENT PANELS IN A PRIMARY CARE PRACTICE: A TWO YEAR FOLLOW UP

Samantha Mannion, Andrew J. Halvorsen, Carl Andersen, Emily Leasure, Vanessa Kronzer, Sara Bonnes

Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #3860726)

BACKGROUND: Patients often prefer gender concordance when selecting a physician, particularly in primary care. Residency programs are tasked with preparing trainees to care for patients from all backgrounds and therefore may seek a more equal gender balance on trainee patient panels to ensure similar training opportunities for male and female residents. We observed the effects of a gender-balancing strategy in a large internal medicine residency over two years.

METHODS: For the incoming PGY-1 class in July 2020, panels were balanced with the goal of equal gender distribution and overall panel size. We examined data for this cohort of residents over two years. Two-sample t-tests were used to compare the number of male and female patients gained/lost between male and female residents at several time points. As a pre-intervention comparison, panels from graduating PGY-3 residents 6 months prior to graduation (January 2020) were also analyzed.

RESULTS: The study included 28 female and 20 male residents. There was a statistically significant difference as early as 4 months; male residents had lost on average 1 female patient while female residents gained/lost none (p = .03), and male residents had gained on average 0.4 male patients while female residents had lost 1.1 (p = .003). At the end of the follow up period (July 2022), female residents had gained an average of 6.2 female patients while male residents lost 7.4 female patients (p < .001). Conversely, male residents had gained an average of 9.8 male patients while female residents lost 6.6 male patients (p < .001). This drift occurred gradually over the two years. At the 2-year endpoint, female panels were on average 52% female and male panels were 36% female. Pre-intervention, female panels were 70% female and male panels were 37% female. Notably, the pre-intervention comparison class had only 13 female residents and 39 male residents. Finally, overall panel size did not differ significantly between male and female residents at the study end.

CONCLUSIONS: Even with a load-levelling strategy upfront, there is a tendency for patient panels to steadily drift towards gender concordance over time. However, compared to a pre-intervention snapshot, the rebalancing strategy did result in a greater degree of gender balance at two years.

EHR BASED INTERVENTIONS FOR INCREASING USE OF GLP-1 AGONISTS IN A RESIDENT PRIMARY CARE CLINIC.

Aaron M. Pruitt¹; Kelly McDermott²; Jennifer Schmidt²

¹General Medicine, Washington University in St Louis School of Medicine, St Louis, MO; ²Internal Medicine, Washington University in St Louis School of Medicine, St Louis, MO. (Control ID #3853232)

BACKGROUND: GLP-1 agonists have emerged as a mainstay of treating patients with type II diabetes. Not only are they effective glucose lowering agents, but they have been shown in RCTs to reduce cardiovascular events and all-cause mortality. Additionally, they have demonstrated effectiveness in slowing progression of CKD, another well-known complication of diabetes. The efficacy of these agents also comes with a favorable safety profile and the added benefit of potential weight loss. Despite this, the uptake of their use in our resident clinic has been slower than expected. The goal of this quality improvement project was to identify patients on our panel who might benefit from the addition of a GLP-1 agonist and measure the effectiveness of discrete interventions at increasing their use.

METHODS: From July 2021 to August 2022 we identified patients seen for primary care in the resident clinic at a tertiary medical center with type 2 diabetes mellitus, and a hemoglobin A1c > 7.0%. Patients with direct contraindications to GLP-1's were excluded. The proportion of patients on a GLP-1 was assessed via chart review at project start and every 3 months thereafter. The first intervention was PCP awareness of the project goal. The second intervention, 3 months after project start, was pre-population of the phrase “strongly consider the addition of a GLP-1 agonist at next visit” into the plan for “type 2 diabetes mellitus” under the EHR problem list. The third intervention, at 6 months, identified patients with upcoming appointments with a non-PCP resident. Those providers were messaged via EHR asking them to discuss the addition of a GLP-1 agonist with the patient and add if appropriate. The primary outcome was number of patients on a GLP-1 agonist at 3, 6, and 9 months. The secondary outcome was number of patients on insulin at 9 months. The number of patients meeting an outcome pre and post intervention were assessed using the Chi-squared test at each time point.

RESULTS: 32 patients met criteria and were included in the project. At project start 2/32 eligible patients were on a GLP-1 agonist. At 3 months, 7/32 (p 0.072) patients were on a GLP-1 agonist. At 6 months, 17/32 (p <0.001) patients were on a GLP-1 agonist. At 9 months, 23/32 (p<0.001) patients were on a GLP-1 agonist. At project start 9/32 patients were on an insulin containing regimen. At 9 months 6/32 (p 0.376) patients were on insulin.

CONCLUSIONS: GLP-1 agonists have proven efficacy and safety in type 2 diabetes. Despite this, baseline use in our resident clinic population was low. With targeted interventions utilizing the EHR we demonstrated a significant increase in the use of GLP-1 agonists among eligible patients by 6mo. This suggests that focused interventions utilizing the EHR may be of benefit in promoting the uptake of evidence based changes in practice. The effects of similar interventions on use of other therapies, as well as impact on patient outcomes are potential directions for future investigation.

EQUITABLE IMPLEMENTATION OF LUNG CANCER SCREENING IN A SAFETY NET HEALTH SYSTEM

Charles J. Stautner⁴; Patrick Chang¹; Nicole Kluz⁴; Amaris Martinez⁴; LaTasha Vanin²; Eda Baykal-Caglar²; Yvonne Queralt³; Michael Pignone^4,1

¹Population Health, The University of Texas at Austin Dell Medical School, Austin, TX; ²CommUnityCare, Austin, TX; ³Diagnostic Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; ⁴Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #3873779)

BACKGROUND: Lung cancer screening with annual low-dose chest CT scans (LDCT) can reduce lung cancer mortality, but has not been implemented widely, particularly in vulnerable patients.

METHODS: We implemented and examined the effectiveness of lung cancer screening in a safety net Federally Qualified Health Center (FQHC) system in Central Texas. High-risk patients ages 50-80 who were current smokers or had quit within 15 years and had at least 20 pack-years of exposure were eligible. Potentially eligible patients were identified through mailed outreach and referrals from within the FQHC system. A social work-trained educator-navigator assessed LDCT eligibility, provided shared decision- making (using a previously developed decision aid) to discuss the benefits and harms of screening, helped patients with accessing screening, and offered intensive smoking cessation to current smokers. To assess equity, we compare LDCT completion rates and median time to completion of imaging across different demographic groups. We also present outcomes of screening based on LungRADS score.

RESULTS: 6,770 patients were mailed outreach materials to introduce the program. 483 patients responded either via mail, phone, or text, of whom 186 (38.5%) of these patients participated in shared decision-making (SDM). Additionally, 311 patients were referred internally; 214 (68.8%) engaged in the SDM visit. Of the

400 total patients who completed the SDM process between November 2020 and September 2022, 392 (98.0%) indicated that they were interested in continuing with lung cancer screening.

Of those 392 agreeing to screen, the mean age was 61.2 and 38% were female. The population was diverse: 35% identified as Latino and 20% as African-American; 10% had private insurance, 29% Medicare or Medicaid, 47% were covered through the county medical assistance program (MAP), and 13.6% were uninsured. 72% of participants were current smokers. For both current and former smokers, the median pack years was 41.

Overall, 324 of 392 (83%) patients completed LDCT. There were no statistically significant differences in completion by age, race/ethnicity, or insurance status. The median time from shared decision making to LDCT completion was 26.5 days (IQR 15-55 days).

Findings on CT were as follows: 174 (89%) had a LungRADS of 1-2, 26 (8%) had a LungRADS of 3, and 8 (3%) had a LungRADS of 4. Among the 8 patients with LungRADS 4, 2 had biopsy-confirmed lung cancer (stage T1bN1M1a and T1bN0M0) and are undergoing treatment.

CONCLUSIONS: We successfully implemented a lung cancer screening program in a diverse population within a large FQHC system. Increasing screening participation in FQHCs has the opportunity to reduce disparities in lung cancer mortality.

EVALUATING IF TARGETED DIDACTICS IMPROVE INADEQUATE WORKUP OF ELEVATED LIVER BIOCHEMISTRIES IN A RESIDENT-RUN PRIMARY CARE CLINIC

Adam Angel¹; Luis Hernandez²; Samantha Zarro¹; Scott McHenry³

¹Internal Medicine, Washington University in St Louis, St Louis, MO; ²Gastroenterology, University of Illinois Chicago, Chicago, IL; ³Gastroenterology, Washington University in St Louis, St Louis, MO. (Control ID #3871859)

BACKGROUND: We have shown a stark deficiency in the quality of care provided to patients with abnormal liver biochemistries in primary care. We identified barriers to high quality care including lack of recognition due to transitions of care, a shot-gun testing strategy, and/or reflexive referrals for immediate hepatology consultation. Thus, we implemented a quality improvement (QI) project with the aim to improve the recognition, workup, and referral pathways for abnormal liver biochemistries in primary care.

METHODS: Didactics covering the American College of Gastroenterology (ACG) guideline-approach to abnormal liver biochemistries were implemented as part of the mandatory outpatient residency educational curriculum in May 2020. Patients with an alanine transaminase (ALT) >40 U/L seen at a resident clinic from 6/2019 – 12/2019 (pre-intervention) and 6/2020 – 12/2020 (post-intervention) were reviewed. We excluded those with a previously established diagnosis of chronic liver disease. We stratified our analysis by the height of the ALT utilizing categories from the ACG guidelines.

RESULTS: Although most testing rates were unchanged (e.g. similar HCV serologies pre vs post intervention), we did see an overall decrease in inappropriate metabolic testing in the borderline (pre 57% vs post 26%) and mild elevation (pre 65% vs post 41%) groups. Also, there was a reduction in inappropriately checking anti-smooth muscle serologies in those with only borderline ALT elevation (pre 20% vs post 6%). Furthermore, there was an increase in those with any increase in ALT undergoing ceruloplasmin testing (pre 3% vs post 13%).

CONCLUSIONS: Education is a necessary but not sufficient, aspect of any QI project. Our next steps include analyzing the year 2021 which had in-person didactics, implementing an audit-and-feedback system, and dissemination of a standardized electronic medical records (EMR) dot-phrase to guide workup of elevated ALT within the clinic.

EXPANDING A MEDICAID-FUNDED STATEWIDE COLLABORATIVE TO INCLUDE DIABETES OUTCOMES

Shari Bolen^1,5; Elizabeth A. Beverly²; Kathleen Dungan³; Jackson T. Wright⁴; Sarah Koopman- Gonzalez⁵; Adam Perzynski¹; Goutham Rao⁶; Saundra Regan⁷; Randell Wexler⁸; Glen D. Solomon⁹; James F. Lamb⁹; Joshua J. Joseph³; Christopher R. Jordan¹⁰; Jordan Fiegl¹¹; Aleece Caron¹; Cristina Sanders¹²; Joseph Daprano¹³; Katherine Jenkins¹⁴; Allison Lorenz¹⁵; Doug Spence¹⁵; Kristin R. Baughman¹⁶; Lance D. Dworkin¹⁷; Juan Juame¹⁷; Elizabeth Littman⁴; Ann Nevar⁴; Catherine Sullivan¹¹; Mary S. Applegate¹⁸; Michael Konstan⁴

¹Medicine, MetroHealth/Case Western Reserve University, Cleveland, OH; ²Family Medicine, Ohio University Heritage College of Osteopathic Medicine, Athens, OH; ³Internal Medicine, Division of Endocrinology, Diabetes & Metabolism, The Ohio State University Wexner Medical Center, Columbus, OH; ⁴Medicine, Case Western Reserve University, Cleveland, OH; ⁵Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH; ⁶Family Medicine, University Hospitals, Cleveland, OH; ⁷Family and Community Medicine, University of Cincinnati College of Medicine, Cincinnati, OH; ⁸Family and Community Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ⁹Internal Medicine, Wright State University, Dayton, OH; ¹⁰Chris Jordan LLC, Cincinnati, OH; ¹¹Center for Health Care Research and Policy, The MetroHealth System, Cleveland, OH; ¹²Dept of Internal Medicine, MetroHealth Medical Center, Lakewood, OH; ¹³Internal Medicine/Pediatrics, MetroHealth Medical Center, Willoughby Hills, OH; ¹⁴The Ohio Colleges of Medicine Government Resource Center, The Ohio State University Wexner Medical Center, Columbus, OH; ¹⁵Ohio Colleges of Medicine Government Resource Center, The Ohio State University Wexner Medical Center, Columbus, OH; ¹⁶Family & Community Medicine, Northeastern Ohio Medical University, Rootstown, OH; ¹⁷Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, OH; ¹⁸Medicaid, State of Ohio, Columbus, OH. (Control ID #3874726)

BACKGROUND: Although the burden of diabetes is high, few states have developed unified approaches in partnership with payers to improve health and reduce disparities in adults with diabetes. We describe the incorporation of diabetes into an existing statewide cardiovascular collaborative and the results of a pilot diabetes quality improvement (QI) project developed to accelerate translation of evidence-based best practices into care.

METHODS: With funding from Ohio Department of Medicaid’s Ohio Medicaid Technical Assistance and Policy Program (MEDTAPP), we used a Collective Impact Model (used more traditionally in public health to address challenging problems requiring cross-sector input) to link Ohio’s 7 medical schools, Ohio primary care clinics, the Ohio Department of Medicaid and Ohio’s Medicaid Managed Care Plans (MCPs) in a statewide health improvement collaborative with the purpose of expanding primary care capacity to improve diabetes health and reduce diabetes health disparities in Ohio. The Collective Impact Model includes 5 key elements: 1) a common agenda, 2) shared measurement, 3) mutually reinforcing activities, 4) continuous communication, and 5) backbone support. The Model also has 4 phases which often transpires over 3-5 years: 1) generate ideas/dialogue; 2) initiate action; 3) organize for impact; and 4) sustain action and impact.

RESULTS: In Year 1 (2020) of the expansion to include diabetes, we developed a Charter with a shared vision, mission, activities and success metrics through an in person kick off followed by virtual meetings. A needs assessment survey of the collaborative focused on diabetes and social drivers of health (SDOH) informed our work. Dissemination activities for primary care teams since 2020 have included 5 virtual case- based learning series on weight management and/or diabetes with an emphasis on SDOH; collaborative development of 35 website evidence-based resources for diabetes health improvement and disparity reduction; 32 monthly newsletters with clinical tips; 24 monthly podcasts; and 5 statewide webinars. Through July 2022, we have 1,615 people in our database, and have 9,997 unique users of our website materials. The collaborative was aligned with a separately funded diabetes QI project for paired implementation, which showed a pre-post 5% absolute improvement in glycemic control using statistical process control charts in 21 high volume Medicaid practices across the state. Clinic interventions focused on A1c testing, timely follow- up in team-based care, and outreach. MCP interventions focused on reducing barriers to obtaining continuous glucose monitors and testing supplies, home A1c testing, and coverage of diabetes self-management education.

CONCLUSIONS: The collective impact model is a useful framework for expanding a statewide collaborative. Forming partnerships with medical schools, primary care practices, payers, and MCPs across the state is feasible and leads to large statewide dissemination along with improvements in care quality.

FIREARM SCREENING, COUNSELING, AND DOCUMENTATION IN GENERAL MEDICINE PRIMARY CARE CLINICS AT A SINGLE ACADEMIC INSTITUTION

Joseph Ladines-Lim^1,2; Kayla M. Secrest¹; Autumn Pu¹; Aaron Sifuentes¹; Elizabeth Spranger¹; Jennifer Meddings^1,2; Jennifer Stojan^1,2

¹Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI; ²Pediatrics, University of Michigan Michigan Medicine, Ann Arbor, MI. (Control ID #3874087)

BACKGROUND: Recent mass shootings highlight the ongoing firearm violence epidemic. The American College of Physicians advocates screening and counseling patients on firearm access and safety. To better characterize internal medicine (IM) provider views and comfort regarding firearm counseling and their perceived responsibility to do so at our institution, outpatient providers were surveyed and a retrospective review of documentation during health maintenance exams (HMEs) was performed.

METHODS: A survey of IM primary care faculty and residents on firearm access screening at new patient HMEs addressed the following: frequency of training on the issue; frequency viewing and addressing patient responses to a firearm access pre-visit screening question; and comfort level and sense of responsibility regarding the issue. A retrospective chart review of all new adult HMEs in May 2022 was performed to assess the following: history of psychiatric or substance use disorder (SUD) in the medical record; pre-clinic visit patient-answered questionnaire responses on firearm access; and evidence of documentation of firearm safety counseling.

RESULTS: 109 of 226 providers (43% faculty, 57% residents) representing 10 clinic sites completed the survey. 32% of providers were unaware of the firearm screening question. 89% had never received related training. 61% sometimes or never address firearm safety during an HME with only 36% of providers feeling comfortable doing so. 39% felt the issue was very important to address, while 32% felt it was only slightly or not at all important. 45% at least somewhat agree the issue falls within their role, while 33% somewhat or strongly disagree. Providers are 78% and 50% more likely to address the issue in patients with mental illness and SUD, respectively. Barriers to addressing firearm safety were cited, including time constraints, lack of knowledge, and competing priorities.

501 charts were reviewed. Only 44% of patients answered the screening question, with 26% reporting firearms at home. Notably, of those who did not answer, 96% completed other social history questions, skipping only the firearm question. Of those reporting firearms at home, 30% and 9% had psychiatric and SUD history, respectively. Documentation of counseling in patients with firearm access was found in 0% of charts.

CONCLUSIONS: Although at a single institution limiting generalizability, our study showed IM providers lack comfort with firearm screening and counseling and perceive lack of responsibility addressing it. Chart documentation does not address firearm safety. Generalized resistance from patient and providers to discuss firearm safety underscores the issue’s complexity, thus simple strategies such as routine questionnaires and automated reminders will likely not increase screening. A better understanding of why patients and providers are resistant, using qualitative methods, appears critical to inform the most appropriate strategies and settings for providing firearm screening and counseling.

HEALTH INFORMATION TECHNOLOGY TOOLS AND WORKFLOWS TO ACCELERATE GASTROINTESTINAL EVALUATION IN PATIENTS WITH IRON DEFICIENCY ANEMIA: A CLUSTER RANDOMIZED CONTROLLED TRIAL

Aparna P. Gupta¹; Dharmesh Patel³; Ji Young Lee²; Michael Schachter⁴; Stephen Persell¹

¹Medicine, Northwestern University, Evanston, IL; ²School of Medicine, Northwestern University, Chicago, IL; ³Northwestern Memorial HealthCare Corp, Chicago, IL; ⁴Information Services, Northwestern Memorial Healthcare, Chicago, IL. (Control ID #3876683)

BACKGROUND: System-level mechanisms do not exist to ensure that patients identified with iron deficiency anemia undergo proper diagnostic evaluations. Providing primary care physicians (PCPs) with lists of patients with unevaluated iron deficiency anemia within the electronic health record (EHR) and an expedited referral workflow might increase the short-term completion of bidirectional endoscopy.

METHODS: We conducted a pragmatic, cluster-randomized trial by physician. Sixteen PCPs and their corresponding 316 patients with EHR-detected iron deficiency anemia and meeting American Gastroenterological Association criteria for bidirectional endoscopic evaluation underwent randomization to immediate access to EHR tools which consisted of a patient registry visible within the EHR, point-of-care alerts, and access to an expedited diagnostic evaluation workflow for iron deficiency anemia or delayed access 121 days later. Outcomes were assessed at 120 days. The primary outcome was completion of bidirectional endoscopy. Secondary outcomes were 1) any endoscopy completed or scheduled, 2) gastroenterology consultation completed, and 3) gastroenterology referral or endoscopy ordered or completed. PCP randomization was stratified by the two health system regions (urban vs suburbs) and was done by an analyst blind to the group assignment until after the randomization was completed. To determine sample size, we examined historically the rate at which patients meeting iron deficiency eligibility criteria completed endoscopic evaluation over a 120-day period. To have at least 80% power to detect an absolute increase in the primary outcome of 15% with an alpha error rate of less than 0.05, we estimated that approximately eight PCPs per group with an average of 10 eligible patients per PCP would be needed. We analyzed the outcomes using generalized logistic regression with physician random effects.

RESULTS: There were no differences in the primary or secondary outcomes. At 120 days, the primary outcome, completion of bidirectional endoscopy, had occurred for 7/174 (4.0%) of the intervention group and 5/142 (3.5%) of the control group. For the three secondary outcomes listed above, rates were 8.6%, 6.9%, and 22.4% for the intervention group and 7.0%, 6.3% and 17.6% for the control group, respectively, p>0.2. Lack of physician time to use the registry tools was identified as a barrier.

CONCLUSIONS: Providing PCPs with lists of patients with iron deficiency anemia and a pathway for expedited evaluation did not increase rates of completing endoscopic evaluation or the ordering of referrals for endoscopy or gastroenterology consultation in the short-term. These findings suggest that additional clinical staff resources may be needed in order to take advantage of the information technology and work flow tools employed here.

HIGH OUTPUT HEART FAILURE: UNDERRECOGNIZED ENTITY. OUR EXPERIENCE IN AN INNER-CITY POPULATION

Syed R. Nabi, Alexandra S. Manaila, Preeti Ramappa

Medical School, Wayne State University School of Medicine, Detroit, MI. (Control ID #3875202)

BACKGROUND: High-output heart failure (HOHF) is an unusual cause of cardiac failure that has not been well characterized and continues to be under-recognized clinically. This study was part of a Quality Improvement project and sought to characterize common etiologies, associated clinical conditions, hemodynamics, and outcomes of HOHF patients in an inner-city hospital.

METHODS: A retrospective analysis was performed of 162 patients who had HOHF on right heart catheterization (RHC) done between 2018 and 2022 at a university hospital. Descriptive analysis was done to evaluate the association among variables.

RESULTS: A total of 162 patients with cardiac output >8 L/minute on RHC were included. Average age was 60 years and just under half were women (45%). Majority of RHC were done as inpatients (72%). Clinical conditions that were closely associated with low systemic vascular resistance (SVR) were hypertension (86%), obesity (69%), and CKD (44%). Thirty out of the 40 patients with CKD had AV fistulas for dialysis. Majority (77%) of patients had Heart Failure with preserved Ejection Fraction (HFpEF). Average CO was 9.2 L/min. Seventy-five percent of the patients had elevated filling pressure (PCWP >15 mm Hg). Following RHC, HOHF was reported only 11% of the time. Mortality for all patients was significantly high at 22%, of which, 33% percent were HFrEF patients and 67% percent were HFpEF patients. Eighty-nine percent of the deceased had a low SVR (<900 dynes/sec/cm⁵).

CONCLUSIONS: HOHF is an under-recognized entity associated with significantly increased mortality.

Our study outlines this high mortality particularly among patients with HFpEF in an inner-city population. Recognition of this entity on RHC was alarmingly low, which is a common occurrence, partly due to a lack of awareness among physicians or a lack of treatment specifically geared towards HOHF. The striking mortality among HFpEF patients highlights the importance of aggressive risk factor management and early referral for RHC in this subgroup of patients. Our future goals include educating providers to identify common etiologies and creating awareness among physicians regarding appropriate diagnosis and management.

HOW TO DO OR HOW NOT TO DO - PRIMARY CARE PROVIDERS AND LOW-DOSE ASPIRIN: A VA RESIDENT CLINIC QUALITY IMPROVEMENT PILOT

Poornima Manikantan, Ankita Gore, Aaron Yu, Viraj Modi, Lisa Fisher

Internal Medicine, Stony Brook University Hospital, Stony Brook, NY. (Control ID #3875037)

BACKGROUND: In the United States, one in five deaths is caused by cardiovascular disease (CVD) - the leading cause of mortality. While low-dose aspirin has been commonly used for primary prevention of CVD, there have been three new randomized control trials (RCT) highlighting the risks of aspirin and association with bleeding in the elderly, diabetic and moderate cardiovascular risk population. In 2020, a study using the national Veterans Affairs (VA) electronic health records highlighted that many patients take low-dose aspirin without indication. We sought to learn how a VA primary care resident clinic implemented the April 2022 United States Preventive Services Task Force (USPSTF) guidelines regarding low-dose aspirin for primary prevention of CVD.

METHODS: We first gauged residents’ knowledge and comfort around the new guidelines using an anonymous survey. We then implemented a fifteen-minute educational intervention through a PowerPoint presentation highlighting the three recent RCTs and new USPSTF guidelines. The same residents were resurveyed to learn how the brief education impacted their confidence in managing low- dose aspirin for primary prevention.

RESULTS: 33 of 48 residents completed our pre-education survey and 28 of 48 residents completed our post-education survey. Pre-education, 36% of residents were not aware of the new USPSTF guidelines.

21% of them did not evaluate the need to discontinue or initiate low-dose aspirin in a routine primary care visit and 12% did not feel comfortable doing so. 84% always or sometimes deferred management of aspirin to a cardiologist. Post-education, 86% found the review of recent RCTs and guidelines useful and all residents stated they were now somewhat or very comfortable initiating or discontinuing aspirin. The percentage who do not evaluate the need to discontinue or initiate low-dose aspirin decreased from 21% to 4%. The percentage who never discuss the risk of bleeding from low-dose aspirin with patients remained unchanged at 18% pre- and post-education.

CONCLUSIONS: In our provider population, we saw both a need for education and the great impact that brief review had on provider comfort in managing low-dose aspirin for primary prevention of CVD. We discovered that educating patients regarding bleeding risks of aspirin remains an area that needs additional intervention. Our study highlights the need for targeted educational tools to increase primary care provider comfort in managing aspirin in order to decrease aspirin use when not indicated. Some limitations of our study include being a one site study and the number of residents who elected to participate in our surveys. As next steps, we plan to expand our study to additional primary care clinics for a larger sample size, incorporate tools to improve patient education regarding risks of low-dose aspirin and create a workflow for shared patient-physician decision-making.

IDENTIFYING THE RELATIONSHIP BETWEEN HOSPITAL RURALITY AND ANTIBIOTIC OVERUSE

Hannah Hardin²; Jennifer K. Horowitz¹; Tejal N. Gandhi³; Elizabeth McLaughlin¹; Andrea White⁵; Julia E. Szymczak⁴; Lindsay A. Petty³; Anurag Malani⁶; Scott Flanders³; Valerie M. Vaughn⁵

¹Department of Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI; ²Biological Sciences, University of Idaho, Moscow, ID; ³Internal Medicine, University of Michigan Health System, Ann Arbor, MI; ⁴Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA; ⁵Internal Medicine, University of Utah Health, Salt Lake City, UT; ⁶Trinity Health Ann Arbor, Ann Arbor, MI. (Control ID #3873642)

BACKGROUND: Antibiotic overuse and the resulting patient outcomes span across all hospitals. While antibiotic stewardship can improve antibiotic use, effective stewardship programs require content expertise and an infrastructure that are not present in all hospitals. Rural hospitals have less access to resources, infectious disease expertise, and participation in academic research. We aimed to compare antibiotic overuse at discharge between rural and non-rural hospitals for patients diagnosed with community-associated pneumonia (CAP) or urinary tract infection (UTI)—the two most common hospital infections.

METHODS: We analyzed data from a 41-hospital prospective cohort of patients treated for CAP or UTI between 7/1/17 and 7/30/19 in Michigan. Antibiotic overuse was defined as treatment that was unnecessary (i.e., patient did not have an infection), excessive (i.e., duration .5 days for CAP), or included suboptimal fluoroquinolone use (i.e., safer alternative available). Overuse was determined based on patient risk factors, symptoms, allergies, diagnostic results, and time to clinical stability. Hospital rurality was defined using the Rural-Urban Continuum Codes (RUCC) score. We defined rural as a score of .4 and very rural as a score of 7-9. We used t-tests to compare the mean percentage of patients with antibiotic overuse at discharge between non-rural and rural (and very rural) hospitals.

RESULTS: Across 41 hospitals, there were 23,449 included patients with CAP or UTI. There were 5 rural (and 3 very rural) hospitals with 2,039 (and 1082) patients. Antibiotic overuse at discharge was present in 43.1% of patients’ cases in non-rural, 52.5% in rural (P=0.04 vs. non-rural) and 58.1% in very rural hospitals (P=0.007 vs. non-rural). Compared to non-rural hospitals, the mean percent of cases with antibiotic overuse at discharge in rural hospitals was 9.4% higher (15.1% higher in very rural hospitals). Results were similar in a subgroup analysis of only patients with UTI (47.0% in rural vs. 37.5% in non-rural, mean difference: 9.5%, P=0.03) but were not statistically significant in patients with CAP (53.8% vs. 48.0%, respectively, mean difference 5.8%, P=0.23).

CONCLUSIONS: In this retrospective study, we found rural hospitals—especially very rural hospitals, had higher rates of antibiotic overuse at discharge than non-rural hospitals. Our findings suggest antibiotic stewardship interventions tailored towards the unique differences in infrastructure, resources, and needs of rural hospitals are essential to community health.

IMAGINE YOU’RE ME – PRIMARY CARE PHYSICIANS’ EXPERIENCES WITH DISCHARGE SUMMARIES

Brittany Chatterton¹; Jennifer Chen¹; E. B. Schwarz²; Jennifer Karlin³

¹General Internal Medicine, Geriatrics, and Bioethics, University of California Davis Department of Internal Medicine, Sacramento, CA; ²UCSF Medical Center, San Francisco, CA; ³Family and Community Medicine, University of California Davis Health System, Sacramento, CA. (Control ID #3873170)

BACKGROUND: Successful transitions of care require communication between inpatient and outpatient physicians, usually in the form of a written discharge summary (DCS). With the goal of improving care transitions, we explored the experiences of primary care physicians (PCPs) in utilizing DCSs and identified areas for improvement.

METHODS: We conducted semi-structured, individual interviews with PCPs purposefully recruited from diverse physician groups and health systems. We collected demographic data about participants using a survey. Interviews were transcribed verbatim and qualitative data were analyzed interactively through thematic analysis.

RESULTS: Twenty PCPs participated in interviews that lasted an average 40 minutes. Sixty percent of participants were female. Most (70%) had trained in internal medicine (IM); 5% had trained in both IM and pediatrics, and 25% in family medicine. Some (45%) participants practice both inpatient and outpatient medicine; 55% had exclusively outpatient practices. Half worked in university affiliated clinics, 15% community clinics, 10% county clinics, 5% private practice, and 20% multiple clinic types. Many PCPs (60%) were in practice for ≥10 years.

Themes identified in the analysis included best practices for the structure and content of the DCS. Participants reported multiple concerns with the DCSs they receive including frustration with lengthy DCSs that seem to be written without their audience in mind. These PCPs requested that the DCS inpatient writer “Imagine you’re me!” to help eliminate information irrelevant to ongoing outpatient care. Additional suggestions for best practices included: (1) Use of a template that specifies reasons for any medication changes (“We'll see this was discontinued … or increased, but there's not a reason for it and then I’ll have to do a lot more digging”); (2) including dates treatments were started and expected to end; (3) adding a to-do- list of actionable items at the top of DCSs (“…because there's such little time … I want to have highlightable, actionable item”); and (4) emphasizing findings that may be incidental in the inpatient setting but require follow up (“I always get scared that something's going to fall through the cracks like an incidental finding that actually needs to be followed up that nobody picks up and reminds the primary care doctor that it needs to be followed”).

CONCLUSIONS: PCPs identified multiple ways to make the DCS more useful in busy outpatient settings and to improve patient care and safety with transitions of care. Among interviewed PCPs, the ideal DCS is a concise summary of the hospital course that highlights medication changes and outlines items requiring outpatient follow up, including notable incidental findings. Attention to the DCS is needed in clinical training programs with training and feedback incorporated into the curriculum.

IMPLEMENTATION OF THE REVISED 2019 AMERICAN COLLEGE OF CARDIOLOGY/AMERICAN HEART ASSOCIATION GUIDELINES ON ABDOMINAL AORTIC ANEURYSM SCREENING IN CLINICAL PRACTICE

Maria Riasat¹; Shaharyar Ali¹; Lakshay Chopra²; amna aijaz²; Tahmina Alam¹; Mina A. Shenouda²; Ankit Shah³

¹Internal medicine, Mount Sinai Beth Israel Hospital, New York, NY; ²Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY; ³cardiology, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3871771)

BACKGROUND: ACC/AHA recommends screening for males aged 65-75 who have ever smoked. Screening studies have reported AAA prevalence in the general population ranging from 1.6% to 7.2%. Most AAAs are asymptomatic until they rupture. Although the risk for rupture varies greatly by aneurysm size, mortality with rupture is as high as 81%.

A single-center study was conducted to assess the prevalence of appropriate and inappropriate AAA screening offered to eligible patients by residents and utilize quality improvement techniques to increase appropriate AAA screening by residents.

METHODS: Male patients aged 65-75, who ever smoked were included in the sample. Chart review of these patients yielded compliance with screening. A questionnaire elicited baseline knowledge among residents treating eligible patients. The intervention included a comprehensive lecture to bridge the knowledge gap and reminders about screening on a group chat. Post-intervention eligible patient charts were reviewed for compliance with screening. Appropriate and inappropriate screening frequencies are reported and multivariable logistic regression was done to determine the difference in odds of appropriate AAA screening pre and post test.

RESULTS: 117 patients made up the pre-test sample and 125 patients made up the post-test sample. In the pretest group, only 39% residents addressed AAA screening. Post test this increased to 66%. Patients inappropriately sent for AAA screening despite having alternate imaging was 17% in the pre-test sample and 28% in the post-test sample. Adjusted odds of appropriate AAA screening post test compared to pre-test are 2.64 (1.41- 4.98), after adjusting for resident level, smoking status and whether AAA screening was addressed.

CONCLUSIONS: Knowledge building and reminders can increase appropriate AAA screening among eligible patients treated by resident physicians.

IMPROVING ADHERENCE TO RISK STRATIFICATION GUIDELINES REGARDING VENOUS THROMBOEMBOLISM PROPHYLAXIS.

Jurgen Holleck^1,2; Danielle Cosentino³; Minna Holleck⁴; Naseema B. Merchant^5,1; Samantha J. Magier^6,2; David S. Jackson²; john chang^1,2

¹Medicine, Yale University School of Medicine, West Haven, CT; ²Medicine, VACT Healthcare System, West Haven, CT; ³Clinical Informatics, Veterans Health Administration, Washington, DC; ⁴Georgetown University, Washington, DC; ⁵Medicine, VA Connecticut Healthcare System, West Haven, CT; ⁶Internal Medicine, Yale New Haven Health System, New Haven, CT (Control ID #3877214)

BACKGROUND: Venous thromboembolism (VTE) accounts for a significant share of preventable deaths. Pharmacologic prophylaxis with enoxaparin or heparin remains the standard and sequential compression devices (SCDs) should be reserved for cases of excessive bleeding risk. The Joint Commission VTE-6 measure pertaining to inpatients requires the use of risk stratification tools however we have previously shown that VTE risk stratification was rarely done. Pharmacologic prophylaxis was at times inappropriately held in high risk patients while inappropriately administered to low risk patients. We created a Padua Prediction Score decision support tool to encourage more consistent use of VTE risk stratification and improve appropriate use of VTE prophylaxis.

METHODS: A Padua Prediction Score decision support tool with links to pharmacologic prophylaxis order sets taking into account BMI, creatinine clearance, and bleeding risk was imbedded in our admission medication reconciliation template in order to ensure compliance and better integrate into providewr workflow. Pharmacologic prophylaxis rates for high and low-risk patients based on the Padua Prediction Score were audited for 12 weeks pre and 11 weeks post- intervention at our hospital.

RESULTS: 28.9% of 228 pre-intervention patients and 26.7% of 703 post intervention patients were on therapeutic anticoagulation and excluded. Pharmacologic and overall prophylaxis rates for high risk patients increased from 64.9% and 70.3% pre to 74.1% and 86.0% post, p=0.15 and p= 0.005 respectively). Inappropriate pharmacologic and overall prophylaxis for low risk patients decreased from 37.2% and 47.6% pre to 16.5% and 16.8% post intervention (p values<0.001).

CONCLUSIONS: The addition of a mandatory Padua Prediction Score decision support tool with links to a VTE order set to the admission medication reconciliation note template improved VTE prophylaxis of high- risk patients and lessened inappropriate prophylaxis of low-risk patients.

IMPROVING INPATIENT COVID-19 VACCINATION RATE IN A U.S. ACADEMIC MEDICAL CENTER

Alexander J. Choi¹; Elizabeth Reznik¹; Jennifer I. Lee²

¹Internal Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY; ²Medicine, Weill Cornell Medicine, New York, NY. (Control ID #3876627)

BACKGROUND: Vaccination remains a top priority to curb the COVID-19 pandemic. NewYork- Presbyterian Hospital began offering COVID-19 vaccinations to hospitalized patients in March of 2021, but inpatient vaccination rate decreased after one month. In December of 2022, 69% of adults in the U.S. were fully vaccinated, but only 20% of adults received a bivalent booster dose. Most of these doses were most likely given in outpatient settings such as clinics and pharmacies. However, the time constraints of clinic appointments may limit opportunities for outpatient providers to encourage patients to receive vaccinations. Another outpatient barrier may stem from the lack of reliable access to vaccinations in certain populations such as rural areas. The inpatient setting may allow medical providers adequate time to encourage patients to receive vaccination. However, little is known about inpatient COVID-19 vaccination rate. Our study aimed to improve inpatient vaccination rate on a general medicine house staff team in NewYork-Presbyterian Hospital over the course of one month.

METHODS: One of the house staff members on an inpatient general medicine service was assigned to offer vaccinations to as many eligible patients as possible. Vaccination data from this service and another inpatient general medicine service without an assigned house staff member were collected over the course of one month. Exclusion criteria included prior severe reaction to COVID-19 vaccine (anaphylaxis, airway angioedema, SJS, vaccine component allergy), hemodynamic instability, COVID-19 positive, acute infection, acute immunosuppression, acute fever, and pre- and post-operative.

RESULTS: 29/98 (30%) and 22/78 (28%) of patients were eligible for the vaccination or booster on the Red and Blue house staff teams, respectively. The Red house staff teams administered 13 booster doses and 1 first dose; the Blue house staff team administered 1 booster dose. 54% (14/26) of eligible Red patients who were offered the vaccine accepted the vaccine. On average, there were 4.1 days between admission date and inpatient vaccine administration.

CONCLUSIONS: Our study demonstrated a higher vaccination rate in the Red house staff team (intervention group) than the Blue house staff team (control group). Our results may elucidate future investigation to expand, optimize, and sustain such improvements in inpatient COVID-19 vaccination rate.

IMPROVING LUNG CANCER SCREENING PROGRAM ENROLLMENT THROUGH RESIDENT EDUCATION OF THE CLINICAL REMINDER SYSTEM: A QUALITY IMPROVEMENT INITIATIVE AT A VAMC

Audrey York¹; Alicia H. Bowles¹; Katarina Wrzos²; Laura Miotke^1,3; Emily Beck²

¹Internal Medicine, University of Utah Health, Salt Lake City, UT; ²Pulmonology, University of Utah Health, Salt Lake City, UT; ³Hematology/oncology, University of Utah Health Huntsman Cancer Institute, Salt Lake City, UT. (Control ID #3875306)

BACKGROUND: The clinical reminder system (CRS) is utilized for preventative care and chronic disease management within the electronic medical record (EMR) at Veterans Affairs Medical Centers (VAMC). Lung cancer is the leading cause of cancer deaths in the United States due to late-stage disease at the time of diagnosis. Lung cancer screening (LCS) with low-dose CT (LDCT) scans allows for diagnosis in earlier stages, improves lung cancer mortality, and is recommended by the US Preventative Services Task Force for high-risk populations. Many VAMCs use the CRS to enroll patients into LCS programs. Inconsistencies in provider usage of the CRS, particularly among resident physicians, result in lower enrollment into LCS programs. Resident education on LCS and how to use the CRS may increase enrollment into LCS programs at the VAMC.

METHODS: We performed an educational initiative for Internal Medicine residents in their continuity clinic at the VAMC. Our intervention included subspecialty education on LCS recommendations and training on using the CRS to enroll patients into the LCS program. We assessed residents’ self-reported usage of CRS before and after our intervention using anonymous surveys. Enrollment into the LCS program via utilization of the CRS was tracked before and after the intervention and analyzed with a P-control chart.

RESULTS: Forty-seven Internal Medicine residents were initially surveyed with a response rate of 36% (17). Of all responses, 35% (6/17) report “never” and 41% (7/17) report “sometimes” using the CRS while zero residents report “always” using the CRS. We observed an increase in the number of patients enrolled in the LCS program following our educational intervention, as evidenced by an increased proportion of LDCTs ordered through the LCS program (45% or 5/11 scans pre-intervention compared to 92% or 12/13 scans post- intervention over a 30-day period). Residents additionally self-reported increased use of the CRS through post-intervention survey. Twenty-seven residents were surveyed post-intervention with a response rate of 35% (10). Eighty percent (8/10) report “sometimes” and 20% (2/10) report “always” using the CRS, while zero residents report “never” using CRS post intervention.

CONCLUSIONS: The CRS within the VAMC EMR is not intuitive and can be problematic. Residents are not educated on how to use the CRS or its purpose and importance. This may lead to gaps in preventative care, specifically in enrollment in LCS programs. Focused subspecialty education for residents on LCS recommendations and how to use the CRS leads to increased enrollment in LCS programs.

IMPROVING PRESCRIPTION OF GUIDELINE-DIRECTED MEDICAL THERAPY (GDMT) FOR INPATIENTS WITH CONGESTIVE HEART FAILURE (CHF) USING TAILORED MESSAGING Michael Swett¹; Sant Kumar³; Kathleen C. Abalos²; Alex Montero³

¹School of Medicine, Georgetown University School of Medicine, Washington, DC; ²Hospital Medicine, MedStar Georgetown University Hospital, Washington, DC; ³MedStar Georgetown University Hospital, Washington, DC. (Control ID #3876779)

BACKGROUND: CHF is a leading cause of hospitalization in the US. We aimed to increase prescribing of GDMT by sending tailored messages to providers.

METHODS: The population included inpatients with a heart failure diagnosis. Exclusion criteria included inpatient mortality, discharge against medical advice, incomplete medication reconciliation, and infiltrative cardiomyopathy. During the intervention period, we sent a message to providers including recommended medications based on LVEF, benefits, and contraindications. Our primary outcome was whether GDMT was escalated with regards to prescription of ACE/ARB/ARNI, beta blockers (BB), SGLT2i, and MRA classes. We performed a retrospective pre/post analysis with pre-intervention controls. We carried out descriptive statistics using means and proportions and we utilized the Chi Square test for all bivariate analyses for each GDMT medication class.

RESULTS: For patients with LVEF < 40%, the proportion of patients successfully escalated on GDMT was higher in the intervention period for ACE (40% vs. 28.6%); BB (83.3% vs. 35.3%); and SGLT2i (50% vs 29.7%) but p values did not reach significance. For patients with LVEF > 40%, the proportion of patients escalated on SGLT2i was lower in the intervention period (6.2% vs. 17.9%) but p value was not significant. In both the baseline and intervention period, significant proportions of patients did not receive all classes of GDMT for which they were eligible. For patients with EF < 40%, the proportion not receiving each class were: ACE 29.5%, BB 19.7%, SGLT2i 67.4%, MRA 65.6%. For patients with EF > 40%, 71.7% did not receive SGLT2i. These findings did not change significantly when restricted to creatinine < 2 and SBP > 100.

CONCLUSIONS: The proportion of patients successfully escalated on GDMT was higher in the intervention period for most classes of GDMT but did not achieve statistically significance, possibly due to limited power. The proportion of eligible patients not receiving GDMT escalation in both the baseline and intervention periods suggests significant clinical inertia on the part of inpatient providers, in particular for SGLT2i and MRA classes. Future interventions are needed to facilitate GDMT escalation in the inpatient setting.

IMPROVING THE QUALITY OF HOSPITAL DISCHARGE DOCUMENTATION: PERSPECTIVES OF CLINICIANS ON DISCHARGE SUMMARIES

Jennifer Li¹; Wendy Du¹; Monica Li¹; Christopher O'Donnell²

¹Internal Medicine, Emory University School of Medicine, Atlanta, GA; ²Medicine, Emory University, Atlanta, GA. (Control ID #3875110)

BACKGROUND: A hospital discharge summary serves as an important document that outlines the patient’s hospital course, medication regimen, and significant studies or events that took place during their stay. Studies have shown that high-quality discharge summaries are instrumental in facilitating safe transitions from the hospital, minimizing adverse events, and reducing hospital readmissions. Lack of proper communication or information in discharge summaries lends to increased risk of rehospitalization, complications due to medication error, morbidity and mortality.

METHODS: In 2018, our institution conducted a multi-center, multispecialty survey that assessed outpatient providers’ preferences and perspectives on discharge summaries. We then formulated a standardized discharge summary template based on what providers believed were the crucial elements of documentation.

In September 2022, we conducted another multisite, multispecialty survey to further assess both inpatient and outpatient providers’ perspectives on discharge summaries. We analyzed the data qualitatively with subsequent visualization using a heat map.

RESULTS: A total of 244 participants were surveyed including attendings, advanced practice providers (APPs), fellows, and residents. Participants were also stratified into critical care medicine, emergency medicine, family medicine, hospital medicine, internal medicine, and medicine-pediatric medicine specialties. Overall, providers had similar opinions regarding the most and least important areas of the discharge summary regardless of specialty or training level with some differences in prioritization between specialties, as illustrated in detail by the heat map in Figure 1.

CONCLUSIONS: Hospital discharge documentation is crucial to continuity of patient care. Understanding priorities for each specialty may improve communication between providers and improve discharge documentation overall. There seemed to be congruencies among specialties and level of training which indicate that standardized template would fit the desires of multiple inpatient and outpatient providers.

INAPPROPRIATE OPIOID PRESCRIBING AMONG VETERANS WITH KIDNEY DISEASE Jessica Ma^1,3; Ariadna Garcia⁷; Anne C. Black^10,11; Karleen Giannitrapani^6,8; Derek Boothroyd⁷; Manjula K. Tamura^2,9; I-Chun Thomas⁹; Amanda Midboe^6,12; Lara K. Troszak^6,2; Shiqi Zhang⁷; Selen Bozkurt⁸; Devon Check⁵; Jessica S. Merlin⁴; Barrett Bowling³; William Becker^10,11; lorenz Karl^8,6

¹Medicine, Duke University School of Medicine, Durham, NC; ²Stanford University School of Medicine, Stanford, CA; ³Geriatric Research Education and Clinical Center, Durham VA Medical Center, Durham, NC; ⁴General Internal Medicine, University of Pittsburgh, Pittsburgh, PA; ⁵Population Health Sciences, Duke University School of Medicine, Durham, NC; ⁶Center for Innovation to Implementation (Ci2i), Palo Alto VA Health System, Menlo Park, CA; ⁷Quantitative Sciences Unit, Stanford Medicine, Stanford, CA; ⁸Primary Care and Population Health, Stanford Medicine, Stanford, CA; ⁹Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA; ¹⁰VA Pain Research Informatics Multi-morbidities and Education Center, West Haven, CT; ¹¹Department of Internal Medicine, Yale School of Medicine, New Haven, CT; ¹²Medicine, University of California Davis, Davis, CA. (Control ID #3860088)

BACKGROUND: Patients with chronic kidney disease (CKD) are at higher risk of opioid-related adverse events including hospitalization and death. Due to altered drug metabolism and toxic metabolite accumulation, certain opioids (e.g. morphine, codeine, hydrocodone) should be avoided in CKD. We assessed the use of contraindicated opioids among Veterans living with CKD in the Veterans Health Administration (VHA).

METHODS: Within the VHA’s corporate data warehouse (2010-2017) which includes medication and lab data, we identified a retrospective cohort of Veterans who: were ≥ 18 years old; had ≥ 2 outpatient visits or ≥ 1 inpatient admissions in the past year; were initiated on long-term opioid therapy (LTOT) defined as 90 consecutive days of opioids (allowing for a 30-day gap in fills) without opioid receipt in the prior 180 days; and had ≥ 2 creatinine values ≥ 90 days apart in the past year. CKD stage and estimated glomerular filtration rate (eGFR) was calculated by CKD-EPI equation. We defined CKD based on with two eGFR < 60 mL/min/m² and categorized CKD stage (no CKD, stages 3, 4, and 5) using the most recent eGFR prior to cohort entry. We evaluated initial LTOT prescriptions and descriptively summarized the data.

RESULTS: Of 178,674 Veterans meeting study inclusion criteria, 21,879 (12%) had CKD stage 3 – 5. Most common initial LTOT prescriptions among Veterans with CKD were hydrocodone (12,833; 59%), oxycodone (4,387; 20.1%), and codeine (3,290; 15%). Relative percentages of opioid medications did not differ considerably by CKD stage. Three quarters of the sub-sample with CKD stage 4 and 5 (3,934) were prescribed contraindicated opioids (hydrocodone (57%, 2,245), codeine (14%, 547), and morphine (3%, 114). Benzodiazepines were often co-prescribed (18%, 716) (Figure 1).

CONCLUSIONS: Despite pharmacologic contraindications to certain opioids in CKD, opioid prescriptions did not vary with the severity of CKD. Improvements in opioid prescribing practices are needed in Veterans with CKD to reduce risk of adverse events.

INTERVENTIONS TO INCREASE HIV PREEXPOSURE PROPHYLAXIS PRESCRIBING IN US PRIMARY CARE: A SCOPING REVIEW OF INTERVENTION TARGETS

Daniel Resnick¹; Miko M. de Bruyn¹; Anandi Sheth²; Meredith Lora³

¹Internal Medicine, Emory University School of Medicine, Atlanta, GA; ²Infectious Diseases, Emory University School of Medicine, Atlanta, GA; ³Internal Medicine, Emory University, Atlanta, GA. (Control ID #3875123)

BACKGROUND: Primary care providers are at the forefront of prescribing HIV preexposure prophylaxis (PrEP), which carries a grade A recommendation from the United States Preventive Services Task Force for HIV prevention. To inform future interventions to increase PrEP prescribing in primary care (PC), we conducted a scoping review of interventions to improve PrEP prescribing in PC settings.

METHODS: We searched PubMed for the terms “quality improvement,” “implementation,” “prescribing,” “primary care,” and iterations of “preexposure prophylaxis.” We reviewed relevant citations and searched for iterations of “preexposure prophylaxis” in leading quality improvement (QI) and implementation science journals. We included articles that studied interventions within a PC setting, occurred in the United States (US), were published in English, and whose interventions aimed at increasing PrEP prescribing. We excluded articles that did not directly test an intervention, interventions outside PC settings, and interventions that targeted other steps along the PrEP cascade. Two reviewers (DR and MDB) examined articles for inclusion. We followed the PRISMA-Scoping Review Checklist.

RESULTS: Our search identified 89 articles. We excluded 65 articles after abstract review, and a further 6 after full article review. Eighteen studies met final inclusion criteria. Intervention types fell into two primary buckets - infrastructure building and patient identification - and some studies examined multiple interventions concurrently. Examples of infrastructure building include hiring a PrEP navigator and incorporating advanced practice providers and pharmacists as prescribers. Examples of patient identification include electronic medical record tools that flag appropriate patients and educational initiatives for providers about PrEP. Most studies tested a preconceived intervention. We only found three QI-specific studies that reported an iterative, Plan/Do/Study/Act (PDSA) approach to intervention design. Eight studies analyzed one or more objective pre/post intervention outcomes (PrEP scripts written, time to PrEP pick up, etc), while other studies examined pre/post subjective acceptability and feasibility data about the intervention. Only 2 studies provided interrupted time series data to better place the intervention within the context of broader prescribing trends. Study settings generally included large academic PC clinics (n=8) or federally qualified health centers (n=6), with all major US geographic areas represented except the Southwest. We did not identify studies conducted in small or rural practices.

CONCLUSIONS: Published efforts to increase PrEP prescribing in PC settings focused on either enhancing the clinics’ infrastructure or assisting clinicians in identifying appropriate PrEP candidates. Further studies are needed that utilize QI frameworks to optimize interventions and that take place in small or rural practices.

LINKING PERFORMANCE ACROSS ASSESSMENT METHODOLOGIES THROUGH AN INTERACTIVE TRAINEE DASHBOARD

Khemraj Hardowar²; Lisa Altshuler¹; Jeffrey A. Wilhite²; Zoe Phillips²; Kathleen Hanley²; Sondra R. Zabar²; Colleen Gillespie³

¹Medicine, NYU Langone Health, New York, NY; ²Medicine, New York University Grossman School of Medicine, New York, NY; ³PrMEIR/IIME, NYU Grossman School of Medicine, New York, NY. (Control ID #3877017)

BACKGROUND: Performance data is routinely used to examine programmatic outcomes and guide curricular interventions. Yet, most simulation learning management systems do not have the capacity to examine longitudinal data on learners or to integrate other relevant educational information into analyses. In our health system, we have over 13 years of performance data from Unannounced Standardized Patients (USPs) [incognito actors portraying patients who evaluate trainees in clinical settings] and objective structured clinical exams (OSCEs)—simulated encounter-based assessments. Analysis of these data provides information to guide individual learner and program level educational needs, as well as medical education research opportunities. We developed and refined a trainee data dashboard capable of describing patterns of performance across multiple assessments. This abstract describes the development, uses, and impact of this process

METHODS: All USP and OSCE data for medical residents at an academic medical center in the mid- Atlantic region was used to create this dashboard. Additional data, including training level, clinical site and residency track, were included. Open-source programming language R (RStudio) were used to pull data from multiple sources (Haven, redcapAPI) and to structure and format the data to produce a digestible, visual presentation (Shiny) based on outcome measures requested by the end user. To protect trainee anonymity, a unique identification number system serves as a link for learners across datasets, allowing for rapid review of group performance measures.

RESULTS: The dashboard data covers USP and OSCE data from 2009-2020 and 2007-2020, respectively, including 987 USP visits and 316 OSCE data points across more than 70 cases. Currently, the dashboard is accessible to Medicine Residency core educators and education researchers. Selection of the most relevant performance domains and the best ways to visualize the data require ongoing input from stakeholder groups to ensure the dashboard met both educational and research needs. Program leadership can now query the performance data of trainees to explore trends in performance by cohort, training level, and type of case. Ongoing efforts to create subsets with learners present across all cases will prove useful in identifying curricular needs for our trainees.

CONCLUSIONS: We were able to develop a dashboard for ongoing performance-based assessments (USPs and OSCEs) utilizing open source computer resources; a low cost solution. Use of an interactive dashboard allows for easy examination of educational impact and trends over time, essential for providing feedback to learners and educators & ensuring curricular goals are being met. The dashboard also allows for higher quality medical education research, exploration of data, and identification of sample sizes and data availability for targeted research questions. Our methods are scalable at other institutions looking to develop creative measures for exploring trainee performance.

MEDICARE’S ANNUAL WELLNESS VISIT IN A SOCIOECONOMICALLY DISADVANTAGED POPULATION: A QUALITY IMPROVEMENT INITIATIVE TO IMPROVE UPTAKE IN A PRIMARY CARE PRACTICE

Danielle Rome, Hye Gi Shim, Delphine Taylor, Nathalie Moise, Jessica R. Singer

Department of Medicine, Columbia University Irving Medical Center, New York, NY. (Control ID #3873370)

BACKGROUND: Medicare’s Annual Wellness Visit (AWV) has had limited uptake, particularly among patients at high medical risk and with greater dual Medicare/Medicaid eligibility. Prior studies show an association between AWVs and improved preventive care delivery but data efforts to improve AWV uptake

in socioeconomically disadvantaged populations are limited. We assessed the impact of a quality- improvement initiative for the uptake of care manager (CM) facilitated AWVs on targeted preventive care metrics in a diverse, low socioeconomic status (SES) primary care setting.

METHODS: AWV-eligible patients were identified for three attending provider champions from January to November 2022. During the one month intervention, eligible patients were scheduled for an AWV and called by a CM the day prior to perform the Medicare Health Risk Assessment. AWV-eligible patients from the same providers over the subsequent ten months were controls. We assessed fall risk, depression, colorectal cancer (CRC) and breast cancer screening, advance care planning (ACP) and flu and pneumococcal vaccination for CM facilitated AWV vs. control. Throughout the one month intervention providers recorded narrative feedback on barriers to AWVs.

RESULTS: 88 patients were eligible (intervention: n=14; control: n=74). Mean age was 75.9±11.5 years.

27.3% were Black, 55.7% Hispanic, 48.9% Spanish-speaking and 79.6% Medicare/Medicaid dual-enrolled. Fall risk screen was done in 100.0% of AWVs vs. 18.9% of controls. ACP was addressed at 50.0% of AWVs vs. 12.2% of controls. The proportion of patients screened was similar for AWV vs. control for depression (100.0% vs. 95.9%) and CRC and breast cancer (100.0% vs. 96.8%). Vaccination for flu (85.7% vs. 87.8%) and pneumococcus (84.6% vs. 83.3%) was also similar. Provider-identified barriers to AWVs were a mismatch between AWV format and patient goals, insufficient time allotted and EHR-based issues.

CONCLUSIONS: In our intervention AWVs improved fall risk screening and ACP, areas in which the widest care gaps existed, while cancer screening and vaccination rates were high at baseline. Our data are limited by small sample size and inability to differentiate whether observed gaps are due to differences in AWV documentation or variation in provider behavior. Our findings support strategies for optimizing AWVs in low SES settings.

MEDICATION ADHERENCE IN OHIO MEDICAID BENEFICIARIES WITH DIABETES

Anirudh Prabu¹; Jordan Fiegl^2,3; Elizabeth A. Beverly⁴; Kathleen Dungan⁵; Douglas Einstadter⁶; Thomas E. Love⁷; Joshua J. Joseph⁵; Catherine Sullivan²; Michael Konstan⁸; Katherine Jenkins⁹; Allison Lorenz⁹; Doug Spence⁹; Shari Bolen^2,3

¹Case Western Reserve University School of Medicine, Cleveland, OH; ²Center for Health Care Research and Policy, Case Western Reserve University, Cleveland, OH; ³The MetroHealth System, Cleveland, OH; ⁴Family Medicine, Ohio University Heritage College of Osteopathic Medicine, Athens, OH; ⁵Internal Medicine, Division of Endocrinology, Diabetes & Metabolism, The Ohio State University Wexner Medical Center, Columbus, OH; ⁶Internal Medicine, MetroHealth Medical Center, Rocky River, OH; ⁷Medicine, Pop & Quant Health Sciences, Case Western Reserve University, Cleveland, OH; ⁸School of Medicine, Case Western Reserve University, Cleveland, OH; ⁹Ohio Colleges of Medicine Government Resource Center, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #3873252)

BACKGROUND: Understanding diabetes medication patterns of use in primary care practices provides opportunities to improve blood glucose control in this population. However, current diabetes medication patterns of use by Medicaid patients within primary care practices is not well characterized. The objectives of this study were: 1) To describe diabetes medication type and adherence in patients on Medicaid with diabetes in a statewide quality improvement (QI) project; and 2) To explore factors associated with medication adherence in this population.

METHODS: We extracted data from electronic health records (EHRs) of practices participating in an Ohio Department of Medicaid funded statewide diabetes QI project and linked to data from Medicaid pharmacy claims. We included individuals with a diagnosis of diabetes and at least one visit at one of 21 participating practice sites and with linked claims data between Jan. 2019 and Sept. 2021. HbA1c results were obtained from EHR data, while data on patient demographics and diabetes medications were retrieved from Medicaid

enrollment and claims data. Medication adherence was defined as a medication possession ratio (MPR) of ≥80%. We used multivariable regression to explore factors associated with medication adherence.

RESULTS: There were a total of 5,549 Medicaid patients with diabetes. The mean age was 52.3 years (SD 12.2); 57.0% were women; 29.2% were non-Hispanic white; 56.4% were non-Hispanic black; and 58.7% were obese (BMI>30 kg/m²). Linked claims data was available for 3,514 (63%) patients. The top 6 diabetes medication classes used were metformin (74%), insulin (47%), sulfonylureas (22%), glucagon-like peptide 1 (GLP-1) receptor agonists (20%), dipeptidyl peptidase 4 (DPP-4) inhibitors (13%), and sodium glucose co- transportor-2 (SGLT-2) inhibitors (6%). For those with HbA1c>9, the top 6 classes were the same with similar rankings. About 25% of diabetes patients had no claims for any diabetes medications between 2019-2021; this rate was similar for those with HbA1c>9. Of 1,350 diabetes patients with at least 2 prescription fills (required to calculate the MPR), 72% were greater than 80% adherent to their medications (MPR>0.8). In a multivariable model, younger age [Odds Ratio (OR) 0.98, 95% CI (0.98-0.99)], identifying as non-Hispanic black (OR 0.66, 95% CI 0.55-0.80) and Hispanic (OR 0.70, 95% CI 0.51-0.97) vs. non- Hispanic white, and having a baseline HbA1c>9 (OR 0.75, 95% CI 0.62-0.90) were significantly associated with lower medication adherence. Sex and number of medications were not significantly associated with medication adherence.

CONCLUSIONS: Among Medicaid patients with diabetes enrolled in a statewide QI project, newer (vs. older) diabetes medications were used less frequently and a substantial group had not filled any diabetes medications. Future interventions should identify reasons for failing to fill medications and be tailored to populations at highest risk for non-adherence.

NOVEL BEST PRACTICE ADVISORIES TO REDUCE UNNECESSARY TESTING: A HIGH VALUE INTERVENTION

Stephan Castellanos¹; Jessica Lin¹; Katie Anicich¹; Amit K. Pahwa¹; Pamela Johnson²; Leonard S. Feldman³

¹Medicine, Johns Hopkins University, Baltimore, MD; ²Radiology, Johns Hopkins University, Baltimore, MD; ³IM and Peds, Johns Hopkins, Baltimore, MD. (Control ID #3874345)

BACKGROUND: Over-testing leads to inflated direct and indirect costs of care. Re-ordering tests prior to a given recommended interval, whether secondary to a lack of awareness of information in the patient’s chart or a lack of knowledge of the given recommended interval, most often increases costs without benefiting patients. Best Practice Advisory (BPA) pop-ups and alarms can potentially be used to curb over-testing, but they can also burden providers in a healthcare system. With physician burnout reaching unprecedented levels, healthcare needs to account for the effects value-based interventions like BPAs can have on both workflow and wellness. We deployed BPA pop-ups in our EMR to reduce unnecessary testing. We are assessing the efficacy of the pop-ups, including the impact of those pop-ups on providers.

METHODS: Three labs were included in this pilot project: Thyroid Stimulating Hormone (TSH), Erythrocyte Sedimentation Rate (ESR), and Hemoglobin A1c (HbA1c). The BPA was active for new orders placed in both the inpatient setting and emergency department. It would fire if the provider reordered lab prior to the end of a recommended interval (e.g., TSH- 6 weeks, ESR- 1 week, HbA1c- 90 days) and informed the provider of three things: 1) The recommended time interval for reordering, 2) The most recent lab result, and 3) The date of that result. Each BPA was a soft stop—if the provider decided to proceed with the order, they had to provide a reason. The BPA would fire regardless of the most recent result’s context, provided it was within our system. We analyzed the number of times each BPA fired and whether the provider followed the recommendation. We are conducting a survey of providers in our health system to assess their impression of the pop-ups.

RESULTS: Cost savings were calculated based on current Center for Medicare & Medicaid Services (CMS) billing practices. The TSH BPA fired 4,744 times from 11/22/21-8/31/22, and providers canceled their TSH order 54% of the times the BPA fired. This percent reduction represents $72,260 in savings to the patient. The ESR BPA fired 2,983 times from 7/15/21-8/31/22, and providers canceled their ESR order 39% of the times the BPA fired. This percent reduction represents $11,730 in savings to the patient. The HbA1c BPA fired 3,569 times from 7/13/21-8/31/22, and providers canceled their order of HbA1c 73% of the times the BPA fired. This percent reduction represents $104,400 in savings to the patient. Our provider survey is in process.

CONCLUSIONS: Novel BPAs for labs commonly repeated too early reduce reordering and potentially reduce bills to patients and insurers. Our survey will help us understand if the additional burden placed on providers outweighs potential benefits.

OUTCOMES AND ADVERSE REACTIONS OF INAPPROPRIATE ALLOPURINOL USE IN PATIENTS WITH LEUKEMIA UNDERGOING CHEMOTHERAPY

Peter Egwom²; Ankita Aggarwal²; Urja Nagadia²; Lillian Sangha¹; Mackenzie Taychert²; Drew R. Nannini²; Hassan Hasanein²; Ghulam Ghous²; Cherian Verghese²

¹UPMC, Harrisburg, PA; ²University of Missouri System, Columbia, MO. (Control ID #3834156)

BACKGROUND: Allopurinol is used as tumor lysis syndrome (TLS) prophylaxis for patients undergoing chemotherapy. Ideally, it should only be given during the first cycle of chemotherapy for leukemia patients up to seven days after chemotherapy administration. The rationale behind this is that the tumor burden is the highest earlier in the treatment stage, providing the highest risk of tumor lysis when cells die. Additional allopurinol beyond seven days could cause unwanted side effects such as acute kidney injury, transaminitis, leukopenia, thrombocytopenia as well as accumulate unnecessary costs and hospital stays. Here, we examine data obtained from the University of Missouri Hospital (MU) inpatient database to find out the outcomes and adverse reactions of inappropriate allopurinol use in patients with leukemia undergoing chemotherapy.

METHODS: The MU inpatient database was analyzed from 2015-2021 and all adult patients with leukemia on chemotherapy who received allopurinol were considered. Two-sample T TEST was performed for comparing numerical variables between patients receiving allopurinol appropriately and inappropriately. Wilcoxon two sample tests were conducted for non-normal distributed numerical variables. The chi-square test was conducted for comparing the categorical variables such as side-effects. Adverse reactions such as acute kidney injury, transaminitis, leukopenia and thrombocytopenia were evaluated in both patients who received allopurinol appropriately and inappropriately. If the patient had these abnormalities prior to allopurinol administration, the adverse reactions were not counted. Money spent on allopurinol as well as average time on allopurinol were considered.

RESULTS: There was a significant difference between two groups with respect to total days on allopurinol (P<0.0001), indicating that the non-appropriate group had a longer average time on allopurinol (18 vs. 9.63). While the mean total money spent on allopurinol was higher in the non-appropriate group ($79 vs $53), it was not statistically significant (P 0.01).

CONCLUSIONS: The average time on allopurinol was significantly longer in leukemia patients on chemotherapy who received it inappropriately compared to their counterparts who received it appropriately. Clinicians may benefit from establishing stop dates on allopurinol prescriptions to lower the pill burden for patients. Moreover, the total money spent on allopurinol and its adverse reactions in the group that received allopurinol inappropriately were also higher. However, it was statistically insignificant, given the small sample size of our study.

PATIENT SAFETY AND THE COVID-19 PANDEMIC: A QUALITATIVE STUDY OF PERSPECTIVES OF FRONTLINE CLINICIANS

Lucy Schulson^1,2; Julia Bandini¹; Armenda Bialas³; Shreya Huilgol¹; George T. Timmins³; Courtney

Gidengil¹

¹Health Care, RAND Corp Boston office, Boston, MA; ²General Internal Medicine, Boston University Medical Campus, Boston, MA; ³Health Care, RAND Corporation, Santa Monica, CA. (Control ID #3873944)

BACKGROUND: Studies on the impacts of the COVID-19 pandemic on patient safety are limited, and most work has focused solely on the early months of the pandemic. Furthermore, few studies have elicited the perspectives of frontline clinicians on the impact of the pandemic on patient safety. Through qualitative interviews, we sought to understand clinicians’ perspectives regarding the impact of the different phases of the COVID-19 pandemic on patient safety.

METHODS: We conducted in-depth interviews with clinicians who worked in the emergency department, intensive care unit, or an inpatient unit during the COVID-19 pandemic in 16 hospitals across the US. Clinicians were asked about their experiences with COVID-19 as it related both to clinician well-being and patient care at different stages of the pandemic. We used a rigorous thematic analysis to code the interview transcripts. This study was part of a larger randomized control trial of an intervention to improve health care worker well-being during the COVID-19 pandemic; the findings described here draw from clinicians who spontaneously raised issues related to patient safety (n=27).

RESULTS: There were eleven physicians and sixteen nurses in our sample. We identified three primary themes related to patient safety: (1) issues around access to health care that may have resulted in patient harm; (2) effects on care delivery that may have put patients at risk of patient safety events; and (3) actual patient safety events stemming from themes (1) and (2). First, clinicians discussed how changes in access to health care early in the pandemic, including a shift to telehealth and deferred care, led to delays in accurate diagnosis and patients presenting later in their disease course when treatment was less likely to be effective. Second, clinicians discussed the effects of COVID-19 on care delivery related to staffing, such as unsafe patient to clinician ratios and clinicians who cared for patients with clinical conditions outside their scope of practice. Clinicians also discussed how they often found themselves deviating from standard of care to manage equipment, space, and staffing constraints. Lastly, four clinicians described actual patient safety events that resulted from issues around access and care delivery including central line infections, patient falls, and serious medication errors.

CONCLUSIONS: Our findings demonstrate clinicians’ perspectives on the lasting effects of the COVID-19 pandemic on patient safety. Several of the interventions put in place to keep clinicians and patients safe during the early weeks of the pandemic created a unique context that resulted in compromised patient safety. As the pandemic progressed, clinicians also described staffing shortages that further compromised patient care. Future pandemic preparedness should consider planning that incorporates a lens of how to prevent patient safety events from occurring during a public health crisis.

PILOT STUDY RETROSPECTIVE REVIEW OF FAILURE MODE FOR THE CONCURRENT PRESCRIBING ECQM

Lauren Zabel¹; James Willey^2,1; Ethan Kuperman^3,1

¹Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA; ²Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA; ³Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA. (Control ID #3874438)

BACKGROUND: Patients who receive dual opioid or opioid and benzodiazepine co-prescriptions have a 10 times greater risk of unintentional overdose than those on monotherapy. Therefore, national guidelines recommend avoiding concurrent prescriptions, and the Centers for Medicare & Medicaid Services (CMS) has mandated an electronic clinical quality measure (eCQM) to identify patients discharged with co-prescription. The aim of this pilot was to identify and quantify local modes of failure for the Concurrent Prescribing eCQM, as well as areas for institutional improvement.

METHODS: This retrospective cross-section chart review was conducted at the University of Iowa Hospitals and Clinics (UIHC) during the 2021-2022 academic year. Inclusion criteria were defined by the Safe Use of Opioids - Concurrent Prescribing eCQM measure and included inpatients 18 years of age or older who were treated at UIHC between 1/1/22 and 6/30/22 and prescribed or continued in the medication reconciliation: two opioids at discharge, or an opioid and a benzodiazepine at discharge. Abstracted data included: discharging specialty, benzodiazepines and opioids prescribed on admission and discharge, indication for medication, pain service consultation, and finally a subjective measure on the appropriateness of each co-prescription based on the clinical data in the chart review.

RESULTS: We identified 599 patients who failed the eCQM within this six-month study period. Three reviewers randomly selected a subset of 44 patients to review. The leading cause of failure was the continuation of chronic prescriptions from home at time of discharge 48% (n = 21), followed by chronic opioid or benzodiazepine with a new indication for opioid on discharge 32% (14). Inappropriate prescribing was identified in 45% (20) of abstracted cases, of which 30% (6) were due to two prescriptions for short- acting opioids. Only 9% (4) of abstracted charts identified a patient with an inappropriate, new co- prescription during their admission.

CONCLUSIONS: The most frequently identified cause of measure failure was the continuation of outpatient co-prescriptions. Only rarely did co-prescription lack a medical indication. Based on the findings of this chart review, reducing co-prescriptions for multiple short acting opioids was identified as a target for future improvement projects.

PREDICTING FALL RISK FOR MEDICINE INPATIENTS WITH A DIGITAL QUANTITATIVE TIMED UP AND GO (QTUG) TEST

Jocelyn A. Carter¹; Natalia Swack¹; Chiamaka Chukwu²

¹Medicine, Massachusetts General Hospital, Boston, MA; ²Tufts University, Medford, MA. (Control ID #3877100)

BACKGROUND: Patient mobility and falls are key risk factors associated with patient readiness for hospital discharge and 30-day hospital outcomes ( readmissions, ED visits,) However, there have been few validated approaches to quantifiably risk-stratify patient mobility prior to hosptial discharge in hospitalized settings.

METHODS: Our hypothesis was that an instrumented version of the Quantitative Timed Up and Go (QTUG) test (6) can help quantitate mobility and physical activity for hospitalized inpatients ≥60 years of age using previously validated inertial sensors to establish mobility, frailty, and fall risk while hospitalized. The instrumented QTUG test is a digital application on a Samsung tablet that generates a risk score based on 1) a 8-question verbally-administered patient mobility questionnaire and 2) a 30-domain computational algorithm assessing mobility while standing, walking, turning and sitting. The QTUG mobility test consists of rising

from a seated position, walking 3 meters, turning 180 degrees, walking 3 meters and retuning to the seated position while wearing a < 2-ounce biosensor positioned along each anterior shin (calf) via a disposable/adjustable leg strap). Inpatients generating QTUG test scores of ≥70 (based on the QTUG mobility testing and patient responses to the questionnaire) may be at an increased risk of falls, hospital readmissions, and ED visits within the first 30 days of hospital discharge. We tested the ability of QTUG to predict post-discharge outcomes. Data sources included post- discharge patient questionnaires administered by phone and electronic health record data.

RESULTS: Outcome data for 155 inpatients (median age= 68; 75% Medicare insured; female (n,%) = 57 (40) demonstrated increased rates of 30-day hospital readmissions (OR=2.1, p= 0.04), 30-day emergency department visits (OR= 1.4, p=0.03), and falls within the first 30 days after discharge (OR= 1.6, p=0.06) among patients with QTUG scores ≥ 70. Most common co-morbidities included hypertension, coronary artery disease, and diabetes mellitus type 2 and no statistically significant differences across participants were noted. Analysis is ongoing and additional univariate and bivariate analysis for demographic data and discharge disposition is pending and expected January 2023.

CONCLUSIONS: This digital version of an analytic physical therapy assessment may optimize risk- prediction of important patient outcomes (hospital readmissions, falls, and ED visits) in the first 30 days after discharge and inform discharge disposition (home vs rehabilitation). Ultimately, this work may assist in establishing a standardized approach to determining the most appropriate hospital discharge disposition and fall risk prevention tools for aging inpatient populations in the future.

PRODUCTIVITY IN PRIMARY CARE: A VALUE-BASED ECONOMETRIC MEASUREMENT APPROACH

Linda D. Tran¹; Todd H. Wagner²; Paul Shekelle³; Stephan D. Fihn⁴; Karin Nelson⁵; Lisa V. Rubenstein⁶

¹Research, VA Palo Alto Health Care System, Palo Alto, CA; ²Surgery, VA and Stanford, Menlo Park, CA; ³Medicine, West LA VAMC, Los Angeles, CA; ⁴Division of General Internal Medicine, University of Washington, Seattle, WA; ⁵Medicine, University of Washington, Seattle, WA; ⁶Medicine, RAND and UCLA, Medford, OR. (Control ID #3874023)

BACKGROUND: Commonly used primary care (PC) productivity measures focus on how many services a provider delivers, without accounting for the quality of the services provided or the interprofessional team members engaged in producing them. We aimed to identify and test a PC productivity measurement approach that integrates a more holistic, value-based set of indicators into a PC productivity measure.

METHODS: We used a systematic literature review and expert panel to identify key elements of a potential PC productivity measurement approach. Our approach uses four key outputs: 1) clinical quality; 2) access; 3) patient experience; and 4) number of Veterans cared for by a clinic, and PC team members as inputs. To test the feasibility of this approach, we identified 685 Veterans Health Administration (VA) community-based outpatient clinics and applied output-oriented data envelopment analysis (DEA), a non-parametric linear programming method for computing Technical Efficiency (TE) scores. A TE score of 1 indicates maximum achievable technical efficiency relative to clinics with similar inputs. Higher scores above 1 indicate greater inefficiency. We used VA clinic performance and survey data to measure the 4 outputs, and full-time equivalents (FTEs) for primary care providers, nurses, administrative staff, medical assistant staff, and pharmacists as inputs. We accounted for differences in clinic patient populations based on age (70+ versus <70) and VA patient risk score (Nosos). To ensure that efficient clinics achieved minimum results for each output, we constrained the DEA to require that the 4 outputs not drop below or exceed certain relative weights.

RESULTS: TE scores ranged from 1 to 3.87. Approximately 9% of 685 clinics achieved a score of 1. Clinics that performed low on one output and high on others could score 1, depending on the mix of input and outputs. Among clinics with comparable staff FTEs, clinics producing greater outputs were scored as more efficient. Of the four output measures, clinical quality followed by total patients contributed more to TE scores than patient experience or access scores.

CONCLUSIONS: In our test case, we identified clinics that were technically efficient, and demonstrated that inefficient clinics had different pathways to improve. DEA provides a method to score clinics on multiple important primary care outputs, including the number of patients seen, but also clinical quality, patient experience and access, in relationship to their team staffing and level of patient complexity. DEA met our preliminary expectations but will require further testing for validity and stakeholder guidance on analytic choices.

PROTOCOLIZED FAMILY SUPPORT INTERVENTIONS IN THE INTENSIVE CARE UNIT: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS Rana Alahmadi¹; Abdullah A. Ghaddaf¹; Nidaa Almehmadi¹; Abeer Alhindi¹; Yara E. Aljefri¹; Abdullah F. Bokhari¹; Laura Spatafora²; Kimberley Lewis²

¹College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; ²Department of Medicine, McMaster University, Hamilton, ON, Canada. (Control ID #3876399)

BACKGROUND: Families of critically ill patients endure significant psychological burden as they are often involved in making difficult decisions. Family support interventions have been proposed to reduce psychological sequelae and enhance the quality of family-shared decision making in the critical care setting. The aim of this study was to evaluate the impact of using protocolized family support interventions on substitute decision makers (SDM) and patients.

METHODS: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and APA PsychInfo databases from inception to May 2022. We selected English-language randomized that compared protocolized family support interventions to usual care in critical care settings. We assessed risk of bias using the Cochrane Collaboration tool, performed the meta-analysis using the random- effects model, and assessed heterogeneity using Chi2 and I2 tests. Finally, we reported the quality of evidence for each outcome using the Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS: We included 14 trials (4078 SDMs and 5441 patients). For SDMs of critically ill patients; protocolized family support interventions reduced the hospital Anxiety and Depression Scale (HADS) score (mean difference (MD) -1.53, 95% confidence interval (CI) -2.98 to -0.08; I2 = 58%; moderate quality), anxiety (standardized mean difference (SMD) -0.21, 95% CI -0.40 to -0.02; I2 = 69%; low quality), and depression (SMD -0.19; 95% CI -0.29 to -0.09; I 2 = 0%; moderate quality), but did not improve satisfaction scores (SMD 0.06; 95% CI -0.09 to 0.22; I2 = 61%; moderate quality). Subgroup analyses by goals of care (curative versus comfort) showed statistically significant improvement in HADS score, and satisfaction score in comfort care setting.

CONCLUSIONS: Protocolized family support interventions may reduce anxiety and depression in SDMs of critically ill patients. Subgroup analyses showed consistently larger effect on SDM-related psychological outcomes in comfort care setting compared to curative care setting.

QUALITY IMPROVEMENT: DOES IMPLEMENTATION OF INTERNAL MEDICINE RESIDENT TOBACCO CESSATION CURRICULUM RESULT IN DECREASED PATIENT TOBACCO USE RATES?

Aimee E. Willett¹; Rini Patadia¹; Danielle Scerbo¹; Amulya Dega¹; Kim M. Jordan²

¹Graduate Medical Education, Internal Medicine, OhioHealth, Columbus, OH; ²Internal Medicine, OhioHealth, Columbus, OH. (Control ID #3871863)

BACKGROUND: Provider implementation of patient counseling and pharmacotherapy is an integral component of successful tobacco cessation management. In our resident teaching clinic, 21.17% of patients reported active smoking. Root cause reflection revealed lack of resident knowledge of tobacco cessation mangement as a contributing factor. Thus, a quality improvement project utilizing the Plan/Do/Study/Act (PDSA) method was implemented with the aim to reduce patient tobacco use.

METHODS: A tobacco cessation curriculum was completed as a two-part lecture series which all residents attended over a 6 week duration. Topics taught included motivational interview techniques along with tobacco use resources and pharmacotherapy. Residents were surveyed on comfort level at baseline and following completion of the education series. Active smoking rates were obtained via direct patient inquiry. Pharmacotherapy data was acquired via EMR review of prescription records.

RESULTS: The percent of current tobacco users did not significantly change in our patient population before (21.17%) and during (21.18%) implantation of the tobacco cessation curriculum. Resident comfort in management of tobacco cessation improved from “uncomfortable” to “comfortable” as the most frequently reported response before and during intervention. Resident utilization of tobacco cessation pharmacotherapy was unchanged before (10.8 prescriptions per 100 tobacco users) and during (10.7 prescriptions per 100 tobacco users) intervention.

CONCLUSIONS: We found no significant changes in patient tobacco use status with initiation of a resident education curriculum. While data shows an increase in resident comfort levels toward tobacco cessation management, there was no change in rates of resident provided tobacco cessation pharmacotherapy with this intervention. Once possible explanation for lack of change is lag time between education and application of learned information. More longitudinal data is needed to further explore this outcome.

QUALITY IMPROVEMENT CURRICULA FOR INTERNAL MEDICINE RESIDENTS—BEST- PRACTICE RECOMMENDATIONS FOR PROGRAM LEADERS, A SCOPING REVIEW

Najlla Nassery, Susan C. Mirabal, Sara Keller

Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. (Control ID #3875053)

BACKGROUND: The Accreditation Council for Graduate Medical Education requires that Internal Medicine residency programs provide quality improvement (QI) training, however, there is little guidance for program leaders on how to impactfully include such training into an already packed educational timeline. The purpose of this scoping review is to synthesize data from published literature and provide best-practice recommendations for program leaders.

METHODS: The authors searched CINAHL, ERIC and PubMed to identify original English language articles, published between January 2011 to 2021, that described QI curricula/interventions targeting internal medicine residents in the United States. The articles were independently reviewed by two authors to assess if inclusion criteria were met, including Glassick’s criteria for scholarship. Assessment discrepancies were adjudicated by a third reviewer and via consensus. The articles’ reference lists were hand-searched for additional manuscripts. Authors performed descriptive statistics and followed PRISMA-ScR reporting guidelines.

RESULTS: The database search yielded 174 articles; 13 manuscripts met inclusion criteria. Hand- searching yielded an additional 18 articles for a total of 31 articles. Twelve (39%) articles described educational interventions, 4 (13%) described QI projects, and 15 (48%) described a combination of educational and QI interventions. The majority of the interventions took place at urban academic centers, 7 (23%) took place at VA institutions, and 4 (13%) explicitly mentioned rural settings. Resources available to teach QI, including faculty with content expertise, varied across programs as did goals for trainee mastery. Educational methods included didactics, peer teaching, reflective group exercises, simulation, and experiential QI project work. Twenty-six (84%) programs offered synchronous and asynchronous curricular options, and 5 (16%) offered strictly asynchronous training. Program evaluation varied in rigor across institutions and included quantitative and qualitative methodologies. Direct trainee assessment (QI knowledge/skillset) was conducted in just a subset of the studies, and was not standardized across programs. Four programs used the validated QI Knowledge Assessment Tool (QIKAT).

CONCLUSIONS: There is no single way to teach QI, however, themes emerged from this review that can help program leaders create an impactful QI curriculum. Foremost is that curricula need to be structured, longitudinal, and include didactic and experiential project work—residents have limited time during training and need guidance by those with expertise. At minimum, the curricular team needs to include a QI specialist, curriculum developer, project champion (a faculty mentor who links residents with resources/stakeholders), and an IT professional/data analyst. Validated tools are needed for formative and summative trainee assessment to ensure that curricular goals are met.

REFLEX URINE TESTING AND TREATMENT OF ASYMPTOMATIC BACTERIURIA

Guinn Dunn⁴; Jennifer K. Horowitz¹; David Ratz⁵; Elizabeth McLaughlin³; Anurag Malani⁶; lama Hsaiky²; Scott Flanders³; Tejal N. Gandhi³; Lindsay A. Petty³; Valerie M. Vaughn⁴

¹Department of Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI; ²Pharmacy, Beaumont Hospital- Dearborn, Dearborn Heights , MI; ³Internal Medicine, University of Michigan Health System, Ann Arbor, MI; ⁴Internal Medicine, University of Utah Health, Salt Lake City, UT; ⁵VA Ann Arbor Healthcare System, Ann Arbor, MI; ⁶Trinity Health Ann Arbor, Ann Arbor, MI. (Control ID #3872032)

BACKGROUND: Asymptomatic bacteriuria (ASB) is common in hospitalized patients. ASB is often misdiagnosed as urinary tract infection (UTI) and treated with antibiotics despite multiple harms associated with antibiotic overuse. To reduce treatment of ASB, many hospitals set urinalysis parameters (e.g. white blood cells above a specified cutoff) that must be met before a urine culture can be obtained (i.e., “urinalysis with reflex to culture”). While this may reduce urine cultures in some populations, other studies suggest reflex urine testing may inadvertently increase ASB treatment. We aim to describe stewardship interventions targeting urine culture practices and evaluate the effect of adding vs. removing reflex testing on ASB treatment over time. Our primary outcome was the National Quality Forum-endorsed metric for evaluating ASB treatment in hospitalized patients: the percentage of patients treated for bacteriuria with antibiotics who had ASB.

METHODS: Hospitals participating in an existing prospective cohort study, the Michigan Hospital Medicine Safety Consortium (HMS), between 12/1/2016 & 2/5/2020 were included. In late 2019 all HMS hospitals were surveyed on stewardship practices—including those related to urine and reflex cultures. Guidelines from the Infectious Diseases Society of America and National Healthcare Safety Network were used to classify patients as having UTI or ASB based on documented symptoms. Using logistic regression with random intercept at the hospital level, we compared the percentage of patients treated for bacteriuria with antibiotics who had ASB before vs. after adding or removing reflex testing.

RESULTS: Thirty-nine hospitals participated in the HMS Survey. Most reported implementing at least 1 diagnostic stewardship intervention targeting ASB. Four hospitals (10%) added reflex testing, 5 hospitals (13%) removed reflex testing; 20 hospitals (51%) reported always having and 10 hospitals (26%) reported never having reflex testing. Of 17,625 patients with bacteriuria, 15,804 (90%) were included of whom 30.5% (4819/15,804) had ASB. Of the 4819 patients with ASB, 78.1% (3766) received antibiotic therapy for a median of 6 (IQR: 4-9) days. The percentage of patients with ASB treated with antibiotics out of all patients with treated bacteriuria was 25.5% (3766/14,751). The percentage of patients treated for bacteriuria who had ASB did not change in hospitals that added reflex testing (27.9% to 30.1%, p=0.80) but fell in hospitals that removed reflex testing (25.2% to 14.6%, p<0.001).

CONCLUSIONS: Most hospitals reported employing interventions to reduce inappropriate use of urine cultures. Specifically related to reflex urinalysis, our data suggest adding reflex testing had no effect on the treatment of ASB, while removing reflex testing was associated with lower treatment of ASB. These data suggest further studies are needed to determine the effectiveness of reflex urine testing as a stewardship intervention.

RELATIONSHIP OF INPATIENT NURSE STAFFING LEVELS AND UNIT-LEVEL PATIENT SEVERITY OF ILLNESS TO ESCALATION TO INTENSIVE CARE OR MORTALITY: A NATIONAL STUDY

Laura A. Petersen^1,3; Melissa K. Knox³; Chase S. Eck^1,3; Christine Yang³; Lynette Dorsey²; Paras Mehta^4,3

¹Medicine, Baylor College of Medicine, Houston, TX; ²Michael E DeBakey VA Medical Center, Houston, TX; ³IQuESt, Michael E DeBakey VA Medical Center, Houston, TX; ⁴University of Houston, Houston, TX. (Control ID #3874524)

BACKGROUND: Studies of registered nurse (RN) staffing have shown that when staffing is low, surveillance of patients is impaired, and the risk of adverse events such as mortality increases. Less is known about the relationship between unit-level characteristics, staffing, and patient outcomes such as transfer to the intensive care unit (ICU). We studied the relationship between patient exposure to RN staffing, mean unit- level patient severity of illness and the risk of ICU transfer or mortality.

METHODS: All Veterans (n = 276,598) admitted to one of 211 medical, surgical, or medical-surgical units in 93 VA Medical Centers in FY2019 who spent 2-10 days on the admitting unit and were either discharged or died. We excluded patients in hospice or palliative care. Patient-level variables included age and Diagnostic Cost Group (DCG) relative risk score (RRS) as measure of severity of illness. RN hours per patient day (RNHPPD) were calculated using estimated daily unit-level RN hours and prorated patient days. Time varying daily unit-level variables and means included patient days, RNHPPD and daily mean RRS. Using survival analysis, we examined factors associated with a patient’s status at the end of their stay on the admitting unit.

RESULTS: Mean age was 67.6 years and the mean sample RRS was 4.45. There were 375 deaths and 11,297 ICU transfers. Patient age (HR = 1.06) and RRS (HR = 1.04) were significantly associated with mortality. Mean level of RNHPPD was not positively correlated with unit-level mean RRS. At the mean level of RNHPPD (M = 8.21), unit-level mean RRS was significantly related to mortality (HR = 1.38). The interactive effect of unit means of RNHPPD and daily mean-RRS on mortality was significant (HR = 0.89).

Relative to medical units, both mixed medical-surgical (HR = 1.55) and surgical units (HR = 2.38) had higher risk of transfer to ICU. At the mean level of RNHPPD, unit-level mean RRS was significantly related to risk of ICU transfer (HR = 1.21). The interactive effect of unit means of RNHPPD and daily mean-RRS on risk of ICU transfer (HR = 0.90) was significant. Daily deviations in mean-RRS (HR = 0.92) and RNHPPD (HR = 01) were significantly associated with transfer to ICU.

CONCLUSIONS: Mean staffing levels were not positively correlated with unit-level mean severity of illness. Higher levels of staffing across units mitigated the effects of unit-level patient severity of illness on mortality and transfer to ICU. Conversely, lower levels of staffing exacerbated the effect of unit-level patient severity on mortality and on transfer to ICU. This suggests that units with higher average patient illness severity would have the greatest potential for improvements in the outcomes of mortality and need for escalated care were additional staffing targeted to these units. Hospitals can explore ways of capturing and incorporating measures of unit-level average patient illness severity into methods for setting nurse staffing targets for inpatient units.

REPORTED EXPOSURE AND COMFORT WITH PATIENT SAFETY BEHAVIORS CONTINUES TO BE LOW: OUR 5-YEAR SURVEY OF INCOMING INTERNS TO OUR HEALTHCARE SYSTEM

Christine P. Beltran¹; Deepak Pradhan¹; Donna Phillips²; Joanne Agnant⁵; Katie E. Tame³; Brielle Blatt⁴; Lynn Buckvar-Keltz¹; Jeffrey Manko⁵; Sondra R. Zabar¹

¹Medicine, New York University Grossman School of Medicine, New York, NY; ²Orthopedic Surgery, NYU Langone Health, New York, NY; ³EFAA, NYU Langone Health, New York, NY; ⁴NYSIM, NYU Langone Health, New York, NY; ⁵Emergency Medicine, NYU Langone Health, New York, NY. (Control ID #3874526)

BACKGROUND: Transition into residency is a stressful time for incoming interns as they assume more responsibilities and come in with heterogeneous experiences and exposures to patient safety processes and behaviors. Our urban academic medical center in the Mid-Atlantic region developed a patient safety orientation aimed at preparing interns to address common patient safety issues and establishing a culture of safety. We describe previous experiences and comfort levels with patient safety processes for cohorts of incoming interns who have participated in this orientation over the past five years.

METHODS: Each year during orientation, incoming interns complete a 23-item entrance survey aimed at understanding their previous experiences and exposures to patient safety activities. Interns were asked whether they had previous experience participating in a formal patient safety curriculum, witnessing and reporting a medical error, escalating a situation, learning how to perform a structured handoff, and utilizing a structured handoff tool. They also rated their comfort with performing patient safety skills, donning and doffing personal protective equipment (PPE), and caring for COVID-19 patients (asked 2020-2022), on a 4 or 5-point scale.

RESULTS: 990 incoming interns participated across all five years [2018 (n=199), 2019 (n=184), 2020 (n=182), 2021 (n=212), and 2022 (n=213)]. Participants reported having few prior experiences with patient safety events, including witnessing a medical error (mean 38%; range 33-44%), escalating a situation (mean 19%; range 14-24%), and reporting a medical error (mean 5%; range 2-10%). Many participants reported learning how to do a structured handoff (mean 75%; range 68-81%), but only half felt comfortable using the structured handoff tool (mean 48%; range 42-53%). Few interns reported previously participating in a formal patient safety curriculum (mean 27%; range 24-30%). More than half of interns reported feeling comfortable with escalating to a supervisor (mean 56%; range 50-59 %), while less reported comfort reporting a medical error (mean 34%; range 27-36 %) and escalating a situation (mean 34%; range 38-44%). Interns during the COVID-19 pandemic (years 2020-2021) learned how to don/doff PPE and reported increasing levels of comfort doing it (mean 62%, 60% to 63%). They also reported increased comfort with caring for COVID patients (mean 26%, 22% to 31%) over time.

CONCLUSIONS: Results from the past five years demonstrate that incoming interns’ levels of previous experiences and reported areas of discomfort with patient safety processes remain relatively stable from year to year. This reinforces the relevance of our patient safety orientation as an important educational program that provides all incoming interns with the opportunity to gain experience and comfort in these areas. Integrating this as a dedicated and well-integrated part of residency orientation helps to establish a community and culture that prioritizes patient safety.

SAVED BY THE SCAN: INCREASING THE RATE OF LUNG CANCER SCREENING IN AN ACADEMIC PRIMARY CARE PRACTICE

Jozef Oweis¹; Patrick J. Tempera¹; Momina Amjad¹; Josephine Lee²

¹Internal Medicine, Albany Medical Center, Albany, NY; ²Medicine, Albany Medical Center, Albany, NY. (Control ID #3872079)

BACKGROUND: Lung cancer is the second most common cancer in the United States. It is by far the leading cause of cancer death, accounting for 25% of all cancer deaths. The likelihood of surviving 5 years or more improves to 68% when lung cancer is diagnosed early before it spreads, yet less than 6% of eligible people get screened. The objective of this study was to investigate and improve lung cancer screening (LCS) rate at the Albany Medical Center Health System Internal Medicine Group (IMG) over 12 months by providing education about LCS to our medical home team and patients. Here, we present our initial findings at 6 months.

METHODS: We reviewed a random sample of 100 patients seen at IMG in 2019 with a current or former cigarette smoking history. Based on the 2013 United States Preventive Task Force (USPSTF) recommendations on screening for lung cancer with low-dose computed tomography (LDCT), inclusion criteria included patients aged 55-80 years who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years. Exclusion criteria included patients who had not smoked for 15 years or developed a health problem that substantially limited life expectancy or the ability or willingness to have curative lung surgery. Of the 100 patients, 46 patients qualified for lung cancer screening. The pre- intervention rate of LCS was assessed based on the number of eligible patients who underwent CT lung cancer screening study ordered by IMG providers.

Interventions to improve LCS rates included educational meetings and flyers posted in patient examination rooms. We presented a PowerPoint explaining the importance of lung cancer screening] and the 2021 USPSTF screening guidelines to attending and resident physicians, physician assistants, and nursing staff.

The flyers included facts about lung cancer and decision aids for high-risk patients.

After the initial 6 months of our intervention, we assessed the rate of eligible patients who underwent lung cancer screening by LDCT based on a random sample of 100 patients seen at IMG in 2022. Of the 100 randomly selected patients with a smoking history, 37 were eligible for screening.

RESULTS: Before our intervention, 12 patients out of 46 eligible patients underwent CT lung cancer screening (26%). Post-intervention, 23 patients out of 37 eligible patients underwent CT lung cancer screening (62.2%).

CONCLUSIONS: Low-dose CT lung cancer screening is underutilized in the United States. By closing the knowledge gap through engagement of the medical home team and patients, we increased the rate of LCS by 2.4-fold in 6 months. During the next 6 months, we plan to re-evaluate the LCS rate and investigate barriers to care.

STANDARDIZATION OF MANAGEMENT OF HIP AND KNEE OSTEOARTHRITIS IN AN OUTPATIENT SETTING- A QUALITY IMPROVEMENT STUDY.

Shrey Gole, Ram Chandra Khatri Chhetri, Jishna Shrestha, Erin Davis-Delay

Internal Medicine, Rosalind Franklin University of Medicine and Science Chicago Medical School, McHenry, IL. (Control ID #3875164)

BACKGROUND: Osteoarthritis (OA) is one of the most common musculoskeletal disorders affecting adults over the age of 55. It is one of the leading causes of disability, functional limitation and is associated with increased risks of falls. The American College of Rheumatology (ACR) strongly recommends using exercise to manage osteoarthritis of the hips, knees, and hands. We sought to identify current practices for the management of hip and knee OA in an outpatient setting and propose an EMR order set to encourage physical therapy (PT) referral.

METHODS: We retrospectively retrieved data from the primary care residency clinic for patients diagnosed with OA between January 2020 and January 2021. Our inclusion criteria included the ICD code for hip and knee OA, which had documented management with either pharmacological treatment (PhT) or PT. Our query resulted in 35 patients who met these criteria. PT consists of isokinetic and isometric weight exercises, stationary bicycling, resistance training, aquatic exercise, and walking on a treadmill or supervised. RESULTS: Thirty-five patients who met the criteria for diagnosed OA with documented management were divided into three groups: managed with either PT or PhT or both (PT+PhT). We observed that 57% (n=20) of patients were managed with pharmacological treatment, whereas only 22% (n =8) of patients worked with PT alone, and 6% (n=2) were managed with combination therapy (PT+PhT). 15% (n=5) of patients preferred to exercise at home and declined PT referrals.

CONCLUSIONS: In our clinic, pharmacological therapy for OA was often initiated without PT or in association with PT. The most common barrier to PT referral was arthritic pain from OA. The proposed EMR algorithm becomes available to the healthcare provider when an ICD diagnosis of hip and knee OA is established in the residency clinic. This study highlights the importance of PT for the management of hip and knee OA and adhering to best practices.

STANDARDIZED ACCEPT NOTE TO IMPROVE THE QUALITY AND SAFETY OF INTER- HOSPITAL TRANSFER

Stephanie Mueller, Cathy Yoon, Jeffrey L. Schnipper

Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA. (Control ID #3875819)

BACKGROUND: The transfer of patients between hospitals (interhospital transfer, IHT), exposes patients to communication errors and gaps in information exchange. In this study, we designed and implemented a standardized accept note to improve communication during IHT and evaluated its impact on patient outcomes.

METHODS: We included all patient transfers from any acute care hospital to the general medicine, cardiology, oncology and ICU services at an 800-bed tertiary care facility between 8/2020 and 6/2022, before and after implementation of a standardized accept note. The standardized accept note was developed and refined with input from key stakeholders, including medicine residents, physician assistants, attending physicians, and nurses within our “Access Center” responsible for coordinating all IHT. The final accept note was implemented in 7/2021 as a templated note within our EHR for use by Access Center nurses. Our primary outcome was clinician-reported medical errors collected via surveys of admitting clinicians within 72 hours after IHT patient admission. We also evaluated clinician-reported failures in communication (via survey), and administrative outcomes including presence and “timeliness” of accept note (hours between note documentation and patient admission); LOS; rapid response or ICU transfer within 24-hours (for non-ICU patients); and in-hospital mortality. We conducted multivariable regression analysis to evaluate clinician- reported medical error rates (medical errors/100 patient transfers) post- versus pre-intervention, adjusted for patient demographics, diagnosis, comorbidity, illness severity, admitting service, time of year, hospital COVID census, and census of admitting service and admitting team on date of admission. Other outcomes were evaluated using similar regression models.

RESULTS: Of the 1012 and 657 IHT patients during pre- and post-intervention periods, surveys were collected on 741 (73.2%) and 464 (70.5%), respectively. Baseline characteristics were similar among patients in each time period and between survey responders and non-responders. Adjusted analyses demonstrated a 27% reduction in clinician-reported medical error rates post- versus pre-implementation (11.4 vs 15.7, aOR 0.73, 95% CI 0.53,0.99 p=0.04). Secondary outcomes demonstrated lower adjusted odds of clinician-reported failures in communication (aOR 0.88; 0.78,0.98) and rapid response/ICU transfer (aOR 0.58; 0.34,0.99), and improved presence (aOR 2.31; 1.76,3.02) and timeliness (-21.4 vs -8.7 hours, p<0.001) of accept note. There were no significant differences in LOS or mortality.

CONCLUSIONS: Among 1669 medical patient transfers, implementing a standardized accept note was associated with improvement in presence and timeliness of accept note documentation, clinician reported medical errors, failures in communication, and clinical decline following transfer. The results suggest that improving communication during IHT can improve patient outcomes.

STANDARDIZED ORDER SET CUTS DOWN COST OF UNNECESSARY TELEMETRY USE Jeffrey Jacob, Parth Shah, Vivien Edi, Jiaqi Mi, Zenobia Jonesfoster

Internal Medicine, WellStar Kennestone Hospital, Marietta, GA. (Control ID #3876739)

BACKGROUND: The initial intent of telemetry monitoring was to help detect life-threatening arrhythmias. However, it is now on the Choosing Wisely Campaign’s Top 12 list of overly used tests/procedures that pertain to excess waste and financial burden on the healthcare system and unnecessary cost incurred by patients. For this reason, the American College of Cardiology (ACC) and American Heart Association (AHA) set guidelines (2004) based on three classes of risk, which differentiates indication of use. Despite these recommendations, telemetry orders are placed at continuous or recurrent frequencies without an appropriate indication. Financially, at our hospital, the gross cost of telemetry is $7072 per patient per day. When adding up all the non-indicated days of telemetry use, it can be costly and unnecessary for both the patient and the health system. The purpose of our study is to compare the effectiveness of implementing a standardized order set in our health system that is built around physician decision-making based on discrete diagnosis with time automation. We hypothesized that the intervention would reduce the amount and duration of telemetry use and thus the overall cost.

METHODS: This is a Plan-Do-Study-Act study design at our hospital from March 2022 to November 2022. The new order set was implemented July 2022. Patients were 18 years or older in either inpatient or observation status that exclude hospice, obstetrics, pediatrics, NICU, nursery, behavioral health, inpatient rehab, skilled nursing, women’s service, long term acute care, emergency department, and procedural care. The outcomes measured were percent of patient census on telemetry.

RESULTS: On a monthly average, 7965 patients were on telemetry from March to June 2022 compared to monthly average of 5320, which is a reduction of 2645 patients (about 33%) after the intervention. This correlates to average percentage of patients on telemetry of 54.6% as pre-intervention compared to 45.8% post-intervention.

CONCLUSIONS: Telemetry was developed for close monitoring of cardiac arrhythmias, but it comes at a cost. Although the ACC/AHA criteria have listed appropriate indications for telemetry use, unnecessary and non-indicated usage, especially if continuous, can be financially burdensome. For this reason, our hospital initiated a simplified order set based on physician clinical decision-making for discrete diagnosis to help reduce the use and duration of telemetry, thus making it cost-effective for both the patient and the health system. From a financial aspect, a reduction of 2645 patients using telemetry as mentioned in the results, at a cost of $7072 of telemetry per patient per day, is equivalent to saving the hospital system $18,705,440 during a 4-month time span.

TEAMWORK MAKES THE DC WORK - HOW "TEAM DISCHARGES" HELP CREATE A SAFER DISCHARGE EXPERIENCE FOR PATIENTS

Armaan Hasan^2,1; Yutong Dong²; Morris Jrada³; Marwa Moussa¹

¹Internal Medicine, NYU Langone Health, New York, NY; ²Internal Medicine, New York University Grossman School of Medicine, New York, NY; ³Internal Medicine, NYU Langone Health, Brooklyn, NY. (Control ID #3877203)

BACKGROUND: Being discharged from the hospital can be a moment of relief for patients and their families. It can also be quite daunting. Cross-sectional and qualitative studies have shown that the inpatient discharge process is often a challenging time for patients, families, and providers. Particularly given the complexity of the inpatient to outpatient transition. A new “Team Discharge” protocol piloted at NYU Langone Brooklyn Hospital seeks to improve communication at the time of discharge with the aim of improving the understanding of the discharge plan and what comes next.

METHODS: During a Team Discharge the primary nurse messages the provider team once the discharge paperwork is completed. As part of the Team Discharge one member of the physician team would be present at bedside to review the final discharge instructions alongside the primary nurse and together answer any questions as opposed to solely the primary nurse reviewing the discharge plan. Once the Team Discharge is complete, the primary nurse enters a smartphrase documenting completion of the Team Discharge process. Using an EMR reporting tool, HCAHPS survey responses were linked to Team Discharge status based on the presence or lack of a Team Discharge smartphrase. Surveyed patients who were not documented to receive a team discharge, and presumably were discharged solely with the nurse present, were the control group. Those who had a documented Team Discharge were the experimental group. Surveys used for this study were conducted over a 9 month period (02/2022 to 10/2022). Surveys were anonymous and completed in private by patients after receiving final discharge papers. Results were analyzed in SPSS 25.0 using a Mann-Whitney U test.

RESULTS: On NYU Langone Brooklyn’s medicine and surgical units, a total of 4446 patients were documented as being discharged using the Team Discharge method. This corresponds to approximately 48% of all patients discharged to home between February and October 2022. Using HCAHPS surveys to measure the impact of Team Discharges on Patient Experience, we noted an improvement in top box scores in the domains of Communication about Medications, Discharge Information, and Care Transitions in the experimental group compared to the control group. The survey results, however, did not show a significant statistical difference in any measured categories.

CONCLUSIONS: The Team Discharge initiative provides an opportunity to bring providers to bedside at time of discharge to help explain discharge instructions to patients in a collaborative manner with bedside RNs. Compliance of the Team Discharge process continues to grow at NYU Langone Brooklyn and it is now the primary way patients are discharged from the hospital. While continued education and coaching can help maximize the benefits of this new way of discharging, initial data suggests improvement in several HCAHPS domains, especially Discharge Information, Care Transitions and Communication about Medications, though lacking statistical significance.

THE HEART HEALTHY OHIO INITIATIVE: A STATEWIDE PRIMARY CARE CARDIOVASCULAR HEALTH COLLABORATIVE

Shari Bolen¹; Douglas Einstadter¹; Jordan Fiegl⁵; Hannah Hill⁵; Adam Perzynski¹; Jackson T. Wright²; Saundra Regan³; Randell Wexler⁴; Christopher Taylor⁴; Stephanie Kanuch⁵; Catherine Sullivan⁵; Aleece Caron¹

¹Medicine, MetroHealth/Case Western Reserve University, Cleveland, OH; ²Medicine, Case Western Reserve University, Cleveland, OH; ³Family and Community Medicine, University of Cincinnati College of Medicine, Cincinnati, OH; ⁴Family and Community Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ⁵Center for Health Care Research and Policy, The MetroHealth System, Cleveland, OH. (Control ID #3874710)

BACKGROUND: Ohio is in the top quartile of states for cardiovascular disease (CVD) events. A statewide primary care quality improvement (QI) collaborative has the strong potential to improve modifiable CVD risk factors of hypertension and smoking, yet little is known related to current day CVD opportunities for improvement and capacity for QI in Ohio primary care practices.

METHODS: The Heart Healthy Ohio Initiative funded by the Agency for Healthcare Research and Quality has an initial aim to establish a statewide QI infrastructure and recruit 50 diverse practices to participate in a pilot QI project focused on hypertension control and smoking cessation. Practices could participate if practice-level blood pressure (BP) control (<140/90 mmHg) was <75%, and/or had >10% smokers. We describe cross-sectional baseline results of practice surveys and electronic health record (EHR) data from these initial practices.

RESULTS: Of the 144,702 patients from 48 practices with baseline 6-month EHR data, the mean age was 55 years (SD 18), 41% were female, 66% were White, 24% were Black, 5% were Hispanic, and 5% were other race/ethnicities. Primary coverage included 30% Medicare, 16% Medicaid, 40% Commercial, and 13% uninsured. In patients with diagnosed hypertension (n= 57,146), BP control was 69%, and varied by race/ethnicity: Hispanic (71%); White (72%); and Black patients (65%). In adults with hypertension who had elevated BP at the last visit (n=17,451), 38% had a repeat BP when the 1^st BP was elevated, and 27% had an appointment for a follow up visit within 35 days. Twenty-one percent of patients with hypertension were not prescribed antihypertensive medications at baseline. Tobacco screening was completed on 92% of all patients, with a smoking prevalence of 20%. Less than one-quarter of current smokers were connected with tobacco cessation resources or prescribed a smoking cessation medication (23% and 22%, respectively). From baseline surveys, nearly half of the practices (46%) lost at least 1 clinician and 30% lost at least 1 head nurse or office manager in the last year. On the Change Process Capacity Questionnaire, several practices reported lower rates of agreement (<3 on a Likert scale) for the following items: designing QI to make less work for clinicians (58%); use of rapid cycle or pre-testing to reduce the risk of negative results from introducing changes (58%); customizing implementation of care to the practice (42%); removal or reduction of barriers to better care (40%); delegating to non-physician staff (38%); and designing deliberately for the patient (34%).

CONCLUSIONS: Diverse Ohio primary care practices within a statewide QI collaborative demonstrate opportunity for disparity reduction in cardiovascular health and improvement in BP control and smoking cessation. Within participating practices, attention to staff and clinician retention, rapid cycle testing, designing QI that can be efficiently employed by clinicians, and reducing barriers to better care are key areas to enhance.

THE LAILA TOV INITIATIVE – LOWERING ASSESSMENTS FOR INDIVIDUALS WITH LOW ACUITY OF VARIED SLEEP: A PILOT EVALUATION OF SAFETY

Christina D'Agostino, Nirvani Goolsarran, Davina Chen, Joseph Mizrahi, Jeffrey Kott, Julia Tsvyakh, Onyinye Njoku

Internal Medicine, Stony Brook University Hospital, East Setauket, NY. (Control ID #3854935)

BACKGROUND: Sleep is critical to recovery of acute illness, yet hospitalization is far from restful. Hospitalized individuals experience frequent disruptions regardless of acuity. While there have been many efforts to improve sleep in this population, there have been no evidence-based attempts to identify individuals who may safely benefit from a targeted intervention. With our baseline data analysis, we used the Modified Early Warning System (MEWS) to not only identify hospitalized individuals who are at a lower likelihood of having adverse events (defined as Rapid Responses, Transfers to Higher Levels of Care, or Cardiac Arrest), but to create a safety screening tool to intervene upon a selected “Low Risk Patients” (LRP) population. We hypothesize that this intervention to maximize sleep in LRP will improve both health outcomes and allocation of resources for health care providers.

METHODS: We conducted an interdisciplinary, QI project aimed at minimizing nighttime disruptions in LRP hospitalized on a General Medical Floor. Prior to intervention, residents and nurses were educated on the study as well as the importance of nighttime sleep. Patients who met inclusion criteria were recruited to the intervention arm and had adjustments made to minimize nighttime awakenings. The control group received the standard of care. Validated sleep surveys were used to evaluate subjects’ overnight sleep. The primary endpoint of the study aimed at measuring rates of adverse events, differences in delirium episodes, and patient satisfaction between the intervention and control groups.

RESULTS: To date, 23 subjects (11 intervention, 12 control) have been recruited with no adverse events or episodes of delirium. Univariate analysis of sleep outcomes trended towards more quality sleep in the intervention group compared to the control group, with statistically more “sound” sleep in the former. The average age of the subjects recruited was 52.4 years with 56% being male.

CONCLUSIONS: Our pilot study suggests our intervention does not lead to increases in adverse events in the LRP. Thus, it is likely safe to minimize overnight interruptions in these select patients. We believe that patient satisfaction can be improved by promoting nighttime sleep. Next steps include expansion to 800 total subjects. We will investigate differences in length of stay, 30-day readmission rates, and changes in the HCHAPS survey. Safety will continue to be evaluated to ensure no unintended harms occur. We hope to validate this tool to help clinicians objectively identify LRP who may benefit from less frequent overnight monitoring, thereby promoting improved sleep.

THE SAFETY OF HEALTHCARE IN THE OUTPATIENT SETTING: THE SAFECARE STUDY David Levine, Ania Syrowatka, Christine Iannaccone, Michelle Frits, David W. Bates

General Internal Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #3876523)

BACKGROUND: Health care services place considerable emphasis on delivering safe care, but substantial patient harm occurs, both inside and outside the hospital. Although most care occurs in the outpatient setting, knowledge of outpatient adverse events (AEs) remains limited. Few large empiric evaluations have been done to identify rates and types of AEs across all types of outpatient care. We sought to perform what is, to our knowledge, the largest assessment of outpatient AEs to date.

METHODS: We performed a retrospective review of all available electronic health record (EHR) data for a sample of patients in 2018 from 13 outpatient sites in Massachusetts, using disproportionate random sampling at each site to produce reliable estimates of AEs for adults at each institution. We counted any encounter as outpatient that involved a licensed independent practitioner and did not involve an overnight stay in the hospital, including primary care, specialty care, radiology, phlebotomy, emergency department

(ED), ambulatory surgery center, and other outpatient services noted in the EHR. The study definition of AE was “unintended physical injuries resulting from or contributed to by healthcare management (including the absence of medical treatment) that require additional monitoring, treatments, or hospitalizations, or that result in death.” Reviewers received training via a manual and norming sessions. Seven nurse reviewers identified possible AEs and AE category. Six physician adjudicators reviewed nurse summaries, ranked the AEs’ severity using a general severity scale, assessed preventability, and ranked confidence whether the AE was due to healthcare management. We used logistic regression to assess the association of having at least 1 AE with age, sex, race, and primary insurance. We compared variation across sites.

RESULTS: We studied 3,103 patients with mean age 52 years (95% CI, 49-55). Patients were more often female (60%), of White race (75%), English speakers (91%), and privately insured (70%). Patients had a mean of 4 outpatient encounters, 0.1 ED visits, and 0.1 hospitalizations. Overall, 6.2% (95% CI, 4.1-8.3) of patients had an AE. Adverse drug events (64%) were most common, followed by healthcare-associated infections (15%), and surgical/procedural events (14%). Regarding severity, 17% of AEs were serious, 2% were life threatening, and none were fatal. Overall, 23% of AEs were preventable. Experiencing at least one AE was associated with age 65-84 (versus age 18-44; aOR, 2.1 [95% CI, 1.3-3.4]), but not sex, race, or insurance. Large variation among sites existed, with a range of 2% - 24% of patients with at least 1 AE at a given site. Similarly large variation by clinical category of AE was present.

CONCLUSIONS: Outpatient harm was common and often serious. Adverse drug events were most frequent. Rates did not differ by sex or race but were much higher in adults aged 65-84. Measures to curtail outpatient harm are urgently needed.

THE SAFETY OF PARACENTESIS IN PATIENTS TAKING APIXABAN

Sarah Van Dorin¹; Rosarie A. Tudas³; Kevin Sanchez¹; Mohammad Amarneh⁴; Andrei Schwartz¹; Ethan Kuperman²

¹Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA; ²Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; ³The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, IA; ⁴Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA. (Control ID #3876832)

BACKGROUND: About 150,000 paracenteses are performed in the United States annually. While paracenteses have a complication risk of less than 1%, the impact of anticoagulation on the risk of bleeding after paracentesis remains unclear. After 2 cases of fatal hemorrhage following abdominal paracentesis for patients on apixaban, a study was designed to further quantify the bleeding risk and risk factors for major bleeding in patients undergoing paracentesis while on apixaban. We hypothesized that the risk of bleeding would be much larger than 1% for a patient undergoing a paracentesis while on apixaban.

METHODS: The study was conducted by identifying paracenteses between 1/1/2016 and 4/1/2022 using the Slicer Dicer tool in Epic. A single reviewer manually abstracted clinical data to identify paracenteses where the patient had exposure to apixaban within 7 days prior to procedure. Inclusion criteria included age greater than 18 years and diagnostic or therapeutic paracentesis either as outpatient or inpatient. Patients were excluded from the study if the index paracentesis occurred prior to arrival. Primary outcome evaluated was whether fatal, major, or nonmajor bleeding occurred within 72 hours of a paracentesis. Other parameters evaluated include antiplatelet use, MELD score, time since last apixaban dose, platelet count, and INR values. A limitation of the study included accurately determining duration that apixaban was held prior to procedure as it was not clear in majority of patients (65%).

RESULTS: Of the 376 audits conducted, there were 20 significant bleeds identified. Nine bleeds were identified with likely or uncertain relationship to the paracentesis. Of these, 67% (6/9) occurred when the apixaban dose was given less than 6 hours prior to the paracentesis. When apixaban dose was given less than 6 hours before the paracentesis, 16% (6/37) of patients had a significant bleed.

CONCLUSIONS: The study showed that the risk of bleed after a paracentesis for patients on apixaban was higher than the risks found in previous studies (up to 2.4% risk of significant bleed versus <1% in previous studies) with the majority of bleeds (67%) occurring when the apixaban dose was given less than 6 hours prior to the paracentesis. There are currently no clear guidelines on the use of apixaban prior to a paracentesis as a paracentesis is considered a low-risk procedure. We plan to use the study to determine whether clinical policies regarding the use of apixaban before a paracentesis should be developed. We also plan to evaluate several other parameters including antiplatelet use, MELD score, Child-Pugh score, platelet count, and INR to determine if any of these parameters increase the risk of bleed following paracentesis.

TIMELINESS OF FOLLOW-UP OF ABNORMAL CHEST CT FOR PATIENTS IN A SAFETY NET HEALTH SYSTEM

Kevin Ferriter¹; Anupama M. Kapadia¹; Francisco Barrios¹; Colleen O'Neill¹; Nicole Kluz¹; Patrick Chang²; Yvonne Queralt³; Michael Pignone¹

¹Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; ²Population Health, The University of Texas at Austin Dell Medical School, Austin, TX; ³Diagnostic Medicine, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #3874743)

BACKGROUND: As part of a novel lung cancer screening program within a large Federally Qualified Health Center (FQHC), we identified CT scans with radiographically concerning pulmonary nodules performed outside of the screening program among eligible patients. We determined if they had appropriate follow-up per evidence-based guidelines.

METHODS: We conducted a retrospective cohort study. We identified eligible patients from a FQHC system’s EMR. Inclusion criteria were based on USPSTF lung cancer screening guidelines: patients aged 55 to 77 with current or former smoking status who had a CT scan completed within the partner network from January 2019 to February 2020. One of 4 residents/faculty reviewed eligible patients’ inpatient and outpatient records. Using imaging findings and smoking history, reviewers grouped initial imaging based on Lung- RADS and Fleischner Society guidelines, identified optimal follow-up interval, and documented if appropriate follow-up was completed and if it was timely or delayed by more than 1 month.

RESULTS: We reviewed 397 patient charts. Mean age was 65.2 years (range 57 to 80 years) and 60% were male. The cohort was diverse: White/non-Hispanic 37.3%, Hispanic/Latino 41.9%, and Black/non-Hispanic 16%. Medical coverage varied: Medicare or Medicaid 49.9%, county medical assistance 30.2%, uninsured 10.8%, commercial insurance 7.3%, and other/unknown 2%. 46% were former smokers, 42% were current smokers and 12% had unknown smoking history.

40 patients (10%) had a known malignancy or causative infection at the time of the initial scan.

Of the remaining 357, 154 (39%) required no follow-up, 75 (19%) required ongoing routine screening, and 61 (15%) had benign CT findings with insufficient smoking history to determine no further testing vs. routine screening.

67 (17%) had nodules that required follow-up: 30 at 12 months, 2 at 12 months (assuming a positive smoking history), 21 at 3-6 months, and 14 immediately.

Of these 67, 32 (48%) had no follow-up,10 (15%) had delayed follow-up, and 25 (37%) had timely follow- up.

Of the 14 requiring immediate follow-up, 10 had follow-up, of whom 7 had a primary lung cancer. 3 of these 7 patients died, 3 had treatment and are alive (2 in remission), and 1 has not been seen in our system since biopsy was completed. The remaining three who completed follow-up had nodules due to tuberculosis or non-primary lung cancers and are alive.

All 4 patients who required but had no immediate follow-up were lost to follow-up. One died from intracerebral hemorrhage due to brain metastases from undiagnosed lung adenocarcinoma.

CONCLUSIONS: Appropriate follow-up for patients with abnormal CT scans is sub-optimal. Improved systems are needed to ensure timely and effective work-up of abnormal findings.

UNDERSTANDING DRIVERS OF RAPID RESPONSES IN AN INPATIENT-AFFILIATED INFUSION CLINIC

Briana P. Patton¹; Christopher D'Avella²

¹Internal Medicine, University of Pennsylvania, Philadelphia, PA; ²Oncology, Penn Presbyterian Medical Center, Philadelphia, PA. (Control ID #3877076)

BACKGROUND: Penn Presbyterian Medical Center is an academic inpatient care facility with co-located outpatient oncology clinic, radiology facility, and infusion suite. The infusion suite cares primarily for oncology and hematology patients, but also performs infusions for patients referred from off-site general medicine, gastroenterology, and rheumatology practices. Medical emergencies that occur in the outpatient facilities are addressed by an inpatient “Rapid Response Team (RRT),” who stabilizes the patient and accompanies them to the Emergency Room. In 2021, it was noted that an increasing number of Rapid Responses were being called to the infusion suite compared to prior years, leading to the limited resource of the RRT being directed out of the hospital and into the clinic setting.

METHODS: Retrospective chart review of the hospital EHR was performed to locate patients with an outpatient infusion encounter from 5/2020 to 3/2022 who had a rapid response note affiliated with their visit. Charts were reviewed individually to compile demographic information, department ordering the medication (oncology, benign hematology, other), infusion medication, reason for Rapid Response, and eventual diagnosis (if found). Data was analyzed in Microsoft Excel.

RESULTS: 46 total Rapid Responses were called to the infusion suite during the study period. 30 Rapids (65%) were for oncology patients scheduled to receive chemotherapy. Of the 16 non-oncology patients, 11 were scheduled to receive a biologic (ex: adalimumab), and 4 for IV iron. 15 Rapids were called prior to initiation of infusion, and 80% of those patients were oncology patients. Vital sign abnormality (ex: hypoxia, tachycardia) was the most common reason for a Rapid (35%), followed by chest pain (22%) and altered mental status (13%). 46% of patients on whom a Rapid was called were admitted to the hospital. The most common diagnosis after ER visit or admission was infusion reaction (30%), followed by infection (11%) and hypovolemia (10%). Of the 14 Rapids called for infusion reaction, 10 (71%) were for non-oncology patients.

CONCLUSIONS: This study revealed two notable groups of patients driving infusion suite Rapid Responses – non-oncology patients receiving infusions ordered by providers not located on campus, and already critically ill oncology patients who were unstable prior to initiation of their infusion. Understanding which patient populations are driving outpatient Rapid Responses will enable us to develop appropriately targeted interventions to reduce need for utilzation of the inpatient RRT.

Scientific Abstract - Women’s Health, Sex, and Gender-Informed Medicine

AFFIRMING ME: THE PERSPECTIVE OF TRANSGENDER PATIENTS ON HEALTHCARE IN A LARGE HEALTH NETWORK

Leslie Deutschman¹; Meredith Manire²; Wesley Perez Cervantes³; Molly A. Fisher¹

¹Internal Medicine, Allegheny Health Network, Pittsburgh, PA; ²Ob/Gyn, Allegheny Health Network, Pittsburgh, PA; ³Drexel University College of Medicine, Philadelphia, PA. (Control ID #3875466)

BACKGROUND: Transgender patients endure discrimination and systematic oppression within the healthcare setting, resulting in subsequent decrease in healthcare utilization. This study seeks to qualify experiences in the primary care setting at one institution to improve future patient healthcare encounters.

METHODS: This was an IRB-exempt study. Transgender adults (N=803) within a large health network in the Mid-Atlantic region were identified in the electronic medical record, EPIC, using the following inclusion criteria: >18 years old and had a diagnosis code related to transgender identity (“transgender,” “gender dysphoria,” or “gender-confirming surgery”). An electronic survey was sent to any patient with the above cross-referenced criteria with an active email address (N=703). Survey questions ranged from dichotomous, Likert scale, and free response questions.

RESULTS: A total of 188 patients completed the survey, which is a response rate of 26.7%. The majority of respondents were non-hispanic white/caucasian (92%) and between the ages of 18 and 34 (71%). Seventy- two percent of respondents reported accurate pronoun usage by staff in the provider’s office. While 17% reported discrimination, 6% reported a provider refused care, and 6% felt unsafe in a provider’s office. The majority (58%) felt fear of seeking a new provider because of past negative experiences. Six areas of improvement were identified in the free response section: mandating gender-affirming general competency training for all healthcare staff, hiring LGBTQIA+ providers, updating office forms with gender neutral language, ensuring electronic based communication includes the patient’s preferred name and pronouns, providing additional medical training to providers, and creating a referral network of LGBTQIA+ competent providers.

CONCLUSIONS: Obstacles to equitable care for transgender patients remain persistent; thus, this study aims to identify areas to improve overall patient experience in the primary care setting.

Pronoun misuse is a systemic problem as evidenced by this study which showed 72% of respondents reported “most-times or all the time” correct pronoun usage by staff in the provider’s office and only half (54%) of patients felt safe correcting staff if someone used the incorrect pronoun.

Discrimination in the healthcare setting continues to be a significant hindrance to equitable care. Seventeen

percent of respondents reported discrimination, 6% reported a provider refused care, and 6% felt unsafe in a provider’s office.

Transgender adults experience significant adversity when seeking healthcare. Pronoun misuse and discrimination are some of the barriers to safe and equitable continuity of care for transgender adults in the primary care setting. The complete transition to gender affirming care is integral in securing equitable healthcare for transgender adults.

ASSOCIATION BETWEEN ADVANCED BREAST CANCER AND SCREENING MAMMOGRAPHY AMONG OLDER WOMEN

Ilana Richman¹; Meghan E. Lindsay¹; Jessica B. Long¹; Shi-yi Wang²; Cary Gross¹

¹Department of Medicine, Yale University, New Haven, CT; ²Chronic Diseases Epidemiology, Yale School of Public Health, New Haven, CT. (Control ID #3872493)

BACKGROUND: Prior work has suggested that screening mammography confers little or no mortality benefit for women age 75 and older, and several guidelines suggest stopping mammography among older women with limited life expectancies. However, mortality reduction may not be the sole benefit of screening. Screening may also help patients avoid diagnosis at an advanced stage, when treatment is substantially more burdensome. The goal of this study was to evaluate whether continuing screening mammography among older women is associated with a lower incidence of advanced cancer diagnosis. We hypothesized that screening would be associated with some reduction in advanced cancer diagnosis among women with the longest life expectancy, but not the shortest.

METHODS: We used data from the SEER-Medicare registry. We included women aged 70 and older who had received a screening mammogram in 2002 and were breast cancer free. Women were stratified by baseline screening status (screened at least once in the next 3 years or not) and life expectancy, which was estimated from claims using a validated algorithm. We defined “advanced breast cancer” according to a definition from the TMIST trial that includes tumors ≥2 cm, positive nodes, or distant metastases. Women were followed until breast cancer diagnosis, death, or end of follow up (12/2017). We used cause-specific Cox models to estimate the cumulative incidence function of late-stage breast cancer. Models were adjusted for a propensity score that captured differences in demographic and clinical differences between screened and unscreened women.

RESULTS: Our sample included 1,190,783 women. The mean age was 77 years, 5% were Black and 88% White. In 2003, 59% of the sample had a life expectancy of >10 years, 32% 6-10 years, and 8% <5 years. At cohort entry, 81% of women were screened at least once. Among screened women with a life expectancy >10 years, the cumulative incidence of advanced breast cancer during the 15-year follow-up period was 1.19% (95% CI 1.15-1.23), versus 1.26% (95% CI 1.16-1.37) among those who were not. For screened women with a life expectancy of 6-10 years, cumulative incidence was 0.99% (95% CI 0.91-1.07) versus 1.08% (95% CI 0.93-1.22) for those not screened. Among screened women with a <5 year life expectancy, cumulative incidence was 1.03% (95% CI 0.56-1.49), versus 0.78% (95% CI 0.54-1.03) among those not screened.

CONCLUSIONS: Among older women with a life expectancy >5 years, late stage diagnosis may be less common among screened women, although differences were small and uncertainty around estimates limits strong conclusions. Among women with shorter life expectancy, advanced cancer may be more commonly diagnosed among screened women, raising the possibility that some advanced cancers may be overdiagnosed.

CERVICAL CANCER SCREENING RATES AMONG EMERGING ADULTS BY WEIGHT STATUS

Alejandra Ellison-Barnes, Nisa Maruthur, Wendy Bennett, Lisa Yanek, Kimberly A. Gudzune

Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. (Control ID #3873487)

BACKGROUND: Emerging adulthood, from ages 18 through 25, is a life stage characterized by frequent change culminating in adult identity formation. Experiences in this period may establish subsequent patterns of healthcare and preventive services utilization, including cervical cancer screening with Papanicolaou (Pap) testing. Prior research suggests that obesity is associated with reduced cervical cancer screening among adult women and that this association differs by race/ethnicity, which may contribute to disparate cervical cancer risks. Whether screening rates differ by weight status among emerging adults is unknown. Our objectives were to determine 1) whether obesity-related disparities in cervical cancer screening are present among a national sample of emerging adults, and 2) whether differences exist by race/ethnicity.

METHODS: We used data from the Cancer Control Supplement of the National Health Interview Survey (NHIS) years 2010, 2015, and 2019, including non-pregnant female participants aged 21 through 25 and excluding those without body mass index (BMI) data. Guidelines recommend first pap at age 21. We used survey weights to account for complex survey design. Our outcome was self-reported ever-receipt of Pap test; independent variables were weight status based on body mass index (BMI; underweight, normal weight, overweight, or obesity) and obesity (BMI ≥30 kg/m2). Covariates were age, race/ethnicity, education level, and insurance status. Rao-Scott chi-square testing was used to evaluate for differences in cervical cancer screening rates by weight status. We also evaluated for interactions between obesity status and race/ethnicity. All analyses were performed in SAS 9.4.

RESULTS: We included 3,155 emerging adult women; 3.9% had underweight, 50.2% normal weight, 23.7% overweight, and 22.2% obesity. Overall, 71.3% reported a prior Pap test. There were significant differences in cervical cancer screening rates by weight category (p=0.03); those with obesity had the highest reported screening rate of 74.1%. Overall, race/ethnicity distribution was 14.0% non-Hispanic Black, 57.0% non- Hispanic White, 20.0% Hispanic, and 4.6% Asian; there were significant differences in race/ethnicity characteristics by obesity status (p<0.0001). We found no interaction between race/ethnicity and obesity status on cervical cancer screening.

CONCLUSIONS: Among a national sample of emerging adult women, those with obesity report higher cervical cancer screening rates than those without obesity. We found no significant differences in screening rates by obesity-race/ethnicity status. These findings differ from previous studies that found lower rates of screening among all adult women with obesity, though notably we looked at ever rather than current screening. We did not explore over-screening, which can lead to unnecessary coloposcopy and biopsy. Given the higher screening rates among those with obesity, additional research should examine whether this impacts emerging adult women's cervical cancer risk.

CLINICIANS’ EXPERIENCES AND CHALLENGES OF INTIMATE PARTNER VIOLENCE ASSESSMENT IN THE TELEMEDICINE SETTING

Emily Min¹; Grace Noel²; Judy Chang³

¹Internal Medicine, UPMC, Pittsburgh, PA; ²University of Pittsburgh School of Medicine, Pittsburgh, PA; ³Obstetrics and Gynecology, UPMC, Pittsburgh, PA. (Control ID #3874615)

BACKGROUND: Intimate partner violence (IPV) is estimated to affect around 37.3% of women and 30.9% of men within their lifetime. Interaction with health care services and providers provides multiple opportunities for meaningful interaction throughout an individual’s life to assess for IPV. The COVID-19 pandemic has both contributed to increased rates of IPV and accelerated the integration of telemedicine across multiple medical specialties. Both before and throughout the pandemic, numerous strategies and screening tools have emerged identifying telehealth opportunities to screen for IPV. There is a gap in the literature for physician knowledge of, and comfort in utilizing, such strategies, particularly when using telemedicine for care delivery and patient communication. Therefore, it is important to determine provider perceptions of telemedicine and its effects on IPV assessment.

METHODS: Semi-structured in-person or video interviews were conducted with practicing physician providers who have conducted telemedicine visits with patients within the fields of internal medicine, psychiatry, and family medicine. Interviews were audio-recorded and transcribed. Each transcript was independently coded by two investigators, with a final coding scheme determined through an iterative process. Common themes were identified based on the final codes.

RESULTS: We interviewed 13 physicians within the fields of internal medicine, psychiatry and family medicine who have conducted telemedicine in their practice. These physicians were concordant in their understanding that the pandemic had coincided with significantly increased number of telehealth visits. Benefits to telemedicine were increased access to care and increased understanding of patient’s home life and environment. Common themes of challenges in telemedicine were: 1) privacy and/or inability to determine who else was present in the meeting, 2) patient’s ability to understand and access telehealth technology, and 3) increased barriers to building rapport with patients and ability to read their body language. Many of these challenges coincided with providers’ perceived barriers to effectively assess for IPV. Strategies for IPV assessment in telemedicine included hand signals and scheduling in-person visits for further care to overcome some of these identified barriers. Many clinicians wanted resources addressing IPV assessment over telemedicine, including ways to connect patients to helpful resources outside of an in-person office setting.

CONCLUSIONS: Telemedicine has enabled increased access to patient care but has also presented new challenges surrounding maintaining a confidential and private space and creating patient rapport that build upon already perceived barriers to in-person IPV assessment. Additional work exploring associations between telemedicine and patient outcomes, including safety, is needed. There is a need to develop new approaches to providing IPV information safely via telehealth.

COMPLIMENTS, CLINICAL IMPAIRMENT, AND POWER PLAYS: STAFF PERCEPTIONS OF PATIENT-PERPETRATED SEXUAL HARASSMENT AT VETERANS AFFAIRS HEALTHCARE FACILITIES

Karissa Fenwick¹; Karen E. Dyer¹; Kristina Oishi¹; Elizabeth M. Yano^1,2; Ruth Klap¹; Alison Hamilton^1,3

¹Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA; ³Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA. (Control ID #3874390)

BACKGROUND: Sexual harassment perpetrated by men patients toward women patients and staff is prevalent in Veterans Affairs (VA) healthcare facilities. Common incidents include catcalling, leering, and denigration of women’s Veteran or professional status. Healthcare staff play a key role in implementing anti- harassment interventions, but little is known about staff perceptions of patient-perpetrated harassment. The objective of this qualitative study was to explore VA staff perceptions of patient motives, intentions, and culpability for harassment, and examine how these perceptions influence staff views about addressing harassment.

METHODS: We used snowball sampling to identify VA clinicians and leaders with expertise related to treating women Veterans and/or managing disruptive patient behavior. We conducted 24 semi-structured interviews across four geographically diverse VA facilities. Two members of the research team analyzed the interview data using the constant comparative method.

RESULTS: Participant attributions for patient-perpetrated harassment spanned three themes: lack of awareness, clinical impairment, and power and control.

Theme 1 (the most common theme) pertained to a lack of patient awareness that their behavior may constitute harassment or cause harm. Participants believed that patients often intend their behavior as a “compliment” and that formal responses (e.g., reporting the behavior) may therefore be disproportionately severe. Participant recommendations for addressing harassment focused on educational campaigns to raise patient awareness about definitions and harmful impacts of harassment.

Theme 2 related to clinical conditions such as mental health disorders and dementia that may increase patient proclivity for harassing behavior. Some participants believed that inappropriate behavior in the context of clinical impairment does not qualify as harassment given that patients may not have the capacity for intentionality or behavioral control. Recommendations focused on treating patient symptoms via medication or counseling.

Theme 3 (the least common theme) pertained to patient desire for power or control. Participants believed that perpetrators intend to subjugate women or reinforce male dominance in the VA patient population and should be held accountable for their actions. Recommendations included reporting and administering corrective actions to patients via formal systems.

CONCLUSIONS: Staff views about addressing harassment hinged on perceptions of patient motives, intentions, and culpability. Findings suggest a need for additional staff education that centers the experience of harassment victims/targets and attends to the complexity of addressing patient-perpetrated harassment in clinical settings. Results offer insight into potential patient motives for harassment that can inform future anti-harassment interventions in VA and other healthcare settings.

DEVELOPMENT OF A STRATEGY TO PROMOTE PRECONCEPTION CARE AND DIABETES SELF-MANAGEMENT AMONG REPRODUCTIVE-AGED WOMEN WITH DIABETES: THE PREPARED TRIAL

Guisselle Wismer¹; Evelyn Velazquez¹; Norma Calderon¹; Stephanie Batio¹; Allison Pack¹; Stacy Bailey²

¹General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; ²General Internal Medicine and Geriatrics, Northwestern University, Chicago, IL. (Control ID #3876203)

BACKGROUND: The incidence of diabetes is increasing rapidly among younger adults, many of whom are women of reproductive age. Women with early-onset type 2 diabetes (T2DM) have a unique risk profile: they are less likely to achieve glycemic control than men and are at higher risk of cardiovascular-related morbidity and mortality. They are also more likely to experience adverse reproductive outcomes. Achieving glycemic control improves women’s own health outcomes and ensures a reproductive risk profile similar to those of women without T2DM, yet >50% of this population has suboptimal hemoglobin A1c (HbA1c). Our Promoting REproductive Planning, And REadiness in Diabetes (PREPARED) trial uniquely addresses both preconception planning and T2DM care in this population.

METHODS: This is an ongoing NIH-funded, clinic-cluster randomized controlled trial. We will evaluate the PREPARED strategy against usual care in 33 academic and community health primary care practices in the Chicagoland area. A total of 840 English and Spanish-speaking women, ages 18-44 with T2DM, who are not currently pregnant or unable to become pregnant will be recruited. In the PREPARED arm, patients will receive an electronic health record (EHR)-generated medication reconciliation and reproductive planning tool to complete prior to their clinic visit. During the visit, an EHR alert will prompt the provider to counsel on contraceptive use and/or preconception care. Post-visit, patients will receive an educational material on reproductive risks and T2DM self-management; this is generated via the EHR. Finally, patients enrolled in PREPARED will receive a series of text messages over 6 weeks post-visit to reinforce positive health behaviors. Participants will complete a phone interview at baseline, 1, and 3 months. Outcomes include knowledge of reproductive risks, engagement in reproductive and T2DM health behaviors, and HbA1c.

RESULTS: To date, 82 women have been enrolled. The mean age of participants was 37 years (range 18-44).

One-third were Black (33%) and nearly one-third were diagnosed with T2DM less than 1 year ago (29%).

35% completed less than a bachelor’s degree. At baseline, only 1 in 5 (21%) reported ever receiving preconception counseling and 29% had not used any form of birth control in the last 12 months. Of those not using birth control, one-third (29%) were hoping to have a baby in the next 2 years.

CONCLUSIONS: Initial findings from this ongoing trial reveal opportunities for promoting reproductive health and preconception counseling among this higher-risk population. Future analyses will examine the effectiveness of PREPARED in improving these outcomes.

EVALUATION OF WOMEN’S HEALTH CURRICULUM WITHIN IM RESIDENCY TRAINING PROGRAM

Leah Koenig¹; Sarah A. Tilstra³; Scott D. Rothenberger⁴; Jonathan Lin⁴; Deborah DiNardo²

¹General Internal Medicine, UPMC, Pittsburgh, PA; ²Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ³Internal Medicine, University of Pittsburgh School of Medicine/Medical Center, Pittsburgh, PA; ⁴Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #3876702)

BACKGROUND: Several leading associations within internal medicine in the late 1990s established that women’s health was integral to internal medicine residency. Many factors have been evaluated as contributors to women’s health (WH) training within residency, including presence of formal curricula, training in residency continuity clinic, participation in WH tracks, among others. Our residency program has opportunities for specialized training both as part of a women’s health track and a standard women’s health curriculum for all residents. Our objective was to examine residents’ knowledge, comfort, and experience in selected core WH topics, and compare these values across residency cohorts. We also aimed to identify gaps in WH training and areas for improvement within our curriculum.

METHODS: We developed a survey questionnaire comprised of both content-based and experiential questions, which was distributed to all internal medicine residents at a single academic institution. Content questions for specific women’s health topics were chosen from a published consensus list and supported by multiple studies. Topics included abnormal uterine bleeding, contraception, cancer screening, menopause, and sexually transmitted diseases and cervicitis. Residents’ confidence in and experience with these topics were assessed with Likert scales. Participant baseline characteristics were described using means and standard deviations for continuous variables, and frequencies and percentages for categorical variables. Composite scores for comfort and experience were calculated, and linear regression modeling assessed for association between variables.

RESULTS: Overall, 35 of 172 (21%) residents completed the survey with representation across all PGY- levels and from residents within and outside the WH track. Overall average knowledge score was moderate at 63%; WH residents did score higher on knowledge assessment (p=0.022). Comfort with diagnosis and management of selected core WH topics were rated on a 5-point Likert scale, with higher scores indicating increased comfort levels. Residents expressed lowest levels of comfort with abnormal uterine bleeding and osteoporosis, and higher degrees of comfort with cancer screening and sexually transmitted infections. There was no correlation between greater knowledge and increased comfort in management, across all topics (p>0.05). The majority of residents indicated a preference for more WH education within their residency training (75% agree/strongly agree).

CONCLUSIONS: The study was limited by the low response rate, but the results suggested no significant differences between knowledge and comfort levels across PGY level or clinic site. Residents within the WH track did score higher on content questions, but this was not correlated with greater comfort in management and evaluation of WH topics.

EVIDENCE-BASED CARE TOMORROW NEEDS EQUITABLE PARTICIPATION TODAY: AN EVIDENCE MAP OF STRATEGIES TO PROMOTE THE REPRESENTATION OF WOMEN IN RESEARCH

Karen Goldstein^2,1; Lindsay Chi Yan Kung³; Megan Shepherd-Banigan^2,4; Aimee Kroll-Desrosiers⁵; Colleen Burke⁴; Julie Schexnayder⁶; Rebecca H. Lumsden⁷; Catherine Sims^2,7; Kate Sheahan⁸; Susan Alton Dailey²; Dhara Patel²; Jennifer Gierisch^2,4

¹Division of General Internal Medicine, Duke University School of Medicine, Durham, NC; ²Durham VA Medical Center, Durham, NC; ³San Diego State University College of Health and Human Services, San Diego, CA; ⁴Department of Population Health Sciences, Duke University, Durham, NC; ⁵Research & Development, VA Central Western Massachusetts Healthcare System, Leeds, MA; ⁶The University of Alabama at Birmingham School of Nursing, Birmingham, AL; ⁷Internal Medicine, Duke University Health System, Durham, NC; ⁸John Snow Inc, Boston, MA. (Control ID #3875149)

BACKGROUND: In order to provide patient-centered, evidence-based care for women, appropriate representation of women in clinical research is needed. Inclusion of women in trials has improved since the 1993 NIH Revitalization Act; however, disparities exist in important areas like cancer and cardiovascular disease. Much is known about effective strategies to boost recruitment of the general population, but approaches to enhance the representation of women specifically remain unexplored. We conducted an evidence map review to explore the breadth of the literature describing strategies to promote the recruitment and retention of women in clinical trials.

METHODS: We used an a priori, publicly-registered protocol to conduct a systematic search of published literature aimed at identifying articles that describe strategies intended to promote the recruitment and/or retention of women in clinical trials. We included descriptive and comparative evaluations to assess the breadth of strategies used across the life of a study (e.g., from trial development to results dissemination). Data abstraction was conducted following standard evidence synthesis practices. We categorized strategies by phase of trial activities and assessed for patterns by intervention type, clinical condition, and population recruited.

RESULTS: We identified 117 articles reporting on recruitment and retention strategies for 130 trials.

Included articles represented 381,595 women trial participants primarily from the United States (75 articles), United Kingdom (12), and Australia (11). Articles described recruitment strategies from single trials (n = 57), compared different recruitment strategies used within or between trials (n = 61), or reported on primary qualitative data collection from participants and/or staff (n = 18). Eighty trials (68%) reviewed strategies for sex-specific conditions (e.g. peripartum, menopause) and 38 reviewed strategies for sex-neutral conditions (32%) (e.g., cardiovascular disease). Thirty-eight trials (34%) focused on recruitment of racial/ethnically minoritized individuals. Strategies were most often deployed during outreach to potential participants (110 trials, 85%), followed by trial planning (48, 37%), enrollment/consent (53, 41%), intervention delivery (77, 59%), outcomes assessment (18, 14%), and analysis and interpretation/dissemination (25, 19%).

CONCLUSIONS: The majority of strategies described were used to promote recruitment of women in clinical trials and have primarily been described for studies focused on sex-specific conditions. Sex-neutral trials should explore strategies to promote equitable representation of women. Opportunities to develop and evaluate strategies related to the enrollment process, intervention and outcomes engagement as well as the dissemination process could improve representation of women in clinical research. Improved representation of women will boost generalizability of research findings and, ultimately, better inform evidence-based care for women.

FEMALE SEXUAL DYSFUNCTION: A KNOWLEDGE AND COMMUNICATION SKILLS CURRICULUM FOR HEALTH CARE PROFESSIONALS.

Hannah Abumusa¹; Brianna Rossiter²; Deborah DiNardo³

¹Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ²Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ³Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #3872616)

BACKGROUND: Sexual dysfunction is prevalent in women. Female Sexual Dysfunction (FSD) knowledge and communication skills-based curricula have been implemented within residency programs. A more robust evaluation of the impact of such curricula has not been reported. We therefore implemented and evaluated a FSD curriculum with a goal of increasing knowledge and comfort in the diagnosis and management of FSD. Additionally, we aimed to improve patient-centered discussion of FSD among providers through an interactive communication-skills session.

METHODS: The curriculum was launched during two half-day virtual, workshops. Participants: Healthcare Providers (HCP) including Veterans Affairs Providers and University of Pittsburgh Medical Center Internal Medicine residents and faculty.

-To increase HCP’s knowledge in the identification and management of the most common causes of FSD: We delivered a 60-minute didactic that covered the basics of healthy female sexual function followed by the major categories of FSD and management options.

-To increase HCP comfort initiating discussions: We held a 30-minute discussion outlining both provider and patient barriers to initiating a discussion regarding female sexual health. We demonstrated patient-centered communication skills in a live demo. This demo used the 5A’s model as an outline for discussing sexual health. The 5A’s has been endorsed as a conceptual framework to efficiently facilitate patient-provider interactions. Additionally, we developed communication drills adaptable for real-life clinical practice.

-To explore potential ongoing facilitators and barriers to application of curricular content: We plan to invite participants to a 30-minute interview to assess comfort level, ongoing barriers, and any changes in practice.

RESULTS: We assessed knowledge, comfort and self-rated knowledge using a pre-and post-survey, created through RedCap. A total of 27 participant identifiers were successfully matched. p-values comparing pre vs post were obtained using Exact Two-sided Signed-Rank Tests. All three tests show statistically significant improvement as illustrated in the tables attached. We will conduct semi-structured participant interviews after the workshop, assessing participants’ comfort and attitudes in initiating FSD discussions.

CONCLUSIONS: A variety of patient and provider barriers to the management of FSD in the primary care setting have been identified. The development and implementation of a knowledge and communication-based curricula for FSD helped to overcome these barriers by increasing both knowledge and comfort in FSD content and communication.

GENDER DISPARATIES IN THE DIAGNOSIS OF SLEEP DISORDERED BREATHING

Kenna Haile, M Safwan Badr, Nesrine Ibrahim, Apala Vaishnav

Wayne State University School of Medicine, Detroit, MI. (Control ID #3875340)

BACKGROUND: Sleep disordered breathing (SBD) is diagnosed in patients via diagnostic polysomnogram sleep studies (PSG) in a sleep clinic. SBD is determined by the presence of respiratory events termed hypopneas (reduction in ventilation of 30% for at least 10s) and apneas (cessation in flow for at least 10s) accompanied by arousal or desaturation events. Currently, diagnostic guidelines require that apneas and hypopneas be accompanied by a 4% desaturation for it to constitute a respiratory event (AHI-Accepted). However, the American Academy of Sleep Medicine recommends expanding the diagnostic criteria to include apneas and hypopneas accompanied by a 3% desaturation or a cortical arousal for diagnosis (AHI- Recommended). Historically, the accepted criteria has been based on male physiology and does not consider the possibility of there being different manifestations of SDB in women. This may explain the greater rate of diagnosis of SDB in men compared to women. We hypothesized that a clinical sample of both men and women would demonstrate a diagnosis disparity, with women being more likely to be misdiagnosed using the accepted criteria compared to the recommended criteria.

METHODS: The clinical sample consisted of all patients receiving a PSG at a Mid-West medical center in 2019. Patient PSGs were reviewed and accepted if there was also accompanying demographic data. 444 patients had qualifying records which were collected. We used t-test calculations to analyze gender, BMI, AHI-R, and AHI-A.

RESULTS: 286 Women and 158 Men were analyzed. For Women, the average age was 52.8 y/o (±13.9), BMI was 40.3% (±9.9), AHI-R was 27.0 events/hr (±27.4), and AHI-A was 15.1 events/hr (±21.4). For Men, the average age was 52.8 y/o (±12.6), BMI was 35.8% (±9.0), AHI-R was 47.1 events/hr (±35.1), and AHI-A was 32.5 events/hr (±31.9). 19.8% of women had an AHI-A greater than 15 compared to 35.3% of women when using AHI-R (15.5% increase). For men, 20.5% had an AHI-A greater than 15 compared to 27.4% when using AHI-R (6.9% increase).

CONCLUSIONS: There was a significant difference between men and women when comparing AHI-A to AHI-R. Using the AHI-R criteria resulted in a greater increase in women being diagnosed with severe SDB compared to men. This indicates that using the recommended criteria benefits women to a greater extent than men. Analyzing the differences in age, sex, and BMI shows significance as well.

GENDER DISPARITIES AMONG INTERNAL MEDICINE GRAND ROUNDS SPEAKERS AT TWO LARGE ACADEMIC CENTERS

Frans J. Beerkens¹; Emily Leven²; Jellyana Peraza²; Lauren T. Grinspan^1,3; Manasi Agrawal^1,2; Elizabeth Spencer⁴; Serre-Yu Wong^1,2

¹Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²The Henry D Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY; ³Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY; ⁴Division of Pediatric Gastroenterology and Nutrition, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3874797)

BACKGROUND: Grand Rounds (GR) remains a forum for speakers to showcase their work and increase recognition, which are important for academic promotion and mentorship. Diversity among such speakers could further promote equity in academic promotion and medicine. Prior reports have shown less women faculty representation among academic GR, yet academic rank and race/ethnicity which could affect gender disparities have not been examined.

METHODS: Records of Internal Medicine GR speakers from two large academic tertiary care hospitals in New York City between 2010-2021 were retrospectively reviewed. Trends in gender disparities among GR speakers were analyzed over time both by counts and female-to-male ratio (F/M). Speaker characteristics were compared by gender and included academic rank, affiliation, race, region, and format of presentation. Multivariate analysis was used to determine predictors of male speakers.

RESULTS: A total of 839 speakers were included. Women were less likely to present as GR speakers compared with men during the study period (37% vs. 63%). There were significant differences in race between genders as women were less likely to be white (60% vs. 74%) and more likely to be Black (8% vs 3%), Asian (26% vs. 20%) or Hispanic (6% vs. 3%) compared with men. Women were more common among junior faculty while men were more common among professors (p<0.01). Internal faculty, speakers from the northeast, and virtual speakers were more often women than men, yet men were more common among external faculty and in-person speakers. Over time, the number of women and F/M ratio increased, reaching highest levels in 2020 (Figure 1). The rank of professor (OR 11.5, 95% CI 1.3-105.4) and external affiliation (OR 1.6, 95% CI 1.1-2.2) were predictive of a male speaker, while Black (OR 0.3, 95% CI 0.1-0.6) and Hispanic race (OR 0.4, 95% CI 0.2-0.9) were predictive of a female speaker.

CONCLUSIONS: Men more commonly present at academic GR compared with women, although women representation is increasing. There are significant differences in rank, affiliation, race, region, and format of presentation between genders. Our results highlight the need to improve the GR speaker selection process to improve academic equity.

GENDER DISPARITIES AND INTRA-HOSPITAL LENGTH OF STAY IN PATIENTS TREATED WITH SYSTEMIC OR ULTRASOUND-ASSISTED CATHETER-DIRECTED THROMBOLYSIS FOR PULMONARY EMBOLISM

Nemanja Draguljevic²; Catherine A. Ostos¹; Kristina D. Menchaca¹; Virginia Velez Quinones¹; Erika Ostos¹; Robert Chait¹

¹Internal Medicine, University of Miami School of Medicine, Miami, FL; ²Internal Medicine, Univerzitet u Beogradu, Beograd, Beograd, Serbia. (Control ID #3877304)

BACKGROUND: Pulmonary embolism is one of the most common causes of cardiovascular deaths worldwide, with similar prevalence in men and women. The severity of diseases, comorbidities, and risk factors are the main determinants of outcomes. However, there is limited data about gender disparities in outcomes and intra-hospital length of stay in patients with different treatment modalities, such as systemic or ultrasound-assisted catheter-directed thrombolysis.

METHODS: This retrospective cohort study identified 1,007 patients diagnosed with pulmonary embolism (PE) across several facilities. Patients were stratified into two groups based on gender: a group of females, 461 (45.78%), and a group of males, 546 (54.22%). Patients were further divided based on the management they received, a group that underwent systemic thrombolysis (ST), 432 (42.9 %), and a group with ultrasound-assisted catheter-directed thrombolysis (US-CDT) with EKOS, 575 (57.1 %). The two groups didn't significantly differ in baseline patient characteristics (hypertension, coronary artery disease, peripheral arterial disease, chronic obstructive disease). We assessed if there is a difference between the two genders, females and males, in terms of intrahospital length of stay (LOS) regardless of treatment category. Negative binomial regression was used to determine the association and prediction for LOS according to different characteristics.

RESULTS: Females hospitalized for PE and who were treated either with ST or US-CDT tended to have extended LOS compared to males, with an incidence rate ratio (IIR) of 1.141 (CI 1.035~1.255, p<0.001). The maximum stay was 143 days, but the average was 7.41 days.

CONCLUSIONS: The study showed gender differences in intra-hospital LOS in patients with PE managed with US-CDT or ST. Regardless of gender, females had a higher risk for an extended stay in the hospital with either treatment; however, the limitation of the study is a small sample size and other possible cofounders from the patients or the disease itself. Future studies are required to investigate gender-oriented specifics.

IMPACT OF BIOLOGICAL SEX ON COVID-19 OUTCOMES IN CHRONIC KIDNEY DISEASE PATIENTS TAKING ANTIHYPERTENSIVES

Sara Koussa, Vidhya Nadarajan, Priyanka Kale, Maham Ahmed, Katerina Furman, Zoya Gurm, Zaina N. Khoury, Paul Kim, Dana LaBuda, Margo Mekjian, Pooja Polamarasetti, Charlotte Thill, Sophie Wittenberg, Sorabh Dhar, Dragana Komnenov

Wayne State University School of Medicine, Detroit, MI. (Control ID #3876629)

BACKGROUND: The role of biological sex and estrogen has been implicated in the incidence and course of chronic kidney disease (CKD) and SARS-CoV2 (COVID-19) infection, specifically involving the Angiotensin Converting Enzyme 2 (ACE2) and the Renin-Angiotensin-Alosterone System (RAAS) pathways. Estrogen is suggested to regulate ACE2 and exert protective effects against COVID-19 infection, which has been linked to improved disease outcomes in the setting of CKD. These effects are diminished following menopause as estrogen levels decline. Previous studies have shown conflicting data regarding the impact of Angiotensin Converting Enzyme (ACE) inhibitors and Angiotensin Receptor Blockers (ARBs) on COVID-19 severity in hypertensive patients, however, this has not been explored in the context of CKD. The present investigation was designed to explore the associations between different antihypertensive medication classes and various comorbidities on COVID-19 morbidity and mortality in an underserved population.

METHODS: We conducted a retrospective study at an urban medical center. Inclusionary criteria consisted of adults > 18 years of age with a positive COVID-19 test (via PCR) on admission. This study was approved by the Institutional Review Board (IRB # 21-05-3579), and included 330 patients. Study data were collected and managed using REDCap electronic data capture tools hosted by the affiliated institution. The statistics were performed using Statistical Package for the Social Sciences (SPSS), Version 28.0.1.0. We used the mean, standard deviation/standard error of mean, and percentage when appropriate for the description of patient characteristics. Group differences (CKD vs. non-CKD) were compared using the Pearson χ2 test.

P-values of <0.05 were regarded as significant. We conducted binary logistic regression analysis to determine the effect of biological sex and CKD status on death due to COVID-19 during hospitalization. Additionally, we completed binary logistic regression analyses to determine the effect of different antihypertensive medications on death during hospitalization.

RESULTS: On regression analyses, the odds of death in the hospital due to COVID-19 infection was not significantly associated with either biological sex or CKD status in our sample population. The odds of dying in the hospital were higher in patients who were on calcium channel blockers (OR 2.99, 95% CI 1.29-6.93, P = 0.01) and steroids (OR 4.23, 95% CI 1.17-15.31, P = 0.03). Significant associations were not observed for patients taking ACE inhibitors, ARBs, mineralocorticoid receptor inhibitors, diuretics, beta blockers and sympatholytics.

CONCLUSIONS: In this project, we aim to further elucidate the impact of biological sex on COVID-19 severity among CKD patients taking antihypertensives in an urban setting. Future studies should expand on the use of different antihypertensives and their influence on COVID-19 health outcomes among patients with CKD and hypertension.

IMPACT OF THE AFFORDABLE CARE ACT ON CONTRACEPTIVE USE AND COSTS AMONG PRIVATELY-INSURED WOMEN, 2006-2020

Cynthia Chuang⁴; Carol S. Weisman²; Sarah Horvath¹; Guodong Liu²; Diana Velott³; Amy Zheng¹; Douglas Leslie⁵

¹Medicine, Penn State College of Medicine, Hershey, PA; ²Public Health Sciences, Penn State College of Medicine, Hershey, PA; ³Public Health Sciences, Penn State Hershey College of Medicine, Hershey, PA; ⁴Department of Medicine, Penn State College of Medicine, Hershey, PA; ⁵Public Health Sciences, Penn State College of Medicine, Hershey, PA. (Control ID #3877225)

BACKGROUND: The Patient Protection and Affordable Care Act (ACA)’s contraceptive coverage requirement, which took effect in August 2012, required that most commercial health plans cover all U.S. Food and Drug Administration (FDA)-approved contraceptive methods with no out-of-pocket cost. Out-of- pocket costs dropped for all FDA-approved contraceptive methods and use of long-acting reversible contraception (LARC) increased in the years immediately following the implementation of the ACA’s contraceptive coverage requirement. It is unknown whether those benefits have been durable as the legality of the contraceptive mandate has been questioned in recent years.

METHODS: Using 2006-2020 MarketScan® claims data, we examine contraceptive use and out-of-pocket costs among commercially-insured U.S. women 13-to-49-years-old. For LARC methods, we report the annual insertion rate for intrauterine devices (IUDs) and contraceptive implants. For other methods, we report the percentage of individuals using the method each year. Individual out-of-pocket costs for each type of contraceptive were estimated by combining copayment, coinsurance, and deductible payments. Individuals were considered to be paying $0 for a LARC insertion if there was no out-of-pocket cost associated with the insertion, and for non-LARC methods if there was no out-of-pocket cost for the entire calendar year. Multivariable analyses model the likelihood of contraceptive use and paying $0 post-mandate (vs. pre- mandate) for LARC and non-LARC methods, controlling for age group, U.S. region, urban vs. rural, and cohort year.

RESULTS: The likelihood of LARC insertion increased post-ACA mandate (aOR 1.127, 95% CI 1.121-1.133), with insertion rates peaking at 3.73% for IUDs and 1.08% for implants in 2019. Although the likelihood of paying $0 for LARC increased after the ACA mandate (IUD: aOR 3.232, 95% CI 3.196-3.269; implant: aOR 6.397, 95% CI 6.220-6.578), the proportion of individuals paying $0 declined to 54% for IUDs and 65% for implants in 2020, after peaking at 60% and 90% in 2016, respectively. For oral contraceptives, both use (aOR 1.028, 95% CI 1.026-1.030) and paying $0 (aOR 20.399, 95% CI 20.301-20.499) increased significantly after the ACA mandate.

CONCLUSIONS: With the exception of oral contraceptives, the proportion of individuals paying $0 for contraception has declined after peaking in 2016 for LARC and 2019 for non-LARC. These declines likely reflect eroded adherence to the ACA contraceptive coverage mandate even prior to the Trump administration’s decision to allow employers to claim religious or moral exemptions to the ACA contraceptive mandate went into effect in 2020 when upheld by the U.S. Supreme Court ruling Little Sisters of the Poor v. Pennsylvania. Continued monitoring will be needed to understand how the decision is impacting contraceptive use and out-of-pocket contraceptive costs in U.S. women.

IMPLEMENTATION OF SOCIAL NEEDS SCREENING FOR NEWLY DIAGNOSED BREAST CANCER PATIENTS FROM MINORITIZED BACKGROUNDS: A MIXED METHODS EVALUATION IN A PRAGMATIC PATIENT NAVIGATION TRIAL

Stephenie Lemon³; Amy LeClair⁶; Deborah Amburgey²; Erika Christenson²; Cheryl R. Clark⁷; Jennifer Haas⁵; karen freund⁴; Tracy A. Battaglia^1,2

¹Medicine, Boston University Medical Center, Boston, MA; ²Boston Medical Center, Boston, MA; ³University of Massachusetts System, Boston, MA; ⁴Tufts Medical Center, Boston, MA; ⁵Medicine, Massachusetts General Hospital, Boston, MA; ⁶Department of Medicine, Tufts Medical Center, Boston, MA; ⁷Brigham and Women's Hospital, Boston, MA. (Control ID #3875459)

BACKGROUND: Social needs can inhibit receipt of timely breast cancer treatment. Systematic social needs screening is a vital part of comprehensive cancer care delivery. However, little is known about the implementation of social needs screening for women with breast cancer. Translating Research Into Practice (TRIP) was a community engaged stepped wedge trial designed to improve receipt of timely breast cancer care among under-served patients through implementation of a city-wide, integrated patient navigation intervention. This project describes social needs screening implementation, including fidelity, acceptability, barriers and facilitators to screening from navigator and patient perspectives.

METHODS: TRIP was conducted at five cancer care sites in Boston, MA from 2018 to 2022. A social needs screening survey covered 8 domains (e.g., housing, food, transportation). Fidelity was defined as completion of a social needs screening within three months of diagnosis. Data sources for this mixed methods study included a patient registry completed by patient navigators and key informant interviews with navigators (n=8) and patients (n=21). Frequency distributions quantified screening fidelity. Rapid qualitative analysis techniques were used.

RESULTS: 602 women newly diagnosed with breast cancer were included. Mean age was 59 (std dev 13), 51% were Black, 27% were Latino, 49% spoke a primary language other than English and 47% had Medicaid insurance. Fidelity to completion of the initial social needs screening was 69%. No screening differences by patient factors were found. Qualitative analyses found high screening acceptability from navigators and patients. Navigators cited strong beliefs in the goals of screening and found the screening tools and training process useful. Barriers to screening acceptability included lack of comfort screening patients across many cultures, uncertainty that patients were comfortable being screened and not feeling part of the cancer care team. Facilitators included practice over time and that the protocol allowed for screening to occur conversationally. Patients reported a higher degree of acceptability being screened for some social needs (e.g., food, transportation) than others (e.g., financial). Barriers to screening included perceived stigma and lack of language concordance with the navigator. Facilitators included feeling comfortable with the navigator.

CONCLUSIONS: With appropriate staffing, protocols and training, systematic social needs screening can be implemented with high fidelity and acceptability by navigators and patients with breast cancer. Continued efforts to integrate social needs screening as a core element of breast cancer care navigation are needed.

MEDICATION CONTINUATION FOR URINARY INCONTINENCE: BARRIERS AND PRIMARY CARE PRACTICE BURDENS

Emily Schmitt¹; Aaron Winn⁴; Kathryn E. Flynn⁵; Emily R. Davidson⁶; R. Corey O'Connor²; Nicole Fergestrom³; Joanna Balza⁵; Joan Neuner^3,1

¹Medicine, Medical College of Wisconsin Department of Medicine, Milwaukee, WI; ²Urology, Medical College of Wisconsin, Milwaukee, WI; ³Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI; ⁴Pharmacy, Medical College of Wisconsin, Milwaukee, WI; ⁵Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI; ⁶Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3876672)

BACKGROUND: Antimuscarinic and beta-3 agonist medications are effective, guideline-recommended treatments for urge and mixed urinary incontinence (UI) in women, particularly when used with behavioral therapy. Prior studies have shown these medications have high discontinuation rates attributed in part to high costs and side effects, but little is known about the relative importance of these in primary care populations, or the burden of navigating these or other barriers on primary care practices.

METHODS: We identified all office visits with primary care physicians (internal medicine, medicine- pediatrics, or family medicine) in the electronic health record of a Midwestern academic and community health system from 2017-2018. From this, we identified all female patients aged 18-89 prescribed an FDA- approved antimuscarinic or B-3 agonist for UI and had not had a prescription for the prior 12 months. A trained research assistant and clinician examined a random sample of charts for patients started on these medications. They examined clinical notes (patient portal messages, telephone and office visits) during a 15- month window for evidence of barriers to continued use of pharmacologic UI treatment, defined as requests for prior authorizations or reports that the patient had concerns about at least one medication’s cost, side effects, or lack of effectiveness. The association of patient demographics and comorbidity with reported barriers of any type was examined with a logistic regression model. We also calculated the percent of the cohort that had no evidence of any UI medication at 15 months (defined as 90 days without an active prescription).

RESULTS: Of the 266 patients who met the inclusion criteria for the study, 19.9% were under age 50, 15.4% were Black, 28.2% were on short-acting antimuscarinics, 31.2% on long-acting antimuscarinics, and 6.0% on a B3-agonist. Overall 46.2% of patients (n=123) had one or more UI medication continuation barriers recorded, of which 52 were reported outside of an office visit. 26.3% of charts reported patient concerns about side effects, 20.7% about efficacy, 16.5% about costs, and 4.1% about prior authorization (patients could have multiple concerns). Only a higher number of comorbidities was associated with fewer reported barriers (p= 0.014). By 15 months 60.9% of patients had discontinued all UI medications, of whom over half (n=91) had at least one continuation barrier noted in the chart.

CONCLUSIONS: Potential barriers to continued use of UI medications were frequently reported in primary care practices, frequently outside of office visits, and reports were higher with initial short-acting medications. Given post-COVID increased demand for asynchronous, frequently uncompensated care, efforts are needed to support initial use of medications with the best risk, benefit and cost profiles, use in combination with behavioral approaches, and to support physicians when medication changes are needed.

PARENTING IN FELLOWSHIP TRAINING

Ashley N. Youngs, Paige Langhals-Totino, Molly A. Fisher, Erica Riddick.

Internal Medicine, Allegheny General Hospital - Western Pennsylvania Hospital Medical Education Consortium, Pittsburgh, PA. (Control ID #3876655)

BACKGROUND: It is well known how rigorous of a process it is to become a physician. From the onset of undergraduate education to medical school and lastly graduate medical education (GME), doctors spend well over a decade of their lives training. Due to this, many trainees choose to delay their childbearing due to fear of increased risk of adverse pregnancy outcomes, negative impact on career, or prolonging training. These fears are accompanied by lack of guidance and understanding of the implications and accommodations for pregnancy, childbirth, and parenting.

METHODS: To better understand the perspectives of fellowship directors, we created a survey assessing demographics of fellows, knowledge of parental leave policies, experiences with these policies, and perceptions of family planning in training. We sent the survey to 49 program directors across multiple fellowship specialties at three large institutions in the Mid-Atlantic and Mid-West regions.

RESULTS: Out of the 49 surveys sent, there were 19 responses, which was a 39% response rate. Within the current fellowship classes, 123 fellows identified as male and 86 identified as female. For those who identified as male, 21 welcomed a child into their family during fellowship. 11 out of the 21 (58%) did not take any parental leave, while 3 out of the 21 (14%) took 4-6 weeks. Of those who identified as female, 10 welcomed a child into their family during fellowship. 3 out of the 10 did not take time off for maternity leave (30%) and 1 out of the 10 (10%) took more than 6 weeks off for maternity leave. All 19 programs that responded indicated they have a formal leave of absence policy, with the majority being institutional based versus program specific. Program directors varied with the degree of knowledge they had regarding specific details of these parental leave policies and the majority indicated they had very little knowledge of the policy overall. 94% of program directors, in all fields, were either not at all likely or not very likely to recommend disclosing pregnancy plans and leave of absence policies during fellowship interviews.

CONCLUSIONS: Fellowship training is part of peak childbearing age, especially for fellows the trainees who identify as female Fellowship training overlaps with women's peak childbearing age. Women make up almost half of fellows. We demonstrate how trainees who have a child during fellowship, regardless of identified gender, decide not to take reasonable time for parental leave. While we are not surprised to see these results, our survey responses highlighted an area for continued research and meaningful improvement. Further efforts are needed to understand how fellows who have childbearing plans can be supported without jeopardizing their training and career goals.

POPULATION-BASED OUTREACH APPROACHES FOR BREAST CANCER SCREENING AMONG VETERANS

Stefanie Deeds^1,2; Leah M. Marcotte^1,2; Kristen E. Gray¹; Linnaea C. Schuttner¹; Carolyn E. Finch¹; Chelle Wheat¹; Eric Gunnink¹; Leslie Taylor¹; Alaina M. Mori¹; Karin Nelson^1,2; Ashok Reddy^1,2

¹US Department of Veterans Affairs, Seattle, WA; ²Medicine, University of Washington, Seattle, WA. (Control ID #3872532)

BACKGROUND: Breast cancer screening (BCS) rates among Veterans remain sub-optimal. One key challenge for Veterans is that many rely on referrals to community providers for BCS, and receipt of this referral typically requires a visit with their primary care provider. Population health strategies that directly engage Veterans outside of an individual clinic visit may be effective in improving BCS. We sought to test two population health strategies: a) Automatic mammography referral placed by the clinic b) Automated phone call sent to the Veteran to elect mammography. The first strategy allows Veterans to ‘opt-out’ of BCS when contacted to schedule the referral. The second allows the Veteran to ‘opt-in’ to request a referral. We sought to evaluate whether an opt-out versus an opt-in population-based BCS outreach program improved Veteran uptake of BCS.

METHODS: We conducted a pragmatic randomized controlled trial to evaluate the effectiveness of an opt- out vs. opt-in outreach strategy for BCS. Study participants included Veterans from a single VA Medical Center who were assigned to a primary care provider and due for BCS. Participants were assigned using 1:1 randomization either to receive: 1) an automatic mammogram referral (opt-out) or 2) an automated phone call where they could elect a mammogram referral (opt-in). Nursing staff placed all referrals and used chart review and clinical judgement to determine if care was not clinically indicated (e.g., documentation that a Veteran had recently declined or was up to date with BCS). All patients with a referral received scheduling calls from administrative staff to coordinate scheduling a mammogram at a contracted outside facility. We assessed outcomes at 100 days post-outreach in an intention-to-treat analysis, with a primary outcome of completed mammogram and secondary outcome of completed or scheduled mammogram.

RESULTS: We identified 833 women Veterans due for BCS, with an average age of 58 years and 67% non- Hispanic White race/ethnicity; 442 were randomized to the opt-in group and 441 to the opt-out group. More BCS referrals were ordered for the opt-out vs. opt-in group (65% vs 32%). There was no significant difference in primary outcome of completed BCS at 100 days between the opt-out and opt-in groups (21% vs. 18%, p=0.3) or secondary outcome of completed or scheduled BCS (27% vs 23% , p=0.08). A higher number of referrals were canceled in the opt-out group as compared to the opt-in group (34% vs 11%; p<0.001).

CONCLUSIONS: An opt-out scheduling outreach intervention yielded comparable rates of completed BCS at 100 days as compared to an opt-in automated phone call. Additionally, a significantly higher number of referrals were canceled in the opt-out group. Canceled mammogram referrals result in increased workload for clinical and administrative staff. While population health strategies may be effective in improving BCS, more work is needed to identify the optimal strategy among Veterans.

POSTPARTUM CARE TRAINING FOR INTERNAL MEDICINE RESIDENTS: A TARGETED NEEDS ASSESSMENT

Jessica Zimo¹; Aashish Didwania²; Brigid M. Dolan³

¹Medicine, Northwestern University Department of Medicine, Chicago, IL; ²Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ³Medicine and Medical Education, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #3877108)

BACKGROUND: Despite calls for increasing women’s health curricular content in medical schools and internal medicine (IM) residencies, gaps persist in knowledge and adherence to best practices in women’s health. IM residents report inadequate training and low levels of comfort managing women’s health topics, and clinicians in practice do not consistently counsel patients with adverse pregnancy outcomes on future cardiovascular risk. To support the creation of an IM resident curriculum in managing postpartum concerns that arise during primary care, we performed a targeted needs assessment to determine resident attitudes and knowledge.

METHODS: We developed and delivered an online survey to evaluate resident attitudes toward and clinical knowledge of postpartum care in the primary care setting. Vignette-based multiple-choice questions assessed knowledge in five domains: 1) expected postpartum course, 2) adverse pregnancy outcomes, 3) lactation, 4) mood disorders, and 5) family planning. Attitudinal objectives were assessed with Likert scales. General Internal Medicine faculty served as a comparison cohort. We calculated mean scores and knowledge assessment reliability indicators using Excel software.

RESULTS: Forty-four participants completed the survey, including 3 faculty and 41 residents from all years of training. The mean resident knowledge assessment score was 39.8% (6.76/17 correct, range 1-13, SD 2.39). Scores improved modestly with participation in the Women’s Health Track (mean 8.57, SD 2.38) but were similar across years of training. Compared with residents, faculty rated higher importance of training and competence in postpartum care (4.33 vs 3.49 on a 5-point Likert scale) but had similar knowledge assessment scores (mean 39.2%, 6.67/17 correct, range 2-12, SD 4.11). A limitation of the knowledge assessment included its brief nature which contributed to a low KR-20 of 0.08.

CONCLUSIONS: IM residents and faculty alike performed poorly on this knowledge assessment, though all agreed with the importance of providing care to patients in the postpartum period. While the faculty cohort was included to lend validity evidence to the instrument, data instead demonstrate an unmet need for postpartum care curricula for both graduate and continuing medical education in IM.

PRACTICE MAKES PERFECT: SPACED REPETITION OSCES INVOLVING TRANSGENDER PATIENTS ACROSS THE UME-GME CONTINUUM IMPROVES PERFORMANCE

Christine P. Beltran¹; Jeffrey A. Wilhite¹; Rachael Hayes¹; Caleb LoSchiavo²; Kelly Crotty³; Jennifer Adams⁴; Kevin Hauck³; Ruth Crowe³; David Kudlowitz¹; Karin Katz⁵; Sondra R. Zabar¹; Richard E. Greene⁶

¹Medicine, New York University Grossman School of Medicine, New York, NY; ²Rutgers School of Public Health, Piscataway, NJ; ³Medicine, NYU Langone Health, New York, NY; ⁴Internal Medicine, NYU Langone Health, New York, NY; ⁵Endocrinology, NYU Grossman School of Medicine, New York, NY; ⁶Medicine, NYU Grossman School of Medicine, New York, NY. (Control ID #3876705)

BACKGROUND: Residents report limited confidence in addressing the needs of transgender patients, suggesting the need for more exposure and practice throughout training. In 2022, Internal Medicine residents at an urban medical center in the mid-Atlantic region participated in an OSCE station where they assumed care for a standardized patient (SP) who identified as transgender and sought care for abdominal pain. The cohort of residents was made up of two groups: 1) learners who had trained at the same medical school (“continuum learners”) and had previous participation in an OSCE featuring a transgender SP (with different

clinical content and requiring less advanced skills) with feedback, and 2) residents who attended different medical schools (“GME learners “) and whose prior exposure to transgender patients or SPs were unknown. Continuum learners participated in a similar OSCE case during the first year of medical school prior to clerkship training and attended a lecture on transgender health that involved a conversation with a transgender community member and a session on inclusive sexual history taking.

METHODS: The case was part of an annual, formative OSCE featuring multiple cases. Residents had 10 minutes to evaluate the abdominal pain and the need for additional testing, complete a sexual history, and ask about the SP’s pronouns and organs. The SP was an individual who identified as transgender and was trained to be a SP.

One of three SPs rated each resident on the following domains: information gathering (5 items), relationship development (5 items), patient education (3 items), time management (2 items), and LGBTQ health (6 items). Items were rated on a behaviorally anchored “not”, “partially” or “well done” (WD) scale and summary

scores (mean % WD) were calculated for each domain. SPs also gave each resident a global recommendation and professional rating using 4-point scales.

RESULTS: 101 residents participated in the case. Continuum learners (N=24), compared to GME learners (N=77), more frequently received a recommend or highly recommend global rating from the SP (88% vs. 70 % WD, p <.05) and were all rated mostly professional or completely professional (100% vs. 94% WD, p <.05) Continuum learner scores were better in the LGBTQ health domain (67% vs. 52% WD, p=NS ), specifically in probing about medically relevant information about SP’s transition (71% vs. 44% WD, p=.02). Additionally, continuum learners more frequently clarified SP’s pronouns (88% vs. 66% WD) and made the SP feel welcomed and affirmed as a trans-identified patient (71% vs. 58 % WD), although differences were not statistically significant.

CONCLUSIONS: These results suggest that more practice and feedback was valuable for skill acquisition in caring for transgender patients, giving continuum learners a learning advantage compared to GME learners.

To our knowledge, this is the first data to suggest that early exposure to transgender OSCEs improves physician skills for interactions with transgender patients.

PRIMARY CARE AFTER PREGNANCY: PATIENTS’ HEALTH CONCERNS, ANTICIPATED BARRIERS, AND CARE DELIVERY PREFERENCES

Mara E. Murray Horwitz¹; Sarah G. Bredy⁵; Jeffrey A. Schemm³; Tracy A. Battaglia¹; Christina Yarrington⁴; Lois McCloskey²

¹Medicine, Boston University, Cambridge, MA; ²Boston University School of Public Health, Boston, MA; ³Boston University School of Medicine, Boston, MA; ⁴OB/Gyn, Boston Medical Center, Boston, MA; ⁵Boston Medical Center, Boston, MA. (Control ID #3877059)

BACKGROUND: Preventive care after complicated pregnancies is important to reduce chronic disease risks. Despite recommendations for ongoing care after complicated pregnancies, most individuals do not see a primary care clinician in the first postpartum year, missing a critical window to optimize long-term health. Patient perspectives on primary care after pregnancy are not well described. Therefore, we conducted a survey of postpartum individuals at our urban safety-net hospital, to better understand their health concerns, anticipated barriers to care, and preferences for health care delivery in the year after pregnancy.

METHODS: After receiving IRB approval, we collected data via an anonymous 23-item trilingual survey in REDCap. Inclusion criteria were delivery at our institution within the past 1-4 months, age ≥18 years, and ability to read or speak English, Spanish, or Haitian Creole. Eligible participants were identified and contacted through the electronic medical record (EMR), then met at Obstetrics or Pediatrics appointments. Individuals who missed appointments received additional EMR and telephone outreach. To obtain a representative sample, we use purposive sampling and focused on virtual and Pediatrics-based recruitment in the latter half of the study period. We conducted descriptive statistics with subgroup analyses by pregnancy complication history (any/none).

RESULTS: From April to July 2022 we contacted 256 eligible individuals, of whom 120 (47%) completed the survey (72/92 = 78% recruited in Obstetrics, versus 48/164 = 30% recruited otherwise). A majority self- identified as Black (63%) or Latina (26%). 18% completed the survey in Haitian Creole and 10% in Spanish. Over half reported having ≥1 pregnancy complication associated with future chronic disease risk. 50% desired a primary care visit within 3 months postpartum and 90% within 1 year, yet most were unable to recall a recommendation for postpartum primary care from their pregnancy care team, regardless of pregnancy complication history. Respondents described a variety of health concerns, all amenable to primary care. The most commonly cited barriers to care were financial and logistical barriers (e.g., transportation, childcare). Preference for virtual care increased from 9% to 34% if self-monitoring tools were hypothetically available, indicating that virtual visits could improve primary care access.

CONCLUSIONS: Despite widespread interest in primary care after pregnancy, most postpartum individuals are unaware of follow-up recommendations. In addition, logistical and financial barriers to care are common.

Given the importance of postpartum and inter-pregnancy care for future health, our findings indicate that postpartum patients – especially those with recent complications – may benefit from increased transition counseling and support for linkage to primary care after pregnancy. For some postpartum patients, virtual visits with self-monitoring tools may be an acceptable means to improve primary care access.

REDUCING RACIAL DISPARITIES IN PREP USING AN INNOVATIVE CARE MODEL IN A SAFETY NET HEALTH SYSTEM IN ATLANTA, GEORGIA

Meredith Lora^1,9; Kate Ferencsik⁵; Ziduo Zheng³; Isabella Batina⁸; Elizabeth J. Chang¹; Robert T. Krafty⁸; Amalia Aldredge^2,9; Dylan Baker^1,9; Kelly Reyna⁴; Ana Duarte⁶; Grant H. Roth⁷; Jessica Sales⁸; Anandi Sheth²; Larisa V. Niles-Carnes⁹; Bradley Smith⁹; Terri Cowan⁹; Valeria Cantos²

¹Internal Medicine, Emory University, Atlanta, GA; ²Infectious diseases, Emory University, Atlanta, GA; ³Biostatistics, Emory University, Atlanta, GA; ⁴Genentech Inc, South San Francisco, CA; ⁵Augusta University, Augusta, GA; ⁶Centers for Disease Control and Prevention, Atlanta, GA; ⁷New York Blood Center, New York, NY; ⁸Emory University School of Public Health, Atlanta, GA; ⁹Grady Health System, Atlanta, GA. (Control ID #3876212)

BACKGROUND: HIV disproportionally impacts people of color. The impact of pre-exposure prophylaxis (PrEP), an effective HIV prevention method, is hindered by racial inequities. The Grady PrEP program, designed as a highly accessible model, was launched in 2018 in a large safety net health system in Atlanta. The program created an electronic medical record (EMR)-integrated population health registry to track patients and trigger outreach at each step of the PrEP continuum. Accessibility features included no-cost medication delivery, unscheduled phone- or portal-based follow up, and walk-in lab testing. This study evaluated the program’s PrEP-related outcomes during its first three years of implementation as well as patients’ satisfaction with the program.

METHODS: We abstracted EMR data from patients referred to the Grady PrEP program from 6/1/2018 to 3/1/2021. Outcome variables included PrEP linkage and 6- and 12-month PrEP care retention. We also conducted 44 exit interviews to assess patients’ overall satisfaction with the program. We conducted descriptive statistics and a multivariate regression model to identify factors associated with PrEP linkage and retention. Exit interviews were analyzed using descriptive statistics and thematic analysis.

RESULTS: Of all 401 patients referred, 61.5% were uninsured. 77.6% were Black, 39.7% were sexual minority men (SMM), 23.6% cis-women, and 13.4% transgender women. 72% (289/401) of participants were linked to care, and 88.6% of them received a prescription. Median time from referral to linkage was 5 days (IQR: 1-13), and 1 day (IQR 0-3) from linkage to prescription. Median time on PrEP was 332 days (IQR 108-520). Six- and 12-month retention were 81.3% (183/225) and 44.6% (86/193), respectively. Among SMM who started PrEP, 87% (105/125) and 65% (52/88) remained in care at 6 and 12 months, respectively.

Black race [OR 0.3, CI (0.1-0.8)] and heterosexual women [OR 0.4, CI (0.2-0.7)], were associated with decreased odds of linkage in multivariate analysis. No racial differences were observed for 6- or 12-month retention. . Heterosexual women and men, and transgender women (TGW) had lower odds of PrEP retention at 12 months compared to SMM. Over 90% of patients reported being “very satisfied” with their care. Themes that contributed to patients’ satisfaction included “easy to receive care,” accessibility, proactive communication, and a non-stigmatizing approach.

CONCLUSIONS: The Grady PrEP program serves a largely uninsured, racially diverse population in Atlanta. The program delivers care using an EMR-integrated registry rather than a brick-and-mortar clinic. During its first three years of implementation, PrEP uptake and retention rates were higher than previously reported in similar settings, and Black race was not associated with lower retention at 6- or 12-months.

Patient satisfaction was high, based on ease of access and frequent communication. Future studies addressing how program-related factors impact these outcomes are needed.

SEXUAL HARASSMENT PREVENTION MESSAGING AT VA HEALTHCARE FACILITIES: A QUALITATIVE ANALYSIS OF EXPERT RECOMMENDATIONS

Karissa Fenwick¹; Karen E. Dyer¹; Kristina Oishi¹; Elizabeth M. Yano^1,2; Ruth Klap¹; Alison Hamilton^1,3

¹Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA; ³Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA. (Control ID #3874362)

BACKGROUND: A 2015 survey found that one in four women Veterans reported experiencing sexual harassment by men Veterans at Veterans Affairs (VA) healthcare facilities. Since then, VA has launched several harassment prevention messaging campaigns via posters, leadership statements, and online platforms. However, culture change requires sustained efforts, and ongoing interventions are needed to create an environment of care that is welcoming toward women. This study’s objective was to identify expert recommendations for sexual harassment prevention messages to guide future campaigns.

METHODS: Using snowball sampling, we recruited experts in sexual harassment prevention and intervention from military, academic, non-profit, VA, and other healthcare settings. Experts included researchers, clinicians, administrators, and program developers. We conducted 40 telephone interviews using a semi-structured guide and analyzed interview data using the constant comparative method.

RESULTS: We identified four themes related to prevention messaging to address patient-perpetrated sexual harassment of women Veterans at VA.

Theme one involved message frame valence. Some participants suggested that negative message frames (e.g., that VA does not tolerate harassment) may deter harassment and support staff in addressing it. However, others stated that positive frames (e.g., that VA is welcoming and inclusive) may be less likely to provoke resistance or backlash.

Theme two related to correcting misperceptions about harassment. Participants stated that underscoring the adverse impact of harassment on women Veterans may reduce perceptions that harassment is harmless. Further, highlighting discrepancies between perceived norms (e.g., that most men Veterans condone harassment) and actual norms (e.g., that most men Veterans oppose harassment) may improve social norms around harassment.

Theme three involved leveraging the strengths of the Veteran population. Participants recommended emphasizing the shared military bonds between men and women Veterans and linking harassment prevention messages to military values (e.g., leadership, honor) to increase message resonance.

Theme four related to effectiveness of harassment prevention messaging. Some participants stated that messaging is a simple and effective way to influence the VA community, but others expressed that messaging alone is insufficient for changing culture.

CONCLUSIONS: Results provide guidance for designing harassment prevention messages, including focusing on desired (vs. undesired) behaviors, targeting social norms, and tailoring to the organizational context. More work is needed to assess patient and staff reactions to different messaging approaches prior to campaign implementation. Prospective campaigns should include evaluations of messaging impact.

THE EFFECTS OF POSTPARTUM LIFESTYLE INTERVENTIONS ON BLOOD PRESSURE: A SYSTEMATIC LITERATURE REVIEW

Mara E. Murray Horwitz¹; Sarah G. Bredy²; Alaina Tabani³

¹Medicine, Boston University, Cambridge, MA; ²Boston Medical Center, Boston, MA; ³Boston University School of Public Health, Boston, MA. (Control ID #3875137)

BACKGROUND: One in 3 parous individuals has a pregnancy complication that indicates an increased risk for future hypertension, diabetes, or heart disease. Persons of color are disproportionately affected by hypertension, both during after after pregnancy. Lifestyle modification is recommended to reduce chronic disease risk after complicated pregnancies. However, little is known about the effects of lifestyle interventions on blood pressure in postpartum individuals. Thus, our objective was to evaluate the evidence for postpartum lifestyle interventions to reduce blood pressure. We hypothesized that postpartum lifestyle interventions are associated with a reduction in blood pressure.

METHODS: We conducted a systematic literature review of 6 databases (Google, Google Scholar, Embase, Clinical Trials.gov, Cochrane Central, and PubMed) for relevant articles published through November 30, 2022. We considered any randomized controlled trial or quasi-experimental, cohort, or case-control study that evaluated a postpartum lifestyle intervention with blood pressure as an outcome. We excluded non-English publications and articles published before 2010. Two researchers independently identified eligible publications via title and abstract screening followed by full-text review, then extracted relevant data; a third researcher resolved any discrepancies. Due to the heterogeneity of the included studies, we were not able to conduct statistical testing.

RESULTS: Of 2,725 unique publications screened by title and abstract, 35 underwent full-text review, of which 9 met the inclusion criteria. Seven of the included studies were randomized controlled trials. Most had relatively small sample sizes (<100). In all but 1 of the studies that reported race, nearly all participants (82%-100%) identified as White. Eight of the studies required participants to have a history of a pregnancy complication, most often preeclampsia. Interventions usually included diet and exercise counseling; 2 involved supervised exercise. Mean blood pressure declined from baseline to follow-up in all of the studies, however in none was there a statistically significant difference in blood pressure change between the intervention and control groups. Supervised exercise interventions appeared most promising in terms of blood pressure effects. Meanwhile, nearly all of the included studies reported statistically significant intervention effects on other cardiometabolic health outcomes, such as physical activity.

CONCLUSIONS: We found no statistically significant effects of postpartum lifestyle interventions on blood pressure. However, the evidence is limited to a handful of published studies characterized by small sample sizes and an overall lack of racial diversity. A focus on more intermediate outcomes (e.g., physical activity) may make the benefits of postpartum lifestyle interventions more apparent. Additional research with more diverse populations and supervised exercise interventions is warranted.

THE LESSENING INCONTINENCE WITH LOW-IMPACT ACTIVITY (LILA) TRIAL: A MULTISITE RANDOMIZED TRIAL OF A PELVIC YOGA VERSUS PHYSICAL CONDITIONING PROGRAM IN MIDLIFE AND OLDER WOMEN WITH URINARY INCONTINENCE

Alison Huang¹; Margaret A. Chesney¹; Michael Schembri¹; Eric Vittinghoff¹; Sarah Pawlowsky¹; Leslee Subak²

¹University of California San Francisco, San Francisco, CA; ²Stanford University, Stanford, CA. (Control ID #3874596)

BACKGROUND: Over a third of midlife and older women experience urinary incontinence (UI), a condition leading to depression, social isolation, physical inactivity, and institutionalization. Due to the limitations of existing clinical treatments for UI, many women are interested in alternate treatment strategies that are not only effective but also better tolerated and more accessible. Pelvic yoga has been recommended as a complementary treatment strategy for UI, but little is known about its efficacy or safety in women across the aging spectrum.

METHODS: The LILA trial is a multisite randomized trial of a group-based yoga program to improve pelvic floor strength, peripheral autonomic function, and overall physical function as factors influencing bladder control in women. Ambulatory women aged 45 or older with at least daily UI were recruited from multiple communities in northern California in 2019-2022 and randomly assigned to a therapeutic yoga program of twice weekly group instruction and once weekly individual practice of study-specific Hatha yoga techniques for 3 months, vs. a non-specific physical conditioning program involving equivalent-time instruction and practice of general muscle stretching/strengthening exercises. Changes in any and type-specific UI were assessed by validated voiding diaries abstracted by blinded analysts. Linear mixed models examined change in frequency of any and type-specific UI over 3 months, controlling for study site and intervention class. RESULTS: Of the 240 women randomized (121 yoga, 119 physical conditioning), mean age was 62.0 ±8.7 years (range 45 to 90 years), and 40% self-identified as ethnic minorities (14% Latina, 6% Black, 16% Asian, 4% multiracial). At baseline, participants had an average of 3.4 ±2.2 UI episodes/day, including 1.9 ±1.9 urgency- and 1.4 ±1.7 stress-type episodes/day. Over 3 months, total UI frequency decreased an average of 75% from baseline (2.4 [95% CI 2.0–2.7] episodes/day) in the yoga vs. 58% (1.8 [1.5–2.2] episodes/day) in the physical conditioning group (P=.04). Urgency UI frequency decreased by 80% in the yoga and 54% in the physical conditioning group (P=.02), but changes in stress UI frequency did not differ significantly by group (70% in yoga and 65% in physical conditioning, P=.60). Over 3 months, 13% of yoga and 15% of physical conditioning participants reported mild musculoskeletal adverse events.

CONCLUSIONS: Among ambulatory midlife and older women with at least daily urinary incontinence, a group-based pelvic yoga intervention was associated with a 75% decrease in UI frequency over 3 months.

Findings support the efficacy and safety of yoga as a community-based, complementary behavioral management strategy for UI in women across the aging spectrum.

THE RELATIONSHIP BETWEEN RELIGION AND HOT FLASHES IN US WOMEN

Annika Agarwal, Holly N. Thomas

Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #3836663)

BACKGROUND: In prior studies, religious affiliation is correlated with positive aging experiences and decreased negative health outcomes. Yet, the relationship between religious affiliation and experience of menopause symptoms in the United States is not well-defined. In this study, we evaluated the relationship between religious affiliation/religiosity and hot flashes among midlife and older women.

METHODS: We used data from the Survey of Midlife in the United States Study 3 (2013-2017), a national survey of Americans aged 39 to 93. Participants competed self-administered questionnaires on demographics, health, symptoms, and religion. For this analysis, we only included women (N=1500). The primary predictors were religious affiliation: (1) Baptist, (2) Lutheran, (3) Methodist, (4) Pentecostal/Evangelical, (5) Other Protestant groups, (6) Catholic, (7) Jewish, (8) Oher non-Jewish and non-Christian groups, (9) Unaffiliated, (10) Spiritual. Religiosity was measured by asking participants how religious they were (very, somewhat, not very, not at all). The primary outcome was experience of hot flashes in the past month, yes or no. We assessed age, race, income, alcohol use, smoking status, and parity as covariates. We constructed univariable and multivariable logistic regression models to examine the relationship between the primary predictors and primary outcome while controlling for potential confounders.

RESULTS: The mean age was 64 years. The majority of women were white (90%). Four percent of women were pre- or perimenopausal, 54% postmenopausal, and 41% had a prior hysterectomy and/or bilateral oopherectomy. Twelve percent of women had hot flashes almost every day, 9% several times a week, 4% once a week, 11% several times a month, 11% once a month, and 53% did not have hot flashes in the past month. When compared to Catholics, Baptists were more likely to have hot flashes (OR 1.53, 95% CI 1.06 – 2.19, P=0.022). Fifty-four percent of Baptist women reported hot flashes, compared to 43% of Catholic women. These findings remained when controlling for age, race, and income. However, when accounting for smoking, these findings did not remain significant. Baptist women were more likely to smoke compared to Catholic women (OR -1.34, 95% CI -2.00 - -0.68, P<0.001), and current smokers were more likely to have hot flashes (OR 1.65, 95% CI 1.14 – 2.34 P= 0.007). Religiosity was not significantly related to the experience of hot flashes (p= 0.922).

CONCLUSIONS: Religious affiliation is significantly related to women’s experience of menopause symptoms, but other sociocultural factors and risk behaviors must be considered as confounders. These findings demonstrate the importance of sociocultural factors on aging experiences.

TRENDS IN ELECTIVE MEDICAL AND SURGICAL ABORTIONS IN THE UNITED STATES DURING THE COVID-19 PANDEMIC

Catherine S. Hwang, Aaron S. Kesselheim, Ameet Sarpatwari, Krista Huybrechts, Benjamin N. Rome

Pharmacoepidemiology, Brigham and Women's Hospital, Boston, MA. (Control ID #3874528)

BACKGROUND: Prior to the COVID-19 pandemic, the Food and Drug Administration (FDA) required mifepristone, a medication used for medical abortions, to be dispensed in-person by qualified prescribers. In July 2020, a federal court temporarily blocked the in-person dispensing requirement. In December 2021, the FDA announced that this change would be permanent, allowing telehealth prescribing and dispensing by certified pharmacies. The impact of these changes on the incidence of medical abortions is unknown. METHODS: Using a national commercial claims database, we estimated the monthly incidence of medical abortions among women aged 18-44 years, from January 2019 to March 2022. A medical abortion was defined by a medical or prescription claim for mifepristone or misoprostol, plus a diagnostic code indicating an elective termination of pregnancy. We determined whether each abortion was associated with claims for a telehealth encounter (any visit type) or an in-person encounter (office visit, prenatal ultrasound, or urine or serum human chorionic gonadotropin test) in the 3 days prior to and including the date of the dispensed medication. For comparison, we estimated the monthly incidence of elective surgical abortions using procedure codes.

RESULTS: Among 11.3 million reproductive-aged women during the study period, the monthly incidence of elective medical abortions was relatively stable, with a mean of 43 and 45 medical abortions per million women before and after March 2020. No medical abortions were administered by telehealth before 2020. Since the COVID-19 pandemic began in March 2020, fewer than 2% of medical abortions were administered by telehealth. In contrast, the monthly incidence of elective surgical abortions decreased by 29% during the pandemic, from a mean of 35 to 25 per million women before and after March 2020. This decline was sustained through March 2022.

CONCLUSIONS: During the COVID-19 pandemic, there was a substantial decline in the incidence of elective surgical abortions and similar rates of elective medical abortions. Despite the removal of the in- person dispensing requirement of mifepristone, nearly all medical abortions continued to be administered in- person. Additional regulation, evidence, and education may be needed before prescribers and patients feel comfortable with medical abortions via telehealth.

VA PATIENT AND STAFF PERSPECTIVES ON SELF-COLLECTED TESTING FOR HUMAN PAPILLOMAVIRUS (HPV)

Elisheva Danan^1,2; Erin Amundson¹; Alexandra Gowdy-Jaehnig¹; Jessica K. Friedman¹; Rebekah Pratt²; Erin E. Krebs^1,2; Michele Spoont¹; Princess E. Ackland¹

¹Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN; ²University of Minnesota Medical School Twin Cities, Minneapolis, MN. (Control ID #3877235)

BACKGROUND: Self-collected testing for Human Papillomavirus (HPV) is poised to disrupt US cervical cancer screening practices. The Veterans Health Administration (VA) is a national integrated healthcare system that provides services to nearly half a million women. We elicited Veteran and VA employee perspectives on offering self-collected HPV testing as a cervical cancer screening strategy in VA.

METHODS: We conducted 30-minute, semi-structured qualitative telephone interviews with (a) female Veteran patients, age 21+, at the Minneapolis VA and (b) VA employees with local, regional, and national women’s health roles (nurses, clinicians, and administrators). Veterans were recruited via posted flyers; VA employees were recruited via email. Separate interview guides were developed for patients and employees. Interview questions addressed selected domains from the Preventive Health Model and the Consolidated Framework for Implementation Research to assess knowledge and interest, potential advantages or disadvantages, and questions the participant would have about self-collected screening. Interviews were audio-recorded and transcribed, then analyzed using rapid qualitative analysis techniques, including structured templates and matrix displays.

RESULTS: Twenty-one Veterans and 27 VA employees were interviewed from May 2021 to May 2022.

Analysis of Veteran and staff interviews each resulted in 7 themes. Both Veterans and staff indicated a mix of enthusiastic and cautious interest, voiced questions about test accuracy and reliability, and explored logistical considerations. Several differences emerged between Veteran and staff perspectives.

Veterans had questions about self-efficacy for sample collection, including the elevated stakes related to cancer screening compared to other forms of self-testing. They suggested that self-collection would be a patient-centered option and identified empowerment and control as important benefits of self-collection for women with a history of sexual trauma.

Staff expressed concerns about the consequences of not performing pelvic exams for screening, including missed opportunities to address sexual health, and missed incidental vulvar lesions. They were concerned that clinicians would offer self-collection to patients who had a clinical indication for a pelvic exam. Staff compared the convenience of self-collected HPV testing to stool testing for colorectal cancer screening, and suggested home testing would particularly benefit rural Veterans. They thought that offering additional choices for screening modalities would improve clinician-patient interactions, trust, and patient satisfaction.

CONCLUSIONS: Veterans and VA employees identified many potential advantages of self-collected HPV testing, particularly for specific subpopulations such as Veterans with a history of sexual trauma and rural Veterans. Both Veterans and employees had questions about accuracy, trade-offs, and logistics. Implementation plans will need to address these questions and concerns.

VA WOMEN’S HEALTH TRAINING ADVANCES PRIMARY CARE PROVIDERS WOMEN’S HEALTH KNOWLEDGE AND CLINICAL SKILLS

Amy H. Farkas^1,2; Sarah B. Merriam^3,5; Melissa McNeil^4,5; Melissa A. Shaughnessy⁵; Christine J. Kolehmainen⁵

¹General Internal Medicine, Medical College of Wiscponsin, Milwaukee, WI; ²VA Milwaukee Healthcare System, Milwaukee, WI; ³Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh , PA; ⁴Medicine, University of Pittsburgh, Pittsburgh, PA; ⁵Office of Women's Health, Veterans Health Administration, Washington, DC. (Control ID #3874432)

BACKGROUND: The VA Women’s Health Mini-Residency (WH-MR) program is aimed at ensuring VA primary care providers (PCPs) have the clinical knowledge and skills needed to provide high quality gender- specific care to women Veterans. In 2022, the WH-MR was offered as a 4-day interactive virtual conference with didactic lectures and case-based discussions. Previously, the program has been demonstrated to improve PCP comfort with gender-specific care and to positively impact provider retention. This work aimed to assess the impact of the WH-MR on PCP clinical knowledge and practice.

METHODS: We offered 3 WH-MR programs in 2022. To assess changes in clinical knowledge, participants completed pre- and immediate post-assessments consisting of 20 case-based questions that corresponded to specific learning objectives for the WH-MR. To assess changes in clinical practice, the pre-survey included questions assessing PCP familiarity with 1) four common gender-specific clinical decision aides (e.g., ASCCP for cervical cancer screening, CDC medical eligibility criteria for contraception, FRAX score for osteoporosis, and breast cancer risk assessment models) and 2) key local WH leaders. A 3 month follow up survey was sent to WH-MR participants asking them to identify changes to clinical practice and to reassess their familiarity with the gender-specific clinical decision aides and with key local WH leaders.

RESULTS: Out of 422 PCPs trained, 310 (73%) participants completed the pre-survey, 267 (63%) completed the immediate-post survey, and 150 (35%) completed the 3 month follow up survey. For each survey, 45-49% of respondents were MD/DOs with the remaining identifying as Advanced Practice Providers. With regards to the clinical knowledge assessment, 18/20 questions demonstrated statistically

significant improvement from pre to post exam in correct answers on the case-based exam. The mean number of correct answers was 10.9 (SD 3.2) and 14.4 (SD 3.1) (pre vs post, respectively, p-value <0.001). With respect to the 3-month delayed post-assessment, the most frequently self-reported identified changes to clinical practice included 1) increase in cervical cancer screening, 2) more likely to treat vaginitis and cervicitis, and 3) more likely to manage menopausal symptoms. Participants also indicated increased familiarity with all 4 clinical decision aides (p-value <0.001 for all) and with key local WH leaders (p-value for all <0.001).

CONCLUSIONS: PCPs who complete the WH-MR show improvements in women’s health knowledge, report changes to clinical practice, and demonstrate increased familiarity with relevant clinical decision aides and with key local women’s health leadership. Future work should assess impact of the WH-MR participation on patient level outcomes.

Clinical Vignette - Acute Disease Management

3-YEAR POST TAVR RESTENOSIS, A RARE COMPLICATION

Ijeoma C. Orabueze^1,2; Olushola Ogunleye²; Mark Harrison²

¹Medicine, Debreceni Egyetem, Debrecen, Hajdú-Bihar, Hungary; ²Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #3858060)

CASE: This is a 70-year-old female with severe aortic stenosis who had a transfemoral transcatheter placement of a 23 mm sapien-3 valve in 2019. Preoperative transthoracic echo (TTE) revealed a severely calcified aortic valve with a mean gradient of 50.3 mmHg, peak velocity of 4.6 m/s and a valve area of 0.64 cm squared. On postoperative day 0, TTE revealed the bioprosthetic valve in the aortic position with a mean gradient of 8.8 mmHg, peak velocity of 2.1 m/s and valve area of 2.3 cm squared. The next day, a slight increase in aortic valve mean gradient to 18.6 mmHg was noted and she was started on rivaroxaban to prevent valve hemodynamic dysfunction. Rivaroxaban was stopped a year later and aspirin resumed, as her aortic valve mean gradients remained stable.

Three years post-TAVR, she developed sudden onset shortness of breath during ambulation, prompting her to visit her cardiologist who noted a loud new-onset murmur on examination. TTE revealed a mean pressure gradient of 71 mmHg and aortic peak velocity of 5.4 m/s and she was started on heparin drip with eventual transition to warfarin and clopidogrel. However, subsequent TTE findings worsened with increased aortic peak velocity of 6.1 m/s, aortic valve mean gradient of 99.8 mmHg, and aortic valve area of 0.37 cm squared. She underwent successful surgical aortic valve replacement (SAVR) and was placed on warfarin afterwards. Culture of the explanted TAVR valve grew Microbacterium paraoxydans, later determined to be a contaminant.

IMPACT/DISCUSSION: Since Transcatheter aortic valve replacement (TAVR) was approved in the United States in 2011, various complications have been associated with it. These include major stroke, moderate to severe residual aortic regurgitation, myocardial infarction, life-threatening bleed, major vascular complications and permanent pacemaker implantation. Long-term complications include TAVR rupture, endocarditis, paravalvular or central regurgitation, valve thrombosis, late bleeding and valve obstruction. Valve leaflet thrombosis was initially considered upon patient presentation. However, the patient failed to improve on heparin drip and warfarin, making this less likely. Next, pannus formation vs early valve degeneration were considered which were ruled out during surgical valve replacement. Also, in the absence of clinical evidence of endocarditis, it was determined that our patient most likely had severe early valve deterioration of unclear etiology despite appropriate anticoagulation.

CONCLUSION: As evidenced by the results of the CHOICE trial by Abdel-Wahab et al, the bioprosthetic valve should typically last over 5 years. We highlight this case to draw attention to early post-TAVR bioprosthetic valve dysfunction necessitating SAVR and add to the conversation on predisposing factors to this rare but potentially life-threatening event. We also draw attention to the need for clear antithrombotic therapy guidelines post-TAVR.

A BIOMARKER OF INFLAMMATION BEHAVING AS A TUMOR MARKER OF A RARE MALIGNANCY

Falah I. Abu Hassan²; Saima Hafiz²; Basheer Mohammed²; Md Rockyb Hasan²; Farah B. Aljuboory¹

¹Internal Medicine, BSA Health System of Amarillo LLC, Amarillo, TX; ²Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX. (Control ID #3854897)

CASE: A 59-year-old homeless male with a past medical history of asthma, tobacco abuse, and alcohol abuse presented to the emergency department with a 3-month history of an intermittent, progressive diffuse abdominal pain. Over the 2 weeks prior to admission, the abdominal pain worsened and was associated with abdominal distension and 2 days prior to admission, he had 2 episodes of vomiting. On arrival, his vital signs were within normal limits. The physical exam was within normal limits and did not reveal any obvious source of infection. Blood work showed microcytic anemia, marked leukocytosis, elevated creatinine, hypercalcemia, hyperlactatemia and was striking for an extremely elevated procalcitonin of 591 ng/ml. The patient was initially treated for sepsis considering this extremely elevated procalcitonin and leukocytosis, however, blood and urine cultures were negative. CT scan of the abdomen showed a large heterogeneously enhancing mass in the retroperitoneum displacing the right kidney and inferior vena cava and abutting the inferior margin of the liver. Thyroid ultrasound results were not clinically concerning. Several smaller soft tissue mass lesions were also seen in the upper mid abdomen. Biopsy of the mass was positive for chromogranin and synaptophysin and revealed a high level of Ki67 raising the suspicion of a neuroendocrine carcinoma (NET) of unknown origin. The patient requested hospice care due to the aggressive nature of the tumor and was discharged to hospice care.

IMPACT/DISCUSSION: There are several cases in the literature describing a high procalcitonin level in patients without infections in the settings of acetaminophen and amphetamine intoxication or even anaphylactic shock. Other case reports we found are related to the presence of various cancers including but not limited to hepatocellular carcinomas, sarcomas, and medullary thyroid carcinomas. To our knowledge, there are only few reported cases of NET associated with significantly high procalcitonin levels. It seems that elevated procalcitonin in NET tumors carries a poorer prognosis and were associated with higher tumor grades. The pathophysiology of procalcitonin production in these tumors is still obscure but it may involve a complex interaction resembling the pathophysiology of procalcitonin production in sepsis. We are reporting a rare case of a neuroendocrine tumor associated with a dramatic procalcitonin elevation.

CONCLUSION: Procalcitonin is used as a helpful addition to diagnose sepsis, however, clinicians should be aware of different causes of procalcitonin elevation especially when the levels are extremely elevated.

ABIOTROPHIA DEFECTIVA: A COMPLICATED CASE OF VERTEBRAL OSTEOMYELITIS AND PROSTHETIC VALVE ENDOCARDITIS

PALLABI SHRESTHA¹; Thi Nguyen¹; Aaron Bertolo¹; Sanjay Polisetty²; Madhan Shanmugasundaram²

¹Internal Medicine, The University of Arizona College of Medicine Tucson, Tucson, AZ; ²Cardiology, The University of Arizona College of Medicine Tucson, Tucson, AZ. (Control ID #3875263)

CASE: 67-year-old male with history of porcine aortic valve replacement secondary to bicuspid aortic valve stenosis presented with worsening back pain and intermittent fever for 2 months. Patient denied history of recreational drug use. Cardiac exam showed 4/6 systolic murmur at the apex, diastolic murmur at right 2nd costovertebral space. Blood cultures were obtained on day 1 of hospitalization. MRI of T-spine revealed septic arthritis of the right 10th costovertebral joint and osteomyelitis of the neck of the right 10th rib. On day 5 of admission, blood culture grew positive with Abiotrophia defectiva. Patient was treated with IV vancomycin with a trough goal of 15.

Transesophageal echocardiogram showed displaced bioprosthetic aortic valve with severe periprosthetic aortic insufficiency and concern for fistula from aortic root into the right ventricle. An abscess was noted on the posterior leaflet of the mitral valve, resulting in posteriorly directed severe mitral regurgitation. Patient underwent redo sternotomy with redo aortic valve replacement (aortic homograft) and bioprosthetic mitral valve replacement. Patient had uneventful post operative course and was eventually discharged on post op day 5 with IV Vancomycin for a total duration of 6 weeks. Patient continued to do well on 2-week follow up after discharge.

IMPACT/DISCUSSION: Abiotrophia defectiva is a rare fastidious gram-positive cocci found as oral or gastrointestinal commensal. Identification is challenging due to their pleomorphic nature, difficult growth in regular media and extended incubation period. It is a rare cause of infective endocarditis accounting for approximately 5% of cases, mostly in diseased valves and is often mislabeled as culture negative endocarditis. There is limited information in literature till date regarding these organisms. It is hypothesized that fibronectin found in saliva and blood is an important ligand that helps them to bind to the host tissues causing bacteremia and endocarditis. These bacteria are mostly susceptible in-vitro but have a high tendency for recurrence (failure rate 40%), increased embolic phenomena and valvular destruction, often requiring surgical intervention for complete resolution. We present an interesting case of infection with this rare organism presenting with spinal osteomyelitis and bacteremia, later found to have dehiscence of prosthetic aortic valve complicated by aortic root to RVOT fistula, and a new valvular abscess with severe MR. We shed light into the aggressive nature of this bacteria and the need for prompt surgical intervention.

CONCLUSION: - Abiotrophia defectiva is an aggressive organism that can cause endocarditis with severe valvular destruction especially if there is a delay in diagnosis.

- Abiotrophia defectiva endocarditis requires prompt surgical intervention.

- Abiotrophia species are susceptible to vancomycin, ceftriaxone, levofloxacin, and clindamycin.

A BREATHTAKING CASE OF LARYNGEAL DYSKINESIA

Ahmed A. Sandhu¹; Elizabeth J. Kim^2,3; George Koutras¹; Rida Aziz⁴; John Dedousis¹; Antonios Tsompanidis¹; Mohammad Zubair¹; Vashti W. Ramphal⁵

¹GME, CarePoint Health, Jersey City, NJ; ²The University of Queensland, Saint Lucia, Queensland, Australia; ³Ochsner Medical Center, New Orleans, LA; ⁴William Carey University College of Osteopathic Medicine, Hattiesburg, MS; ⁵GME, Bayonne Medical Center, Bayonne, NJ. (Control ID #3875558)

CASE: We present a case of a 50 year old female with a history of Severe Asthma, Obstructive Sleep Apnea, GERD, Systemic Lupus Erythematosus, Rheumatoid Arthritis, Type 2 Diabetes Mellitus, Myocardial Infarction in her 30s, and hypertension who presented to the ED due to severe dyspnea. Patient was diagnosed with asthma at the age of 14. Her asthma was uneventful until her mid 40s. Her only known exacerbating factor is emotional stress. She is on budesonide, ipratropium-albuterol, and prednisone, but notes they do not help. She was scheduled to start dupilumab but moved states prior to initiation. Since moving a month ago, she experienced 5 previous episodes of stridor resulting in intubation. The day prior, she experienced wheezing shortly after having a disagreement with her daughter. EMS administered nebulizer treatments and intramuscular epinephrine without improvement. In the ED, she had labored breathing and stridor but was saturating 100% on nonrebreather. Chest X-Ray showed clear lung fields. EKG showed normal sinus rhythm without ST-T changes. Normal Leukocyte count, normal lactate levels noted. Patient was intubated for impending respiratory compromise. She was successfully extubated the next morning. Pulmonary physician suspected laryngeal dyskinesia given her history of intubations, clear lung findings, poor response to medications, and nature of her excerbations. Workup was pending. Overnight, patient became agitated and experienced stridor. Decision was made to intubate and sedate patient. On review of rapid response, patient was agitated from room change and her medication before the onset of stridor and wheezing. Chest X-ray after intubation showed clear lung fields.

IMPACT/DISCUSSION: Laryngeal dyskinesia is a rare respiratory condition with a psychogenic component and unclear etiology. It is characterized by paradoxical vocal cord closure during inspiration causing stridor. It is commonly misdiagnosed as severe asthma exacerbation, resulting in multiple intubations short in duration. Stridor and dyspnea are out of proportion to patient’s clinical findings and there is minimal or no response to treatments. Emotional stress is a common trigger. In addition, the episodes rarely occur while patient sleeps. It is more common in females ages 20-45 and associated with Gastroesophageal Reflux Disease (GERD) and psychiatric conditions. Laryngoscopic examination of the vocal cords can confirm the diagnosis. Current treatment includes sedation and continuous positive airway pressure for acute management. For long term management, speech therapy, psychiatry, and respiratory and ENT physicians work together to assist the patient in managing the condition.

CONCLUSION: - Consider laryngeal dyskinesia when patient has history of refractory asthma, emotional triggers, multiple intubations, and unremarkable PFTs

- Delay in diagnosis causes increased hospitalizations and harmful interventions; early diagnosis improves quality of life and offsets healthcare burdens

A BRIDGE TOO FAR MYOCARDIAL BRIDGING AS A CAUSE OF NSTEMI

Jordan Stokka¹; Megha Penmetsa²; Ali Hama Amin²

¹Internal Medicine Residency, Carilion Roanoke Memorial Hospital, Roanoke, VA; ²Cardiology, Carilion Roanoke Memorial Hospital, Roanoke, VA. (Control ID #3870088)

CASE: A 65-year-old female with a history of HTN, idiopathic myocarditis, and HLD presented to the hospital with substernal chest pain that radiated to her left arm. The pain was pressure-like in nature. She denied a positional component to her symptoms. Additionally, she reported a cough and sore throat for four days but denied any shortness of breath, palpitations, or fevers. She took three nitroglycerin with minimal improvement.

Vital signs were BP 175/83, HR 79, RR 18, O2 98%. Physical examination was normal including cardiovascular exam which revealed a regular rate and rhythm without murmurs. Labs were notable for a normal CBC and CMP, COVID negative, ESR 5 and CRP <0.40. Initial troponin-I HS was 51ng/L; it continued to rise and peaked at 1085. EKG demonstrated normal sinus rhythm without ST changes or T-wave inversions. Chest x-ray was negative for consolidations or cardiomegaly. She was started on acute coronary syndrome (ACS) protocol and admitted to the cardiology service for further management.

Transthoracic echocardiogram (TTE) showed EF 60-65% without wall motion abnormalities. The patient underwent coronary angiography (CAG), which showed systolic narrowing of the middle left anterior descending (LAD) coronary artery with no significant atherosclerotic plaque. Given the patient’s prior history of myocarditis, cardiac magnetic resonance imaging (cMRI) was obtained and showed subendocardial late gadolinium enhancement (LGE) consistent with MI in the distal LAD territory with no evidence of active inflammation or myocarditis. She was diagnosed with NSTEMI due to MB. The patient was discharged on metoprolol with close outpatient follow up.

IMPACT/DISCUSSION: MB occurs when a portion of a coronary artery is fully embedded in the myocardial tissue. Though estimated to be present in 1 out of 3 adults, a higher prevalence has been observed in autopsy findings (up to 86%). Although MB is usually asymptomatic, the tunneled artery can cause coronary vasospasm, leading to angina, ACS, and sudden cardiac death. Due to the varying presentation of patients with MB, it is important to include this diagnosis in the differential for NTEMI, especially if CAG reveals no obstructive lesions. This case demonstrates the need for early identification of MB in order to initiate appropriate medical therapy.

MB is commonly found incidentally on cardiac catheterization through the “milking effect” of the tunneled artery during systole. However, non-invasive imaging modalities such as coronary computed tomography angiography (CCTA) are becoming more of the gold standard for the diagnosis of MB. Once the diagnosis is made, first-line treatment consists of beta-blockers, while surgical options such as myotomy and coronary artery bypass grafting are considered solely in refractory cases.

CONCLUSION: Despite its estimated prevalence, myocardial bridging remains an uncommon yet important cause of NSTEMI.

Myocardial bridging can be diagnosed both invasively with CAG and non-invasively with CCTA.

A CASE OF ACUTE TOXICITY OF CALCIUM CHANNEL BLOCKER (CCB) CAUSED BY OVERDOSE

Mariam Alamgir^1,2; Dua Sikandar³; Sujan Badal¹

¹Internal Medicine, Washington State University, Pullman, WA; ²St George's University, St George's, St George's, Grenada; ³Bahria University Medical and Dental College, Karachi, Sindh, Pakistan. (Control ID #3873518)

CASE: A 54-year-old female with history of type 2 diabetes, hypertension, stroke, chronic kidney disease stage 3 presented 2 hours after intentional overdose of 845 mg amlodipine together with 395 mg lisinopril, 1539 mg aspirin, and 600 units of insulin Lantus. In initial ED presentation, patient is non-encephalopathic but hypotensive and bradycardic with heart rate at 50s, and blood glucose is mildly elevated at 112 mg/dL. Patient was treated with vasopressors, high-dose insulin (HDI), calcium chloride, fat emulsion and transferred to intensive care unit (ICU). Within 2 hours, patient is less responsive requiring intubation. Later, becomes hypoglycemic requiring high amounts of dextrose infusions and IV steroids. Next day, patient gets severely volume overloaded (~16L) from dextrose infusions and develops oliguric AKI requiring Sustained low- efficiency dialysis (SLED). Hospitalization was complicated by aspiration pneumonia, ongoing oliguric AKI requiring hemodialysis, and gastrointestinal bleeding. Patient came off of hemodialysis after 1 month of treatment.

IMPACT/DISCUSSION: CCB blocks intracellular entry of calcium by binding to L-type calcium channel located primarily in cardiac and vascular smooth muscle and to a lower extent in pancreas. Symptoms from toxicity include refractory hypotension, bradycardia, hyperglycemia subsequently leading to multiorgan failure and death without proper treatment.

On initial evaluation patient must be urgently transferred to ICU, time since ingestion should be investigated, as well as doses of medications are determined. Activated charcoal can be given within 1-2 hours of ingestion. Whole bowel irrigation (WBI) should be initiated as soon as possible to minimize the absorption of CCB especially the extended-release formulation. In our case, patient was out of window for activated charcoal and WBI was not thought of. WBI would have led to significantly lower adverse effects from overdose.

Furthermore, CCB poisoning results in insulin resistance and hyperglycemia. HDI is considered as initial therapy as it enhances carbohydrate utilization within myocytes, increasing inotropy, vascular dilatation, and increased intracellular glucose transport. In our case, concomitant overdose of Lantus led to persistent hypoglycemia which was challenging to manage with high-dose dextrose infusions leading to volume overload. Concentrated dextrose infusions were used for first 5 days, additionally we used scheduled IV steroids to improve blood sugars and prevent hypoglycemic injury.

CONCLUSION: Since the mid 1980s, new prescriptions for CCB's have increased and are responsible for 48% of deaths related to cardiac drug exposure and it is crucial to understand the challenging management. Patient presenting with CCB intoxication must be immediately managed in the ICU. Early initiation of HDI has been proven effective, however, clinical presentation and management can be complicated by other concomitant overdose.

A CASE OF BABESIOSIS-ASSOCIATED SEVERE IMMUNE THROMBOCYTOPENIA

Thin Z. Khine, Olushola Ogunleye, Nili Gujadhur, Rossana Seno

Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #3872848)

CASE: 86-year-old female with hypertension and hyperlipidemia was transferred from another facility in June with fever, chills, and abdominal pain for 2 days. She denied sick contacts, recent travel, bleeding/clotting disorders and recent tick bite. On initial presentation, she was febrile (102.3°F), hypotensive (93/51 mmHg), and had petechiae on her lower extremities. Labs revealed anemia (hemoglobin of 10.2 g/dL), severe thrombocytopenia (4×10⁹platelets/L), hyperbilirubinemia (1.7 mg/dL). CT abdomen and pelvis showed mild splenic prominence. She was given one unit of platelets and 40 mg of IV dexamethasone due to suspicion of ITP prior to transfer to our facility. Upon arrival, she was hemodynamically stable with platelet count 21 × 10⁹ /L. Tickborne illness workup showed babesiosis with parasitemia index of 1.7% in peripheral blood smear, positive for Babesia PCR and Lyme IgM. Work-up also revealed platelet clumping and hemolytic anemia (low haptoglobin <10 mg/dL and elevated LDH of 333 U/L) but negative Coombs test.

Patient was treated with oral atovaquone 750 mg every 12 hours, IV azithromycin 500 mg every 24 hours and oral doxycycline 100 mg every 12 hours for concurrent babesiosis and Lyme disease. For ITP treatment, she received 2 doses of intravenous immunoglobulin and a 4-day course of IV dexamethasone. Her clinical status and platelet count improved to 119 × 10⁹/L and parasitemia index dropped to 0.72% after 4 days of hospitalization. She was discharged with oral atovaquone, azithromycin and doxycycline to complete a total of 14 days of treatment. Laboratory evaluation at 3 weeks post-discharge showed resolution of thrombocytopenia with platelet count of 177 × 10⁹ /L.

IMPACT/DISCUSSION: Immune thrombocytopenia (ITP) is an acquired cause of thrombocytopenia due to autoantibodies against platelet antigens. Babesiosis is not a common infectious cause of secondary ITP. Factors commonly associated with thrombocytopenia in babesiosis include peripheral platelet destruction and splenomegaly, direct consumption/disseminated intravascular coagulation (DIC), and bone marrow suppression. The spectrum of clinical features of babesiosis can range from asymptomatic to severe hemolytic anemia, complications, and death. Severe babesiosis occurs in persons >50 years of age, immunosuppressed, or asplenic. Criteria used to define severe babesiosis include parasitemia ≥4% and/or the presence of complications. Our patient had only 1.7% parasitemia at presentation, suggesting that the occurrence of ITP in babesiosis does not correlate with the disease severity. To hasten recovery, patients with babesiosis-associated ITP will require ITP-specific treatment in addition to antimicrobial treatment for babesiosis.

CONCLUSION: This case highlights the importance of recognition of babesiosis as one of the causes of secondary ITP even in mild parasitemia.

In addition to antbiotics for treatment of babesiosis, ITP-specific treatment should be initiated for severe ITP to accelerate the recovery.

A CASE OF BACLOFEN ENCEPHALOPATHY IN RENAL INSUFFICIENCY

Cindy O. Nguyen¹; Samuel Gregerson²; Saad Shams²; John Buckley³; Patrick McBride²

¹Wayne State University School of Medicine, Detroit, MI; ²Internal Medicine, Henry Ford Hospital, Detroit, MI; ³Pulmonary Disease, Critical Care Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #3867572)

CASE: A 64-year-old woman with a history of type 2 diabetes on long-term insulin complicated by gastroparesis, essential hypertension, and chronic kidney disease G5/A3 not on hemodialysis presented to the pain clinic 2 weeks prior to presentation for polyneuropathy and muscle spasms. She was prescribed gabapentin 100 mg three times daily and baclofen 5 mg 1-2 tablets three times daily. Two weeks after initiating baclofen, our patient fell at her home and was seen by family with bilateral shaking of upper extremities. Per family, the patient was confused but denied hitting her head or losing consciousness. She was brought to the Emergency Department for suspicion of stroke. The patient presented disoriented, lethargic and non-verbal with no focal deficits. Her presenting blood pressure was 215/98.

She was admitted to the medical intensive care unit for hypertensive emergency with acute encephalopathy requiring continuous intravenous antihypertensive medication. Her physical exam demonstrated global encephalopathy but no focal neurological deficit. Her labs were significant for creatinine 3.96 (baseline 3.2) μmol/l. A brain computerized tomography (CT) without IV contrast showed stable chronic bilateral encephalomalacia in the cerebellar hemispheres with no acute intracranial abnormalities. Given her acute kidney injury superimposed on chronic kidney disease and persistent confusion despite resolution of hypertensive emergency, baclofen-induced encephalopathy was diagnosed. The patient underwent urgent hemodialysis with complete resolution of encephalopathy after the first 3.5h session. The patient underwent a second 4h hemodialysis session and was discharged 48 hours later with baseline mentation.

IMPACT/DISCUSSION: Encephalopathy is a broad differential diagnosis including toxometabolic, infectious, traumatic, environmental and pharmacologic etiologies. Baclofen is a GABA agonist and acts through inhibition of pre-synaptic motor neurons to teat spasticity, pain, muscular rigidity, and spasms. As baclofen is primarily excreted by the kidneys, most cases of baclofen toxicity have been reported in dialysis- dependent patients, usually 2-3 days to 6 weeks following ingestion of the drug. Intoxication signs and symptoms include seizures, autonomic disturbances, respiratory depression, and altered consciousness

CONCLUSION: In patients with severe chronic kidney disease, baclofen should be avoided if possible. If baclofen cannot be avoided, it is important to initiate at low, renally-adjusted dosages. If toxicity is suspected, hemodialysis is an appropriate treatment to reduce clearance time and alleviate clinical symptoms.

A CASE OF CABERGOLINE-INDUCED CONSTRICTIVE PERICARDITIS

Yamann A. Sahlool, Neil Gerts, Jeong Hwan Kim, Ramesh Nathan, Saro Avedikian, Jasprit Takher, Varol Togay

Internal Medicine, Los Robles Regional Medical Center, Thousand Oaks, CA. (Control ID #3873387)

CASE: Introduction

With increased use of dopamine agonists in treatment of conditions such as hyperprolactinemia, the adverse effects of dopaminergic drugs are becoming more prominent. Here we present a case of a 49-year-old female with a history of pituitary adenoma on Cabergoline for the past ten years, found to have constrictive pericarditis. After discontinuation of Cabergoline, the patient was noted to have resolution of pericarditis.

Case Presentation

A 49-year-old female with history of pituitary adenoma presented with a chief complaint of flu-like symptoms along with nonproductive cough, increasing abdominal distension, and bloating. On presentation, BP 95/60, HR 95, RR 16, T 98.8. Physical exam demonstrated JVD, decreased breath sounds, and abdominal ascites with distended abdomen. CBC was unremarkable, with a CMP remarkable for AST of 73, ALT of 110 and ALK 187.

CT abdomen & pelvis showed bilateral pleural effusions, small-to-moderate pericardial effusion, mild-to- moderate amount ascites, and extensive periportal edema through the liver with hepatomegaly.

A paracentesis was negative for WBCs, with negative cultures and gram stain, but demonstrated a SAAG of 1.4. Echo showed EF at 55% to 65% with no wall motion abnormalities. The pericardium was noted to have moderate thickness along with a small-to-moderate circumferential pericardial effusion.

The only home medication was Cabergoline 0.5mg for the past ten years.

Cardiology was consulted, who recommended a course of Prednisone and Colchicine which improved symptoms. A right and left heart catheterization demonstrated equalization of right and left ventricle end diastolic pressures, along with increased right atrial pressures with inspiration, decreased with expiration, along with a prominent Y descent; all in support of constrictive pericarditis. Cabergoline was discontinued, and patient discharged. A Cardiac MRI two months later demonstrated no pericardial thickening, and noted that previous pericardial effusions had resolved.

IMPACT/DISCUSSION: Discussion

Constrictive pericarditis is a disorder characterized by fibrous calcification of pericardium. Recently there has been an increased concern of drug-induced constrictive pericarditis, specifically from ergot alkaloids. Clinical features include liver congestion commonly demonstrated by transaminitis, abdominal distention with ascites, dyspnea, and increased JVP. The pathogenesis is currently not understood, but it has been suspected that ergot alkaloids stimulate inflammatory reactions which may be the cause of fibrosis. Corticosteroids, along with discontinuation of causative medication has been shown to provide improvement. With increased use of Cabergoline, it is important to raise a concern of Cabergoline-induced constrictive pericarditis, and understand its associated workup and treatment.

CONCLUSION: One should be aware of the possibility of Cabergoline-induced constrictive pericarditis.

Physicians should be able to recognize potential adverse effect of Cabergoline.

A CASE OF CLINICALLY SIGNIFICANT DRUG-DRUG INTERACTIONS OF PAXLOVID (NIRMATRELVIR/RITONAVIR) WITH CONCURRENT MEDICATIONS IN THE MANAGEMENT OF COVID-19

Sydney Weill, Anisha Reddy, Eva Bugos

Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #3874956)

CASE: Ms. M is a 78 year old female with history significant for Parkinson’s disease and recent COVID-19 infection who presented with encephalopathy, mainly lethargy and confusion. Two days prior to presentation, she met via video visit with her primary care provider in the setting of a mild sore throat and was found to have a positive COVID test. She was otherwise hemodynamically stable without any respiratory complaints. She was subsequently started on Paxlovid. On admission, the patient was afebrile, hemodynamically stable, without increased work of breathing saturating appropriately on room air. Notably, she was lethargic with orientation only to self. Labs were grossly unremarkable and work-up, including urine analysis and culture, chest xray, CT head, were all unrevealing. Medication reconciliation was completed and patient was found to have co-administration of buspirone and clonazepam, drugs she had been taking daily without recent change for years. Paxlovid was held. The following day, patient was examined and noted to have improved back to her baseline. She was alert and oriented to self, place, and time without encephalopathy or any residual deficits. Given patient remained hemodynamically stable without any signs of hypoxia or respiratory distress, suggesting mild COVID-19 disease with low risk of severe disease or hospitalization, Paxlovid was discontinued upon discharge.

IMPACT/DISCUSSION: Paxlovid (nirmatrelvir/ritonavir) is widely used as a 5-day outpatient treatment for patients with mild to moderate COVID-19 at high risk of progression to severe disease. While studies have shown an 89% reduced risk of COVID-19 related hospitalization and death within 28 days when started within 3 days of symptom onset, there have also been reports of clinically significant side effects as a result of drug-drug interactions (DDIs) when taken with concurrent medications. The ritonavir component boosts plasma concentrations of nirmatrelvir through rapid inhibition of the drug-metabolizing enzyme, cytochrome P450 3A43. Thus, it has the potential to cause harmful DDIs with other drugs metabolized through this pathway.

Safe management requires thoughtful medication reconciliation when deciding whether or not to prescribe Paxlovid. If a potential DDI exists, the provider must evaluate the potential severity, identify strategies for mitigating the DDI, and balance the benefit of Paxlovid to prevent severe disease against the risk of having a possible significant DDI.

CONCLUSION: Paxlovid can cause harmful DDIs when used along with other drugs metabolized through the cytochrome P450 pathway. For safe treatment, it is important for providers to be aware of medications that are absolute contraindications as well as ones that can safely be co-administered.

A CASE OF COCAINE-INDUCED ACUTE ISCHEMIC STROKE.

Md Rockyb Hasan¹; Tahsin Tabassum²; ASM ISLAM³

¹Internal Medicine, Texas Tech University System, Lubbock, TX; ²School of Community Health and Policy, Morgan State University, Baltimore, MD; ³Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX. (Control ID #3867498)

CASE: A 59-year-old female presented to the ER following the sudden onset of a seizure and left-sided hemiparesis. On examination, she was found hypertensive and her NIH score was 6. Neurological evaluation revealed that left-sided weakness was consistent with acute stroke. CT head did not show acute hemorrhage. Urinary toxicology was positive for cocaine. On query, It was found that she took an injection of cocaine for the first time 24 hours prior to the onset of symptoms. Further Investigation for the etiology of Ischemic stroke was within normal limits. The patient was managed with standard treatment of acute stroke and antiepileptic. She was advised to avoid cocaine and continue physical therapy.

IMPACT/DISCUSSION: According to a nationwide study conducted in the U.S., around 24.6 million individuals were found to have used cocaine with other illicit drugs in 2013. Large hospitals serving populations with high cocaine use typically admit about 5–10 patients with cocaine-induced strokes per year. A recent study demonstrated that the risk of Ischemic stroke is seven times higher in individuals within 24 hours of cocaine use. Injection of crack cocaine has been reported to be more lethal than snorting cocaine since its concentration in blood elevates faster as well as to a much higher level. Acute cocaine use has been found to be responsible for the increased incidence of stroke than established risk factors including hypertension, diabetes, and even smoking. It has been reported that some individuals develop stroke after a single dose of cocaine. However, others remain spared despite chronic abuse. Cerebral vasoconstriction and genetic susceptibility remain possible pathophysiology to date. Pre-existing vascular risk factors including hypertension, smoking, polysubstance use, and even underlying vascular pathology might contribute to both ischemic and hemorrhagic stroke. Since definite pathophysiology has not been developed, it is not surprising, that no specific treatment has evolved for cocaine-induced stroke. Avoidance of cocaine has been the best way to prevent such deadly complications. Researchers have suggested screening every individual, especially young patients with stroke for cocaine usage. Traditionally, cocaine is considered a risk factor for all types of strokes. However, substantial scientific evidence for a causal association between the use of cocaine and ischemic stroke is yet to be established. Cocaine-induced neurovascular changes and genetic susceptibility is an emerging areas of research to shed light on guidelines for specific treatment.

CONCLUSION: Early development of ischemic stroke has been observed following cocaine use, although some chronic users have been spared. To date, no specific treatment protocol has been developed for cocaine- induced stroke. The take-home message for individuals remains strict avoidance of any type of cocaine.

A CASE OF CONTRAST INDUCED THYROTOXICOSIS IN A PATIENT NEWLY DIAGNOSED WITH HYPERTHYROIDISM

Esraa Askar, Ramy AbuKwaik, Bharathi Reddy

Internal Medicine, Forest Hills Hospital, Forest Hills, NY. (Control ID #3875550)

CASE: A 68-year-old female presented to the emergency department for 2 weeks of intermittent substernal chest pain associated with diaphoresis. She was diagnosed with hyperthyroidism by an outside clinic approximately one week prior to her presentation and was prescribed methimazole but did not start it. She was not taking any medications. Her physical examination was significant for mild exophthalmos. EKG showed ST depression in anterolateral leads. Laboratory data showed a troponin of 0.328 ng/ml (0.0.015-0.45) which trended up to 4.830 after 3 hours and TSH of <0.005 mIU/L (0.358-3.74), otherwise BMP and CBC were within normal limits. Patient was started on aspirin, statin and heparin infusion along with methimazole. Patient was transferred to tertiary hospital for urgent cardiac catheterization that showed 90 % stenosis of left anterior descending artery (LAD) and 95 % stenosis in distal right coronary artery (RCA). A successful drug eluting stent was deployed in LAD with a plan of staged PCI in RCA. An hour after the procedure, Patient complained of palpitations and diaphoresis. Laboratory findings at that time revealed Free T4 of 17.5 ng/dl (0.9-1.8), Free T3 of 12.3 pg/ml (1.8-4.6) with positive Thyroperoxidase antibody, TSI and TSH Receptor Antibody. Thyroid ultrasound revealed diffusely heterogeneous thyroid gland with increased vascularity, consistent with Graves’ disease. The patient was diagnosed with thyrotoxicosis secondary to contrast administration. She was treated with methimazole 20 mg TID, metoprolol tartrate 25mg BID and hydrocortisone 25 mg BID. Decision was made to postpone the second procedure until trending down of thyroid hormones and improvement of symptoms. A successful staged RCA PCI was performed eight days later and patient did not experience any complications despite exposure to the same dose of iodinated contrast.

IMPACT/DISCUSSION: It is quite uncommon for thyrotoxicosis to manifest itself after the administration of iodinated contrast. Although the actual prevalence has not yet been identified, estimates showed that the prevalence in areas with iodine deficiency is 0.25 to 0.5% and 0.025% in non-iodine-deficient areas with higher risk in elderly patients. Iodine-induced thyrotoxicosis was first known when iodine supplementation was given to patients in regions of endemic deficiency of iodine. In the US, it is typically iatrogenic. Rarely, hyperthyroid patients may experience chest discomfort and EKG abnormalities that are consistent with cardiac ischemia. This usually happens in older patients with known underlying coronary artery disease in response to the rise in cardiac contractility and strain caused by thyrotoxicosis. Our case did not have any history or risk factors of coronary artery disease other than hyperthyroidism.

CONCLUSION: This case highlights how recognition of hyperthyroidism may alter management, because the use of some procedures or treatments may acutely exacerbate the condition of the patient.

A CASE OF COVID -19 INDUCED ACQUIRED THROMBOTIC THROMBOCYTOPENIC PURPURA

Kejal Shah⁴; Hema Kondakindi²; Karthik Chamarti¹; Raghavendra Sanivarapu³; Jaanki Khandelwal⁴; Kelash Bajaj¹

¹Internal Medicine, Texas tech university of health sciences - Permian basin, Odessa, TX; ²Internal Medicine, texas tech university of health sciences, Odessa, TX; ³Pulmonary Critical Care, Texas Tech University Health Sciences Center, Lubbock, TX; ⁴University of Texas- Houston, Houston, TX. (Control ID #3877237)

CASE: 58-year-old unvaccinated Latino male, with medical history significant for type 2 diabetes mellitus and hypertension presented with subjective fevers, frequent occipital headaches and intermittent numbness to right face, fingers, arms, scalp lasting a few minutes for the past month. Initial vitals were stable, afebrile. On exam he was alert and oriented, conjunctival pallor present, visibly jaundiced with a large hematoma on blood draw site on left arm. Investigations revealed anemia (Hemoglobin 8g/dl), reticulocyte % 16.3 %, thrombocytopenia (platelets 9 x10^3/mcL), hyperbilirubinemia (Total bilirubin 2.9 mg/dL, Indirect bilirubin 2.1mg/dL), haptoglobin<10, and elevated lactate dehydrogenase at 998 U/L, Fibrinogen 271 mg/dL with normal coagulation profile. CT of head and abdomen normal. COVID PCR positive. Chest Xray was normal. Autoimmune workup, hepatitis panel, HIV, and direct Coombs test were negative. Peripheral blood smear showed true thrombocytopenia with 2+ schistocytes in each high-power field. PLASMIC Score 6, implying high risk for Thrombotic thrombocytopenic purpura (TTP). He was diagnosed with COVID-induced acquired TTP and treatment with prednisone 1mg/kg daily and plasmapheresis initiated. Once confirmed with ADAMTS13 inhibitor 6.9 Bethesda unit (BU) (reference <0.4 BU), and ADAMTS13 activity <5 % (reference > 61 %), rituximab was initiated. After five-rounds, plasmapheresis was stopped as platelet count improved. However, TTP relapsed within a day, and treatment with Caplacizumab initiated; steroids changed to solumedrol 1g daily. Platelet count gradually improved after eight rounds of plasmapheresis and two of rituximab.

IMPACT/DISCUSSION: TTP is a rare hematologic disorder with formation of disseminated microvascular platelet thrombi because of loss of regulation of von Willebrand factor (vWF) multimers essential for tethering platelets together. Acquired TTP is a medical emergency that is highly fatal if undetected or untreated expeditiously. Our case highlights that milder COVID-19 infections may also be associated with highly fatal TTP. Studies have shown that COVID-19 induces significant inflammation and a hypercoagulable state with raised factor VIII levels, perturbation of the endothelium with elevated VWF antigen, and a mild to moderate reduction of ADAMTS13 activity. It may also provoke IgG-type autoantibody against ADAMTS13. Perhaps the inflammatory markers associated with COVID could lead to endothelial damage and expose ADAMTS13 antigen causing antibodies formation. There is growing evidence that COVID-19 infection may trigger TTP via increase in vWF levels that cannot be adequately regulated by ADAMSTS-13. Since a causal relationship between covid-19 and TTP has not yet been defined, this is an interesting presentation prompting clinician awareness.

CONCLUSION: This case elucidates the importance of remembering that milder covid infections can lead to medical emergencies like TTP that need treatment promptly.

A CASE OF COVID-19 VASCULITIS COMPLICATED BY HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS

Tulika Saggar, Atul Sinha, Melvin Joy, Prachi Anand

Internal Medicine, Nassau University Medical Center, East Meadow, NY. (Control ID #3877001)

CASE: 67-year-old male with history of uncomplicated COVID-19 infection seven months prior presented with bilateral lower extremity vasculitis. Antibody panel was inconclusive and skin biopsy of the lesions showed medium and small vessel vasculitis secondary to COVID-19 thrombotic vasculopathy. Oral steroid therapy, rituximab and IVIG infusion were given. The lesions progressively worsened leading to septic shock requiring vasopressors and stress dose of corticosteroids. Patient developed pancytopenia with ANC nadir of 900, thrombocytopenia (PLT: 29k), LDH of 1300 U/L, ferritin 20,000 ng/nL. Bone marrow aspirate revealed mostly non-viable cells, scattered megakaryocytes and scattered macrophages with hemophagocytosis. Based on the clinical history and morphological findings, patient met the H-score criteria for diagnosis of hemophagocytic lymphohistiocytosis. Treatment with filgrastim and dexamethasone was given, however he clinically deteriorated and died within four days of diagnosis.

IMPACT/DISCUSSION: Hemophagocytic lymphohistiocytosis (HLH) is an acute and rapidly progressive systemic inflammatory disorder characterized by cytopenia, excessive cytokine production and hyperferritinemia resulting in multi-organ failure. Primary HLH is mainly due to genetic inheritance whereas secondary HLH is due to malignancy, infection or autoimmune stimulus. COVID-19 can involve all organ systems, including the circulatory system, causing thrombosis and vascular dysfunction leading to cutaneous vasculitis. Severe COVID-19 infection causes cytokine hyperinflammation, triggering an intense immune response that may be the mechanism of HLH development. We chose this case to review the clinical picture of HLH development in a patient with a history of COVID-19 vasculitis and its severe outcomes. COVID-19 induces a wide range of clinical symptoms, including vasculitis and HLH. The H-score helps in calculating the probability of having HLH. It includes fever, hepatosplenomegaly, cytopenia, hyperferritinemia, transaminitis, hypofibrinogenemia, hypertriglyceridemia, underlying immunosuppression and hemophagocytes on bone marrow aspirate. The H-score of 169 is considered as a cut-off for considering HLH. Our patient had a score of 208, indicating 88-93% probability of HLH. Treatment options include chemotherapy, cytokine inhibitors, immune suppression and hematopoietic stem cell transplantation.

CONCLUSION: Due to its rarity, variable presentation and rapid disease progression, a high degree of clinical suspicion is warranted to diagnose HLH, especially in the setting of COVID-19 vasculitis. Clinicians can use the H-score criteria to calculate the probability of HLH. Earlier diagnosis and intervention help prevent long-term morbidity and mortality as well as reduce the need for highly toxic treatment. HLH is a very rare condition with high mortality and should be considered in the differential diagnosis of patients with prolonged non-resolving fever and multi-system involvement.

A CASE OF CUTANEOUS MUCORMYCOSIS AT THE SITE OF ADHESIVE LUMBAR PUNCTURE DRESSING

Ellen Mikrut¹; Eric Brucks²; Christy Lougheed²; Joao Paolo Ferreira²

¹College of Medicine, The University of Arizona College of Medicine Tucson, Tucson, AZ; ²University of Arizona, Tucson, AZ. (Control ID #3875261)

CASE: A 56-year-old male with recently diagnosed B-cell acute lymphoblastic leukemia (B-ALL) presented to the emergency department with a purulent, left lower back lesion after a failed course of outpatient antibiotics. Exam revealed a 2 cm ruptured abscess with induration at a site where adhesive tape had previously secured a dressing after a lumbar puncture (LP) two weeks prior. He was admitted for IV vancomycin and cefepime, however despite broad spectrum antibiotics he failed to demonstrate improvement. On hospital day 8, the lesion had progressed to a 3 cm necrotic eschar; a punch biopsy was performed which demonstrated dermal necrosis with ribbon-like fungal hyphae showing irregular 90° branching. Antimicrobials were changed to isavuconazole, liposomal amphotericin B, and meropenem and the patient was taken to the operating room for excision of affected tissue. Fungal PCR demonstrated Rhizopus oryzae and a workup for disseminated disease was negative. On hospital day 25, after significant clinical improvement, the patient was successfully transferred to the bone marrow transplant service for continued treatment of B-ALL. He continued on isavuconazole until complete resolution of the wound and completion of immunosuppressive therapy.

IMPACT/DISCUSSION: Mucormycosis is an opportunistic fungal infection most common in patients with underlying diabetes or malignancy. This case demonstrates a rare presentation of cutaneous mucormycosis given the affected anatomic location and the likely mode of transmission, hypothesized to be the adhesive tape used for LP dressing. In a recent review, only 5% of cutaneous mucormycosis cases involved the back, with the most common anatomic site being the lower extremities. Adhesive tapes/bandages were identified as the mode of transmission responsible for 5.3% of reviewed cases.¹ A literature review of case reports on pubmed yielded only 1 report of cutaneous mucormycosis at a LP site and 13 cases associated with adhesives, none of which were LP dressings.

Understanding and identifying risk factors and clinical manifestations of cutaneous mucormycosis is extremely important given the mortality of the disease. Clinicians must maintain a high index of suspicion regarding cutaneous mucormycosis, which typically presents as a necrotic eschar with surrounding erythema and induration. Furthermore, clinicians must consider early histopathological testing for diagnosis of this disease as delays in antifungal treatment have been shown to significantly increase mortality, particularly in patients with underlying hematologic malignancy.

1.Skiada A, Drogari-Apiranthitou M, Pavleas I, Daikou E, Petrikkos G. Global Cutaneous Mucormycosis: A Systematic Review. Journal of Fungi. 2022; 8(2):194.

CONCLUSION: - Adhesive tape is a rare but documented mode of transmission of mucormycosis

- Cutaneous mucormycosis typically presents as a necrotic eschar with surrounding erythema and induration

- Delayed diagnosis of cutaneous mucormycosis is associated with increased mortality

A CASE OF CYTOMEGALOVIRUS COLITIS INITIALLY MISDIAGNOSED AS COLONIC ISCHEMIA IN AN IMMUNOCOMPETENT JAPANESE MAN

Atsuro Hamano¹; Takaaki Kobayashi²; Sandra Y. Moody^3,4; Akihito Yoshida¹

¹General Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan; ²Infectious Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA; ³Hospital Medicine & Geriatrics, University of California San Francisco, San Francisco, CA; ⁴Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA. (Control ID #3874696)

CASE: A 74-year-old woman with a past medical history of coronary artery disease status post coronary artery bypass graft, aortic valve replacement for aortic stenosis, cecal carcinoma status post ileocecal resection, and hepatocellular carcinoma status post left medial segment (S4) partial liver resection who presented with a 2-week history of abdominal pain and non-formed bloody stool. She denied smoking and alcohol use. Vital signs were unremarkable, but tenderness of the left lower abdomen was noted. Human immunodeficiency virus was negative.[s1] Computed tomography of her abdomen showed edematous thickening of the wall of the descending colon. Given her extensive cardiovascular disease, colonic ischemia was suspected. Supportive care was initiated with nothing by mouth (NPO). Her diarrhea subsided slightly over the next few days, and she was discharged on the seventh day. However, severe diarrhea restarted soon after her discharge, and she was further evaluated as an outpatient. Stool culture was negative. Colonoscopy demonstrated multiple ulcers in the transverse, descending, and sigmoid colon, and histopathology showed cytomegalovirus (CMV)-infected cells with immunohistochemistry stain. CMV antigenemia assay was negative. CMV colitis was diagnosed, and valganciclovir was initiated with significant improvement in her symptoms.

IMPACT/DISCUSSION: CMV is a member of the herpesvirus family. The proportion of humans with prior CMV infection varies worldwide, with seroprevalence rates ranging between 40% to 100% of the adult population. CMV can cause a wide range of manifestations potentially involving the gastrointestinal tract, lungs, retina, brain, adrenal glands, liver, and spleen. While CMV infection is common in normal adults and is generally asymptomatic, it can be symptomatic in patients with defective cell-mediated immunity like HIV/AIDS, those who have undergone organ transplantation, and those receiving immunosuppressive therapy or chemotherapy. Though CMV colitis is generally diagnosed in patients who are immunocompromised, CMV colitis in immunocompetent patients has also been reported. Common symptoms ofCMV colitis are fever, abdominal pain, diarrhea, and bloody stool. CMV colitis can be diagnosed by visualization of characteristic lesions on endoscopy and intranuclear or cytoplasmic inclusions on histopathology. CMV gastrointestinal disease cannot be excluded based on a negative plasma or whole- blood PCR result. CMV culture of stool specimens is less reliable because a positive culture may represent either asymptomatic viral shedding or disease. Oral valganciclovir can be used for patients with CMV colitis who can tolerate and absorb oral medications, while severe disease requires intravenous ganciclovir.

CONCLUSION: CMV colitis should be considered in a patient presenting with bloody stool even among immunocompetent patients. Medicine trainees need be aware that CMV colitis can occur in patients without immunocompromised conditions.

A CASE OF DISSEMINATED ZOSTER AFTER BIVALENT COVID BOOSTER VACCINATION

Bhanu L. Swamy, Jennifer Lukela

Internal Medicine, University of Michigan, Ann Arbor, MI. (Control ID #3873875)

CASE: Bivalent COVID vaccines have an established safety profile and serve as a tool to mitigate severe illness in the COVID 19 pandemic.However, in some individuals,adverse events can occur.The relationship between herpes zoster and COVID vaccination appears to be controversial.We present a case of disseminated zoster shortly after bivalent mRNA COVID vaccination.A 50 year-old female with a history of breast cancer treated with neoadjuvant chemotherapy and lumpectomy on exemestane maintenance therapy presented to clinic with a four day history of left sided back pain initially thought to be musculoskeletal. Six days prior to onset, the patient had received the Moderna SARS-COV2 bivalent booster. One day after evaluation in clinic, she developed an erythematous vesicular rash in the distribution of the L1 dermatome on her back and thigh consistent with herpes zoster.Valacyclovir was initiated for seven days. Her pain and rash progressed to the L2 dermatome despite her use of gabapentin, cymblata, and over the counter analgesics; thus predisone was added. One week later, she returned to the clinic for left ear pain, headache, fatigue, and chills. Exam was notable for a tender left ear canal with yellow drainage and concern for vesicle formation. Swab obtained from the ear canal was positive for varicella zoster. MRI of the brain was unremarkable with no evidence of menigeal involvement or inflammation. Patient was hospitalized for disseminated zoster and treated with intravenous acyclovir for four days and ultimately discharged with a 14 day course of oral valacyclovir.

IMPACT/DISCUSSION: Our case describes a patient with disseminated zoster shortly after receiving a bivalent COVID booster vaccine.There have been few case reports of herpes zoster following COVID vaccination raising a possible link between COVID vaccination and herpes zoster reactivation.One theory is the vaccine creates immune dysregulation potentiating a reactivation of latent varicella infection. In the CDC vaccine adverse event reporting system(VAERS), there were 2 cases of disseminated zoster virus infection and 878 cases of herpes zoster of a total 966 vaccine adverse cases as of December 2,2022. Per the Morbidity and Mortality Weekly Report, there were no reports of herpes zoster recorded as an adverse effect from August 31 to October 23, 2022 with bivalent COVID vaccine doses.A cohort study in November 2022 found that there was no increased risk of herpes zoster infection among patients receiving the COVID-19 vaccines demonstrating the safety profile. Additionally, a meta-analysis by Chu et al in 2020 did not find an association.However, both these studies were limited and more research is warranted.

CONCLUSION: The link between bivalent mRNA COVID vaccination and herpes zoster remains unclear, but given the potential association and risk for disseminated disease, clinicians should have awareness of this potential adverse effect to allow for early recognition and initiation of treatment to prevent complications.

A CASE OF DRESS IN THE SETTING OF RIFAXIMIN-INDUCED BODILY FLUID DISCOLORATION

Patrick McBride, Tyler Andrews, Samuel Gregerson, Tyler Trahan

Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #3872679)

CASE: A 59-year-old male with decompensated alcohol-induced liver cirrhosis was transferred to our facility for liver transplant evaluation. At the preceding facility, he presented with acute hepatic encephalopathy and was started on Lactulose 20g tid and Rifaximin 550mg. At our facility, he developed a fever of 101.1F and diffuse erythematous papules with confluence over the bilateral chest, shoulders, neck and head. The patient also developed bright-orange bodily fluid discoloration. CT abdomen/pelvis demonstrated diffuse inflammatory lymphadenopathy. A complete blood count demonstrated absolute eosinophilia. Dermatology performed punch biopsy showing superficial perivascular and interface dermatitis with eosinophils. Rifaximin was discontinued at this time, and Solumedrol 100 mg IV was initiated. Bodily fluid discoloration resolved 3 days after cessation of Rifaximin. On day 15, the rash was entirely resolved and rifaximin was restarted for severe hepatic encephalopathy. Yellow secretions appeared in the next several days and Rifaximin was again discontinued, with resolution of symptoms.

IMPACT/DISCUSSION: Hepatic encephalopathy is a neuropsychiatric manifestation of advanced liver disease in result of inadequate hepatic clearance of toxins, namely, hyperammonemia. Pharmacological treatment relies on decreasing production and augmenting ammonia clearance. Rifaximin, a rifamycin derivative, is standard in pharmacological management of hepatic encephalopathy.

Since FDA approval for liver disease in 2010, adverse effects of rifaximin use have been largely benign. Mechanistically, rifaximin’s negligible systemic absorption likely prevents the side effect profile displayed in other rifamycin products. However, this case describes discoloration of bodily fluids and DRESS syndrome, both of which are well documented complications with rifampin use.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is DRESS secondary to Rifaximin is an exceedingly rare phenomenon. In most patients, symptoms will appear 2-8 weeks after initiation of drug therapy. Systemic symptoms can include fever, lymphadenopathy and rash.

CONCLUSION: It is important to identify drug reactions in the hospitalized patient swiftly to avoid iatrogenic complications as the necessary intervention is cessation of inciting agent. Rifamycin antibiotics, such as Rifampin, rarely have been associated with DRESS Syndrome; few, if any, cases have ever been described of Rifaximin inducing DRESS Syndrome.

A CASE OF FATAL HEMORRHAGE WITH NEW ONSET BULLOUS PEMPHIGOID: A FAST- TRACKED PATHOGENESIS

Udit Asija¹; Lakshmi Priyanka Pappoppula²; Maria Rose Dominic^3,1

¹Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA; ²Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA; ³Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA. (Control ID #3876927)

CASE: A 77-year-old female presented with a two-day history of rapidly progressing tense bullous lesions extending over bilateral extremities, trunk, and vaginal mucosa. Skin biopsy revealed a clear linear pattern with deposition of IgG, C3, and C5B-9 on direct immunofluorescence suggestive of bullous pemphigoid, later confirmed by elevated Anti-BP230 (BPAg1) and Anti-BP180 (BPAg2) antibodies. She was started on doxycycline and intravenous steroids, which significantly improved lesions. However the next day she developed sudden flank pain and in a few hours became hemodynamically unstable requiring vasopressors. Serial labs revealed down-trending hemoglobin; the CT abdomen showed retroperitoneal hematoma and hemoperitoneum. She required a massive transfusion with 14 units of packed red blood cells and 6 units each of platelets and fresh frozen plasma. Despite these, she remained hemodynamically unstable and a repeat CT scan showed an interval increase in the hematoma size. She eventually was found to have a bleeding right lumbar artery and needed arterial embolization by interventional radiology. The remaining lab work showed decreased factor VIII assay at 22% and elevated partial thromboplastin time at 63 seconds. The mixing study failed to correct aPTT, indicating the patient had a factor inhibitor in the intrinsic pathway. The patient’s hospital course was further complicated by bacterial sepsis ultimately resulting in her death.

IMPACT/DISCUSSION: Bullous Pemphigoid (BP) is an autoimmune bullous disease characterized by autoantibodies against hemidesmosome proteins Anti-BP230 (BPAg1) and Anti-BP180 (BPAg2) on the skin and mucous membranes. Acquired Hemophilia A (AHA) is a rare bleeding disorder caused by the spontaneous production of circulating autoantibodies against coagulation factor VIII and can present with potentially life-threatening hemorrhage. AHA is associated with autoimmune diseases, malignancy, pregnancy, and certain medications, however, it is idiopathic in approximately 50% of cases. AHA is a rare complication of BP, postulated to develop due to the cross-reactivity of autoantibodies. Patients developing AHA can have rapid clinical deterioration due to life-threatening complications like massive hemorrhage or airway obstruction, and the mortality rate of AHA is estimated to be 7.9-22.2%. Typically AHA occurs a few months after the diagnosis of BP, but there have been instances when it developed rapidly within days (as in this case) or even concomitantly with BP. Bleeding control and elimination of autoantibodies with immunosuppressive drugs such as corticosteroids, Rituximab, and Cyclophosphamide are the mainstays of treatment. However, the prognosis depends on the severity of hemorrhagic complications, the time of initiation of immunosuppression therapy, and the patient’s response to it.

CONCLUSION: Patients with BP who develop signs of bleeding should be promptly evaluated for AHA and treatment initiated at the earliest to avoid life-threatening complications.

A CASE OF FEVER IN AN IMMUNOCOMPROMISED HOST

Tara Ward, Carolina Ortiz-Lopez

Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #3875257)

CASE: A 59-year-old woman with a history of Granulomatosis with Polyangiitis managed with Rituximab, presented to our academic medical center in August with two weeks of fatigue, six days of a maculopapular rash involving her arms, legs, torso, and back, that resolved prior to presentation, and one day of fever. She lives in Colorado with her husband and three dogs. She is an avid hiker and camper. Examination revealed fever to 38.3 C with otherwise normal vital signs. Initial physical exam was notable for an oriented woman with no neurological deficits and unremarkable skin exam. Her initial laboratory studies were all unremarkable. Chest x-ray revealed no acute cardiopulmonary process. On hospital day 3, she developed acute encephalopathy and expressive aphasia. MRI Brain without contrast was unremarkable and negative for stroke and EEG was negative for seizure. Lumbar puncture (LP) revealed lymphocytic pleocytosis and elevated protein. She was started on empiric courses of doxycycline and IV acyclovir. She continued to have recurrent fevers until hospital day 4. Her encephalopathy fluctuated during the admission but began to improve on hospital day 9. Repeat MRI brain revealed subtle diffuse leptomeningeal enhancement. Serum and CSF studies were negative including serum and CSF West Nile virus (WNV) IgG/M. By day of discharge on hospital day 12, she was neurologically back to baseline with the exception of mild word- finding difficulties. Two days after discharge, her CSF WNV PCR resulted positive.

IMPACT/DISCUSSION: WNV is transmitted primarily by the bite of infected mosquitoes that acquire the virus by feeding on infected birds. Most patients with WNV are asymptomatic, though symptoms are seen in about 20 to 40 percent of infected patients. Symptoms include fever, headache, malaise, back pain, myalgias, anorexia, and maculopapular rash. Neuroinvasive WNV occurs in only 1% of patients. If WNV infection is suspected, serum WNV IgM antibody should be performed. A LP should also be performed in cases with neurologic symptoms to test CSF for WNV IgM antibody. Patients with neuroinvasive disease generally have lymphocytic pleocytosis in the CSF. Nucleic acid testing using PCR is valuable as a supplemental test to IgM antibody testing in immunocompromised patients since viremia may be prolonged, and IgM development may be delayed or absent. This finding was seen in our case report, where the patient’s serum and CSF WNV IgM were negative, but her CSF WNV PCR was positive. Treatment of WNV infection is primarily supportive. The diagnosis of WNV is often challenging due to the variable presentation and overall rarity of the disease requiring a high index of suspicion and a multidisciplinary approach.

CONCLUSION: Most patients with WNV infection are asymptomatic and neuroinvasive WNV is rare. Nucleic acid testing using PCR is valuable as a supplemental test to IgM antibody testing in immunocompromised patients since viremia may be prolonged, and IgM development may be delayed or absent.

A CASE OF HEMOLYSIS AFTER TREATMENT OF SEVERE MALARIA WITH ARTESUNATE Douglas Peters, Heather Balch

Department of Internal Medicine, University of Utah, Salt Lake City, UT. (Control ID #3869019)

CASE: A 61-year-old male presented with altered mental status and fever; his exam was otherwise unremarkable. He had recently returned from a trip to Africa. His labs were significant for Hg of 12.3, PLT 25, +2 parasites on CBC, Glucose <60, Creatinine of 2.66, pH of 7.295, PCO2 of 12.6, Lactic acid was 12.4.

Malaria rapid screen and giemsa stain demonstrated Plasmodium falciparum with 24.4% parasites. He was treated for severe malaria with artesunate (AS) IV. His parasitemia cleared after 3 days of treatment and he was transitioned to artemeter/lumefantrine. He was discharged with a 3-day course.

The patient returned 13 days after discharge with fatigue and jaundice. Labs were significant for Hg 5.1 (from 7.8 prior), WBC 8.9, PLT 363, haptoglobin <10, LDH 3192, total bilirubin 5.3, direct bilirubin 1.4, negative G6PD testing, Direct anti-globulin testing (DAT) was C3d+, IgG-, Cold agglutinin negative, ANA + (1:640), and negative Giemsa stain. The patient did not respond to initial pRBC transfusion, which was concerning for a drug-induced immune hemolytic anemia (DIIHA). Treatment was started with high dose prednisone and subsequent transfusion was successful. Hemoglobin remained stable and the patient was discharged on a prednisone taper.

IMPACT/DISCUSSION: Severe malaria is defined as one having one of the following: hyperparasitemia (>5-10%), encephalopathy, seizures, acidosis, hypoglycemia, AKI, shock, jaundice, severe anemia, or pulmonary edema. Intravenous AS is the recommended treatment for severe malaria. Post Artesunate Delayed Hemolysis (PADH) is defined as a 10% drop in hemoglobin occurring more than 1 week after treatment with artesunate with hemolysis. Post-treatment patients should be monitored for PADH with weekly CBC. PADH occurs in approximately 20% of patients treated with AS for severe malaria. AS binds intracellular plasmodium rings and they are subsequently expelled in a process called “pitting” which does not immediately lyse RBCs. The delayed clearance of pitted RBCs is theorized to be responsible for PADH. Studies have shown there is a 40-45% incidence of positive DAT (either C3d+ and/or IgG) in PADH. It is uncertain if these antibodies represent artesunate induced hemolytic anemia or insignificant immune response. In a case series of patients with PADH and +DAT many were treated with steroids for possible DIIHA. Our patient was treated with steroids due to his C3d antibody, and poor response to initial transfusion. He improved on steroids. Given the unclear significance of +DAT in patients with PADH, it is unclear if improvement was from the steroids or resolution of PADH.

CONCLUSION: -The first line for treatment of severe malaria is artesunate.

-PADH is a well-known complication of treatment with artesunate, defined as a 10% drop in hemoglobin at least 1 week after treatment.

-The role of anti-globulin antibodies in PADH is still unclear and treatment with steroids can be considered in the right clinical context

A CASE OF HISTOPLASMOSIS SECONDARY TO POTTING SOIL

Melissa A. Colaluca¹; Matthew Widlus¹; Julia Kostka⁴; Marilyn Katz²; Lisa M. Chirch³

¹Internal Medicine, UConn Health, Farmington, CT; ²Internal Medicine, University of Connecticut School of Medicine, Hartford, CT; ³University of Connecticut, Farmington, CT; ⁴Infectious Disease, UConn Health, Farmington, CT. (Control ID #3874506)

CASE: A 73-year-old male with a past medical history of polymyalgia rheumatica, and Crohn’s disease presented to his primary care physician with complaints of hemoptysis.

Three weeks prior, the patient developed night sweats, exertional dyspnea, and pleuritic chest pain. As weeks progressed, he developed a productive cough with pink-colored sputum. The patient received certolizumab biweekly injections for Crohn’s disease. He also had a 51-pack-year tobacco smoking history. He smoked marijuana daily, growing such at home using potting soil containing bat guano. He denied a history of TB exposure and HIV testing had been negative.

Chest x-ray and chest CT revealed a focal density at the apex of the right lung. Respiratory and AFB stain and culture were negative. Quantiferon Gold Plus was negative. Histoplasma galactomannan antigen was mildly positive at 2.7. Coccidioides and Histoplasma antibodies were negative. A bronchoscopy was performed, where AFB, fungal and bacterial cultures along with cytology were unrevealing. A repeat chest CT one month after demonstrated an improved right upper lobe lesion and a new opacity in the left upper lobe.

The patient continued to clinically decline, with further weight loss and anorexia. He was started on itraconazole for presumed pulmonary Histoplasmosis. He did not tolerate this well and was transitioned to voriconazole. He clinically improved, with resolution of his cough and night sweats. A follow-up CT scan revealed improvement in the bilateral opacities.

IMPACT/DISCUSSION: Histoplasma capsulatum is a fungus that thrives in soil rich with bird or bat feces.

Outbreaks of Histoplasmosis occur during events that disturb dropping-laden soil and is transmitted by inhalation of spores. Macrophages ingest but cannot kill the fungi, and if cellular immunity is insufficient, fungi-filled macrophages enter the bloodstream and travel to organs, creating granulomas. Tumor necrosis factor (TNF) plays a significant role in Histoplasma destruction, thus, individuals receiving TNF inhibitors are more likely to experience disseminated disease. While low-inoculum typically is asymptomatic, increased exposure may result in pulmonary Histoplasmosis.

Although culture is the gold standard for Histoplasmosis diagnosis, this patient was never culture-positive. While his Histoplasma urinary antigen was positive, it can cross-react with other pathogens such as Blastomyces, Coccidioides, and Paracoccidioides. Nevertheless, the patient was started on therapy for Histoplasmosis based on the positive antigen test, risk factors, imaging findings, and the constellation of symptoms. The patient may have acquired Histoplasmosis through bat-guano-containing potting soil, in addition to immunosuppression from certolizumab.

CONCLUSION: Histoplasma should be considered as a diagnosis in immunocompromised patients with new respiratory symptoms in addition to classic imaging findings. Maintaining a high index of clinical suspicion can aid in prompt therapeutic decision-making.

A CASE OF HYPERAMMONEMIC ENCEPHALOPATHY WITH NORMAL LIVER FUNCTION IN A 92 YEAR OLD: AN UNCOMMON SIDE EFFECT VALPROIC ACID

Pratiksha Moliya¹; Azeem Arastu¹; Joseph Joseph¹; Thambirajah Nandakumar²

¹Internal Medicine, Jamaica Hospital Medical Center, Jamaica, NY; ²Neurology, Jamaica Hospital Medical Center, Jamaica, NY. (Control ID #3875945)

CASE: A 92-year-old male with a history of dementia and hypertension presented with confusion and lethargy for one day. He was started on valproic acid five days back for epileptic activities seen on the EEG during a stroke workup. On admission, his labs were significant for lactic acidosis (2.5 mmol/L) and hyperammonemia (113 umol/L; normal 11-32 umol/L). Liver function tests, hepatitis panel, and serum electrolytes were within normal limits. The CT scan of the head was unremarkable. Valproic acid was discontinued immediately and he was started on a different anti-seizure medication

(oxcarbazepine) along with oral lactulose. Within one day, the ammonia level returned to normal range

(9.8 umol/L) and his mental status returned to baseline. It was concluded that the patient had developed valproate-induced hyperammonemic encephalopathy (VHE). At one month follow-up, he was awake and alert, and reported no complaints.

IMPACT/DISCUSSION: Valproic acid (VPA) is commonly used to treat migraines, epilepsy, and multiple other mental disorders. VHE is a rare but dangerous adverse effect of using valproic acid.

Although asymptomatic hyperammonemia occurs in 15-50% of valproate-treated patients, the reported incidence of VHE is only 1-2.5%. If left untreated VHE can cause raised intracranial pressure, seizures, coma, and even death. However, with timely recognition and appropriate treatment, it can be reversed. The exact mechanism of VHE is unclear, but it is thought to be caused by VPA induced inhibition of various enzymes of the urea cycle including carbamoyl phosphate synthetase-1 and N-acetylglutamate synthase, and by reduced hepatic carnitine synthesis which leads to a build-up of ammonia. The mainstay of treatment is discontinuation of VPA, lactulose, L-carnitine supplementation, and hemodialysis if medical therapy fails. It is important to note that the degree of encephalopathy is not directly related to serum VPA levels, which might be in the normal range.

CONCLUSION: For patients on valproate presenting with confusion, the possibility of VHE must always be entertained. With prompt recognition, discontinuation of valproate, and with treatment with lactulose, VHE can be easily reversed. Delaying the diagnosis can potentially be fatal.

A CASE OF LEFT LEG NECROTIZING FASCIITIS CAUSED BY STREPTOCOCCUS PYOGENES IN A HEALTHY JAPANESE MAN.

Miyu Takagi¹; Takaaki Kobayashi⁴; Sandra Moody²; Akina Fukushima³; Akihito Yoshida³

¹General medicine, Kameda Medical Center, Kamogawa, Chiba, Japan; ²Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA; ³General Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan; ⁴University of Iowa Hospitals and Clinics, Iowa City, IA. (Control ID #3872007)

CASE: A 50-year-old man with no past medical history presented with left leg pain. One day prior to admission, the left leg pain gradually started when he was working at a construction site. On the day of admission, the pain progressively worsened with appetite loss and shaking chills. He denied sore throat or recent trauma. On physical examination, his temperature was 38.4°C, blood pressure 115/67 mmHg, and heart rate109 beats per minute. Mild erythema of his left thigh to lower leg was noted. While tenderness of the left proximal thigh matched the area of erythema, tenderness of the distal left leg did not. Computed tomography of the left leg showed swelling in the subcutaneous fatty tissue without obvious gas, or abscess. During the initial evaluation, his systolic pressure decreased to the 80’s mmHg. Necrotizing fasciitis (NF) was suspected, and surgical exploration conducted. Necrotic lesions were seen in the deep soft tissue including the fascia, and the peripheral blood vessels were compressed by necrotic lesions. Emergency debridement was performed, and he was started on vancomycin and clindamycin intravenously. After streptococcus pyogenes (GAS) was identified from the culture of the operative specimens, vancomycin was discontinued, and penicillin G was added to the clindamycin. Clindamycin was continued for 10 days and penicillin G was continued through day 30. He was discharged home on day 36.

IMPACT/DISCUSSION: NF is a life-threatening infection that spreads along the fascial planes. Risk factor include diabetes mellitus, liver cirrhosis, obesity, malignancy, heart failure, and kidney disease. However, NF due to GAS may occur among patients without penetrating trauma who have no other risk factor. Since cutaneous manifestations with NF due to GAS can be initially minimal, the diagnosis may be delayed. One of the characteristic symptoms of NF is severe pain out of proportion to exam findings. While laboratory testing is generally not specific, radiographic imaging can be helpful if gas is identified in soft tissues. Early recognition is critical given that a patient with NF is at high risk for systemic toxicity, limb loss and/or death. Although our patient presented only with mild erythema of his left lower extremity, severe pain out of proportion to the cutaneous findings with acutely worsening vital signs helped us suspect NF. Treatment for NF consists of surgical debridement and antibiotics therapy. For NF due to GAS, a combination of penicillin and a bacteriostatic, such as clindamycin or linezolid that inhibits toxin production, should be continued for at least 2-3 days. Mortality has been reported to be close to 100% in the absence of surgical debridement.

CONCLUSION: NF should be suspected when a patient presents with pain out of proportion to skin findings. When NF is suspected, emergent surgical exploration and debridement are required, given that antibiotics without surgery is associated with a high mortality rate.

A CASE OF LISTERIOSIS PROGRESSING TO LISTERIA MENINGITIS

Tony Huynh. Internal Medicine Residency, Washington State University, Pullman, WA. (Control ID #3855082)

CASE: A 63-year-old female with history of alcoholic cirrhosis, COPD, and C. difficile infection presented to the emergency room after an acute tonic-clonic seizure. Her husband reported the patient had a 1-week cough, alcohol use of 1-2 drinks daily, and one year of chronic diarrhea. Subsequent interview revealed they recently changed grocery stores and consumed unwashed vegetables a few weeks prior.

At admission, the patient was somnolent, unresponsive, and with an upper extremity tremor. She was tachycardic, her lungs had reduced air movement at the bases, and her abdomen exam was unremarkable. Admission labs include WBC 25.4, AST 50, ALT 18, ALP 406, Ethanol <10, and lactate 1.7. Her urinalysis and MRI brain were unremarkable. Chest X-Ray revealed diffuse airspace disease throughout the right lung. Her initial EEG revealed frequent sharp waves with a propensity for the right frontal lobe.

Empiric Meningitis treatment was started utilizing ceftriaxone, cefepime, vancomycin, and acyclovir. Seizure prophylaxis was Levetiracetam and Lacosamide. Oral vancomycin was given for C. difficile gastroenteritis and azithromycin for Community-Acquired Pneumonia. On Day 2, the patient was intubated because of acute respiratory failure from aspiration pneumonia in right lower lobe. Her blood cultures grew Listeria Monocytogenes. Lumbar puncture revealed 728 WBC, 82 RBC, 61% neutrophils, 9% Lymphocytes, Glucose 59, and Protein 400. CNS pleocytosis with L. Monocytogenes bacteremia confirmed Listeria Meningitis.

Treatment consisted of 14-days of gentamicin and 28-days of ampicillin. She was extubated on Hospital Day 10. Her mentation gradually improved, and she was discharged on Day 35.

IMPACT/DISCUSSION: Listeria monocytogenes is an uncommon bacterial pathogen in Washington, with 10-25 cases of Listeriosis a year. Listeriosis is a foodborne illness caused by ingestion of L. monocytogenes, found in dairy products, vegetables, fruits, poultry, fish, and meats. Infections are usually limited and may cause fever, malaise, nausea, and diarrhea. For this patient, her chronic diarrhea may have masked acute symptoms. In immunocompromised patients such as in cirrhotic patients, the infection is known to spread into the CNS causing bacterial meningitis.

Altered mental status and subsequent tonic-clonic seizures are common presentations of meningitis and should raise suspicion of potential infectious etiologies. This should expand the differential and guide history taking to understand infection source. Revisiting the history and obtaining further information from patients and family can help clarify clinical mysteries: in this patient the possible source of her Listeriosis.

CONCLUSION: Patient history can always be further elaborated, and re-interviewing can help elucidate the clinical course.

Chronic illnesses and symptoms can mask more acute issues, this patient's chronic diarrhea clouded the acute nature of her Listeria gastroenteritis

A CASE OF LUNG ADENOCARCINOMA METASTASIZING TO THE COLON

Keerthi Thallapureddy¹; isiah Gonzalez²; Ritwick Mynam²; Farah Ladak³; Patrick Snyder³

¹Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ²School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ³Gastroenterology, The University of Texas Health Science Center at San Antonio, San Antonio, TX. (Control ID #3858098)

CASE: A 72-year-old woman with hypertension presented to the emergency room with five days of left leg swelling and cramping. She had two months of persistent cough which was presumptively treated as pneumonia with multiple antibiotics without improvement. She reported an unintentional 25-pound weight loss over the prior month. Her physical exam was pertinent for tachycardia with a pulse of 135 and left lower extremity (LLE) edema, erythema, and tenderness to palpation. Chest x-ray revealed a prominent left pulmonary hilum and left upper zone airspace opacities. Ultrasound (US) revealed LLE deep venous thrombosis, and heparin was initiated. Computed tomography (CT) showed no evidence of pulmonary embolism; however, diffuse left pulmonary tree-in-bud ground glass opacities, consolidation in the lingula and left upper lobe, diffuse lymphadenopathy, and a moderate-sized left pleural effusion were noted. Cytology from endobronchial US and thoracentesis were consistent with malignant pleural effusion from primary lung adenocarcinoma. CT of the abdomen and pelvis demonstrated enlarged mesenteric lymph nodes, circumferential wall thickening of the sigmoid colon, and potential adrenal metastasis. No correlation with the sigmoid thickening on CT was found on colonoscopy; however, two incidental 4 mm polyps in the cecum and ascending colon were resected. Biopsy showed poorly differentiated adenocarcinoma consistent with metastatic lung adenocarcinoma.

IMPACT/DISCUSSION: This is a rare case of metastatic lung adenocarcinoma found incidentally as two polypoid lesions on colonoscopy in a patient with no gastrointestinal (GI) symptoms. Lung cancer is the third most common cancer in the United States and has the highest mortality, with up to 50% of patients having metastases at the time of diagnosis. Common sites of metastasis include the adrenal glands, brain, bone, and liver. GI metastasis from primary lung cancer is unusual, with a prevalence of 4.7-14%. The stomach is the most common site of GI spread. Metastasis to the colon is incredibly rare at an estimated 0.1% of all metastatic non-small cell lung cancer (NSCLC), and this case joins a limited number of similar case reports in the literature. While the colon metastases lacked clinical or prognostic significance in this patient without symptoms and with known metastatic disease, colon metastases may cause bowel obstruction or represent the first sighting of NSCLC or NSCLC spread. Our case demonstrates the importance of expanding the differential diagnosis to cancer metastases when polyps are seen on colonoscopy in a variety of clinical settings.

CONCLUSION: 1. Although unusual, NSCLC can metastasize anywhere in the GI tract.

2. Colonic metastasis of NSCLC is incredibly rare and can present incidentally or symptomatically.

3. NSCLC may be initially diagnosed or upstaged based on detection on colonoscopy.

A CASE OF LYMPHANGIOLEIOMYOMATOSIS

Amlak Bantikassegn, Sanket Pattanaik

Internal Medicine, Wake Forest Baptist Medical Center, Winston- Salem, NC. (Control ID #3876913)

CASE: A 49-year-old female with no major past medical history presented to an urgent care clinic due to progressive shortness of breath. The exact onset of shortness of breath was two years ago, but the patient had worsening respiratory symptoms over the past two months. She denied associated cough, sputum production, fever, chest pain, palpitations, or lower extremity edema. She had an echocardiogram and cardiac stress test done four months prior, which were negative. She denied tobacco use, recent travel, or sick contacts. She works as an administrative assistant. Labs done during a clinic visit a week prior showed only mild leukocytosis. Chest X-ray showed diffuse interstitial changes. An outpatient high-resolution chest CT was ordered but not completed. On physical exam, the patient was afebrile and saturating 92% on room air. She had moderate respiratory distress with mild wheezing on auscultation in all lung fields. Due to the new onset of hypoxic respiratory failure, she was transferred to the nearest emergency department (ED).

Upon arrival to the ED, the patient was placed on 2 liters nasal cannula. A CT PE study was done to rule out a pulmonary embolism, which incidentally showed numerous cystic lesions throughout all lung fields. There was no evidence of consolidation or embolism. She was given a one time dose of intravenous methylprednisolone and ipratropium bromide/albuterol nebulizer treatment and admitted to the medicine floor with a pulmonology consult.

IMPACT/DISCUSSION: Lymphangioleiomyomatosis (LAM) is a rare lung disease that mainly affects women in their 30s /40s and is characterized by cysts secondary to proliferation of immature smooth cells and perivascular epithelioid cells called LAM cells. The condition can be spontaneous (sporadic LAM), but is also associated with tuberous sclerosis complex (mutations in the TSC1 or TSC2 genes that lead to constitutive activation of the mTOR pathway). Sporadic LAM is estimated to affect 3.3 to 7.4 per million women worldwide. Diagnosis is dependent on high resolution CT, which will demonstrate multiple thin- walled cysts within the lung parenchyma (Figure 2). Pathology can be confirmed with transbronchial biopsy or video-assisted thoracoscopic lung biopsy. Patients can present with symptoms similar to asthma or COPD, including: shortness of breath, chest pain, small volume hemoptysis, or even more dramatically with a spontaneous pneumothorax or chylothorax. There currently is no curative strategy other than a lung transplant, but it has been shown that mTOR inhibitors (e.g. sirolimus) may slow down the deterioration of lung function which is assessed periodically with pulmonary function tests.

CONCLUSION: This case describes a rare pulmonary etiology known as LAM, which is characterized by enumerable cystic lesions of the lung parenchyma. Its clinical presentation may be mistaken for other obstructive lung diseases (COPD and Asthma) and radiographic imaging is necessary to make the delineation.

A CASE OF MYELIN OLIGODENDROCYTE GLYCOPROTEIN ANTIBODY-ASSOCIATED DISEASE (MOGAD)

Mina A. Shenouda¹; Violetta Laskova³; Yuhong Yang¹; Maria Riasat²

¹Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY; ²internal medicine, Mount Sinai Beth Israel Hospital, New York, NY; ³Medicine, MSBI, New York, NY. (Control ID #3871881)

CASE: A 27-year-old male originally from Panama with a nonsignificant medical history presents to the hospital with one week of bilateral eye pain on extraocular movement, headache, sensitivity to light, and blurry/ yellow vision. The physical exam is notable for eye redness, bilateral disc edema on the fundus exam, and visual acuity of 20/30 in both eyes. MRI Brain and Orbits show swelling and enhancement of both optic nerves' mid to distal intra-orbital segments, consistent with optic neuritis and two punctate T2 signal hyperintense foci without enhancement in the cortical right frontal white matter. MRI of the cervical and thoracic spine is unremarkable. Methylprednisolone 1g intravenous was started for optic neuritis and concern for multiple sclerosis (MS). Lab workup showed HIV, RPR, ANA, ANCA, and NMO antibodies are negative. A lumbar puncture revealed elevated myelin basic protein 4.4, no oligoclonal bands or toxoplasma IgG antibodies, albumin 22 mg/dl, WBC count 16/uL, RBC count 0/ul, lymphocyte 78%, and monocyte 22%. The patient subjectively improved after 48 hours of steroids with the complete resolution of symptoms. He was discharged on prednisone 60 mg PO daily for 11 days then tapered per optic neuritis treatment trial. After two weeks, MOG antibodies (abs) came positive with elevated MOG FACS titer, S 1:1000, and a diagnosis of myelin oligodendrocyte glycoprotein antibody disease (MOGAD) was made.

IMPACT/DISCUSSION: MOGAD is a rare immune-mediated demyelination of the central nervous system (CNS) predominantly targeting the optic nerves, brain, and spinal cord. The median age onset is 20 to 30 years. The function of MOG has not been fully elucidated. However, its location on the CNS makes it a target for the MOG abs causing demyelination of CNS and overlap with MS and aquaporin-4-immunoglobulin G positive neuromyelitis optica spectrum disorder. Hence, it is very crucial to distinguish MOGAD from MS since some MS treatments appear to be ineffective. The diagnostic criteria consist of positive MOG abs, CNS symptoms mainly optic neuritis, and exclusion of alternative diagnosis. Our case resembles a patient with optic neuritis who was found to have positive MOG abs and didn’t meet an alternative diagnosis. His symptoms significantly improved on steroids and were discharged on a prednisone taper. The overall prognosis of MOGAD is favorable with its course divided into the monophasic or relapsing course.

CONCLUSION: MOGAD should be suspected in young adults who present with bilateral optic neuritis without other classic symptoms of MS. Also, acute disseminated encephalomyelitis-like presentations accompanied by T2 hyperintense lesions in the brain should raise suspicion for the diagnosis. MOG ab is the gold standard diagnostic test. The treatment of choice for acute attacks is Methylprednisolone IV 1g for 5 consecutive days with rapid response in most cases that serve as a diagnostic tool as well. Slow prednisone taper over a few months may reduce the risk of early relapse.

A CASE OF NON-FATAL SEVERE HYPOKALEMIA INDUCED BY STARVATION WITH CONCOMITANT DIURETIC USE

Nneka U. Chukwu, Ayesha Munir, Olushola Ogunleye, Brett Erdreich. Internal Medicine, Vassar Brothers

Medical Center, Poughkeepsie, NY. (Control ID #3874003)

CASE: 74-year-old female with history of atrial fibrillation, COPD, heart failure, and hypothyroidism presented to VBMC emergency department with fatigue, poor oral intake, and shortness of breath of five days duration. Review of systems was negative for fever, chest pain, palpitations, lightheadedness, muscle aches, vomiting, diarrhea, and constipation. The patient had been taking oral furosemide 40 mg intermittently for diuresis but denied excessive use over the preceding days. On initial examination, vital signs were remarkable for BP of 73/54 mmHg and oxygen saturations of 91% breathing ambient air. The patient was euthermic, appeared well-oriented, and neurologically had normal muscle strength and reflexes. Notable laboratory data included: WBC count of 21.1 × 106/μL, potassium of 0.8 mmol/L, sodium of 125 mmol/L, magnesium of 1.2 mg/dL, troponin of 0.4 ng/mL, and creatinine of 3.69 mg/dL. Urine potassium level and urine anion gap were 29.3 and 20, respectively. Electrocardiography depicted ST segment depression and U waves in contiguous leads.

The patient was admitted to the intensive care unit (ICU) for aggressive electrolyte repletion (via oral and central venous routes), volume resuscitation, and close cardiac monitoring. She had normal thyroid stimulating hormone and cortisol levels. She responded appropriately to electrolyte repletion and, by day 3, was transferred out of the ICU. The remainder of her hospital course was unremarkable. Following restoration of normal renal function and overall clinical improvement, she was discharged on day 7.

IMPACT/DISCUSSION: When compared to similar patients with normokalaemia, hypokalemia is associated with a higher all-cause mortality for common conditions such as heart failure, CKD, and diabetes. Symptoms generally do not manifest until serum potassium falls below 3 mEq/L. The severity of clinical manifestations is often proportional to the degree and rate of reduction in serum potassium. The spectrum of clinical manifestations ranges from asymptomatic to lethal heart arrhythmias. Patients presenting with hypokalemia will often have varying degrees of muscle cramps/weakness, intestinal paralysis, rhabdomyolysis, and fatal complications of respiratory failure and cardiac death. Interestingly, another underrecognized complication of hypokalemia is kaliopenic nephropathy, in which hypokalemia impairs renal tubular transport and induces tubulointerstitial nephritis.

CONCLUSION: This case highlights classic electrocardiographic findings of severe hypokalemia (ST depression and U waves) as well as uncommon manifestations of kaliopenic nephropathy. Despite the severity of our patient’s electrolyte abnormalities relatively minor symptoms of hypokalemia were present; suggesting a prolonged reduction in her serum potassium levels. This case highlights the importance of identifying the various clinical manifestations of severe hypokalemia, rapid disposition, and treatment to forestall life-threatening complications.

A CASE OF NON-FATAL SEVERE HYPOKALEMIA INDUCED BY STARVATION WITH CONCOMITTANT DIURETIC USE

Nneka U. Chukwu¹; Olushola Ogunleye¹; Brett Erdreich²

¹Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ²Critical Care/Pulmonology, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #3867696)

CASE: Our patient is a 74-year-old female with history of atrial fibrillation, heart failure, and hypothyroidism who presented to the emergency department with 5 days of fatigue, shortness of breath and poor oral intake (with her daily diet now comprising of just apple sauce and Jell-o). Review of systems was negative for fever, chest pain, palpitations, lightheadedness, muscle aches, vomiting, diarrhea, and constipation. The patient had been taking oral furosemide 40 mg intermittently for diuresis but denied excessive use over the preceding days. She reported no history of alcohol intake. On initial examination, vital signs were remarkable for blood pressure of 73/54 mmHg and oxygen saturation of 91% breathing ambient air. The patient was euthermic, oriented, and had normal muscle strength and reflexes. Notable laboratory data included: white blood cell count of 21.1 × 106/μL, potassium of 0.8 mmol/L, sodium of 125 mmol/L, magnesium of 1.2 mg/dL, troponin of 0.4 ng/mL, and creatinine of 3.69 mg/dL. Urine potassium level and urine anion gap were 29.3 and 20, respectively. Electrocardiography depicted ST segment depression and U waves in contiguous leads. The patient was admitted to the intensive care unit (ICU) for aggressive electrolyte repletion via oral and parenteral routes, volume resuscitation, and close cardiac monitoring. She had normal thyroid stimulating hormone and cortisol levels. She responded appropriately to electrolyte repletion and, by day 3, was transferred out of the ICU. Following restoration of normal renal function and overall clinical improvement, she was discharged on day 7.

IMPACT/DISCUSSION: When compared to similar patients with normokalaemia, hypokalemia is associated with a higher all-cause mortality for common conditions such as heart failure, chronic kidney disease, and diabetes. Symptoms generally do not manifest until serum potassium level falls below 3.0, the severity of clinical manifestations is often proportional to the degree and rate of reduction in serum potassium. The spectrum of clinical manifestations ranges from asymptomatic to lethal heart arrhythmias. Patients presenting with hypokalemia will often have varying degrees of muscle cramps/weakness, intestinal paralysis, rhabdomyolysis, or fatal complications of respiratory failure and/or cardiac death. Interestingly, another underrecognized complication of hypokalemia is kaliopenic nephropathy in which hypokalemia impairs renal tubular transport and induces tubulointerstitial nephritis. Our case highlights classic electrocardiographic findings of severe hypokalemia as well as uncommon manifestations of kaliopenic nephropathy.

CONCLUSION: Despite the severity of our patient’s electrolyte abnormalities, relatively minor symptoms of hypokalemia were present suggesting a slow decline in her serum potassium levels. This case highlights the broad range of clinical presentations of severe hypokalemia, but rapid recognition and treatment is important to avoid life-threatening complications.

A CASE OF NON-TRAUMATIC, NON-EXERTIONAL RHABDOMYOLYSIS WITH ASSOCIATED PERONEAL NEUROPATHY

Melanie Rosado, Heather Balch

Department of General Internal Medicine, University of Utah, Woods Cross, UT. (Control ID #3877258)

CASE: A 20-year-old female with type 1 diabetes, hypothyroidism, and history of a pituitary mass presented with a five-day history of sudden onset bilateral foot pain with numbness and lower extremity edema. The initial assessment showed lower extremity weakness and tense edema, sodium 107, potassium 3.4, chloride 76, and CK 77,000. Workup showed TSH 13.53, T4 <0.42. She was found to have adrenal insufficiency (AI) likely secondary to her pituitary mass, with cortisol 1.8, ACTH 2.4. Differential for her rhabdomyolysis (RM) included myxedema versus hyponatremia secondary to her AI, with AI thought to be more likely given the relatively mild hypothyroidism. There was concern for compartment syndrome (CS) given the RM and lower leg anterior compartment fasciotomies were performed. No compartment pressures were checked, but she was found to have muscle necrosis. The patient had persistent foot drop and neuropathic pain and was discharged in foot drop boots with fludrocortisone, hydrocortisone, levothyroxine, and pregabalin. Two weeks later she was re-admitted with persistent unchanged bilateral lower extremity pain, numbness, swelling, and foot drop.

IMPACT/DISCUSSION: Non-traumatic, non-exertional RM can be due to electrolyte abnormalities, endocrinopathies, genetic etiologies, toxins, medications, infections, and inflammatory myopathies. Our case demonstrates a patient with severe hyponatremia and mild hypothyroidism who developed RM and probable CS with severe neuropathy. Hypothyroidism is thought to cause RM by inhibiting glycogen breakdown and damaging mitochondria. There are multiple case reports of hypothyroid myopathy with CS secondary to RM and resultant nerve damage. However, in most of these cases the TSH is above 50. Given our patient’s mildly elevated TSH, hypothyroidism may have contributed to her RM but her hyponatremia was more likely the primary etiology. Hyponatremia is a rare cause of RM, and its possible mechanisms remain unclear. The current proposed mechanism involves cell membrane disruption as a result of sodium-potassium ATPase dysfunction. In RM, nerve damage is most often caused by mechanical compression from prolonged immobility or edema from CS. However, neuropathy has also been described in those who do not have CS, likely secondary to nerve inflammation from surrounding muscle damage. Peroneal nerve damage with resultant foot drop is a known complication of RM when it causes anterior leg CS. Recovery of nerve function is variable. Our patient had severe pain and weakness, with minimal recovery after many weeks.

CONCLUSION: In patients with non-traumatic, non-exertional RM, the differential diagnosis should include electrolyte abnormalities, endocrinopathies, toxins, medications, infections and genetic or autoimmune conditions. Complications of RM include CS and peripheral neuropathy, both of which contribute to pain. Additionally, little is known about the prognosis of patients with neuropathy related to RM.

A CASE OF OPIOID USE AMNESTIC SYNDROME

Mariam Alamgir, Darren Pouv

Internal Medicine, Washington State University, Pullman, WA. (Control ID #3875675)

CASE: A 28-year-old male with medical history of polysubstance abuse was found down altered at home with multiple foil packets around him by his family after losing contact for 4 days. On arrival to ED, he was confused, vomiting, and was intubated for airway protection. Urine toxicology was positive for benzodiazepines, opiates, and fentanyl. Blood ethanol level was normal. Labs notable for leukocytosis, hypokalemia, AKI, lactic acidosis, and rhabdomyolysis. Urinalysis and TSH were normal. CT head was normal. There was concern for seizures and infection. EEG, LP, meningitis panel were unremarkable.

After extubation, his neurological exam was normal except he demonstrated moderate retrograde amnesia and mild anterograde amnesia that lasted for two days. He had no recollection of days prior to his admission. Moreover, his cognitive and social skills were regressive. He was noted to prefer laying in fetal position, was socially awkward, and had pseudobulbar affect with uncontrollable crying. MRI brain with and without contrast 4 days into hospitalization showed symmetric diffusion abnormality involving insular cortex bilaterally with mild cortical thickening in these regions.

Over the next few days, his mental function improved and almost back to baseline prior to discharging home. Repeat MRI 11 days into hospitalization showed resolution of diffusion abnormality but presence of chronic small vessel disease.

IMPACT/DISCUSSION: Opioid-associated amnestic syndrome (OAS) is a recently defined clinical and radiologic entity characterized by acute onset amnesia, recent opioid use (particularly fentanyl), and characteristic bilateral hippocampal signal abnormalities found on MRI. Extrahippocampal abnormalities on imaging are not uncommon and vascular imaging is often negative. Several mechanisms of this phenomenon have been proposed: inhibition of inhibitory interneurons through stimulation of mu receptors or even direct neurotoxicity induced by opioids.

Our patient could be considered a case of OAS because he had new onset amnesia lasting more than 24 hours in addition to recent opioid use as confirmed on toxicology. However, he did not exhibit characteristic findings of bilateral hippocampal ischemia but instead demonstrated some mild hyperintensities in the insular cortices bilaterally. Only 19 cases of OAS have been identified in the United States and Canada. Therefore, while OAS is a recently defined clinical-radiological entity, some patients may not exhibit characteristic radiological findings even though they clinically are consistent with OAS.

CONCLUSION: As opioid use increases in the United States, clinicians should be aware of OAS. While a brain MRI may show characteristic hippocampal findings, our case illustrates a situation where the radiographical finding is not always characteristic yet we would still treat this patient with OAS. We share this in the hopes that it raises awareness of OAS and OAS like presentations in light of increasing opioid use in the United States.

A CASE OF PULMONARY EMBOLISM AND SUPRATHERAPEUTIC INR AS A COMPLICATION OF COVID-19 INFECTION IN A PATIENT ALREADY ON ANTICOAGULATION WITH WARFARIN FOR ATRIAL FIBRILLATION

Ufaq Ishtiaq¹; Thin Z. Khine¹; Muhammad Afzal Khan². ¹Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ²Internal medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #3847621)

CASE: 84-year-old man with atrial fibrillation on warfarin and COVID infection one year prior and reinfection diagnosed 10 days prior to admission, presented with fever, cough, shortness of breath and right- sided chest pain. He was vaccinated for COVID but had not received a booster dose. His international normalized ratio (INR) one week prior to admission was therapeutic at 2.8. On presentation, he was febrile (100.3°F), tachypneic (24 breaths/min) and hypoxic (SpO2 92%) with diminished breath sounds up to the right mid lung on auscultation. Labs revealed supratherapeutic INR (6.3) and elevated D dimer (847 ng/ml). Chest x-ray showed infiltrate at right base. Chest angiography showed small acute subsegmental pulmonary embolism (PE) in the left lower lobe, moderate loculated right pleural effusion and near complete collapse of right lower lobe. Warfarin was held and antibiotics, along with remdesivir and dexamethasone, were started for COVID pneumonia and suspected bacterial superinfection with possible empyema. He underwent thoracentesis, revealing exudative fluid consistent with uncomplicated parapneumonic effusion. The patient’s INR continued to rise as high as 10.8 despite being off warfarin and receiving one dose of vitamin K. Warfarin failure was suspected, but the mixing study ruled out presence of an inhibitor. His respiratory status gradually improved and he was discharged on hospital day 10, with an INR of 4.6, off of warfarin, with recommendation for close follow-up.

IMPACT/DISCUSSION: The global COVID-19 pandemic has led to over six million deaths worldwide as of August 2022. The clinical spectrum ranges from asymptomatic to mild respiratory/gastrointestinal symptoms to severe respiratory distress, shock, multiorgan failure and venous/arterial thromboembolism. Severe COVID-19 infection contributes to the three major components of Virchow’s triad (endothelial injury, stasis and hypercoagulable state), leading to thromboembolic complications. Severe respiratory distress syndrome and multiorgan dysfunction in COVID leads to a state of consumptive coagulopathy similar to disseminated intravascular coagulation, evidenced by thromboinflammatory biomarkers, including elevated D-dimer, prolonged PT/INR and thrombocytopenia. Studies have shown increased severity and mortality with prolonged INR in COVID. This patient developed PE while therapeutic on warfarin. Suspicion of PE was initially low given patient’s anticoagulation and supratherapeutic INR, along with other causes, such as pneumonia and pleural effusion. The patient also had persistent rise in INR despite stopping anticoagulation. Given the myriad presentation of COVID, it was important to consider thromboembolism and elevated INR as potential complications, irrespective of the anticoagulation status.

CONCLUSION: This case highlights the importance of recognizing COVID as a cause of persistent supratherapeutic INR and thromboembolic complications before considering other potential causes, including warfarin failure.

A CASE OF RECURRENT BENIGN ESOPHAGEAL STRICTURE COMPLICATING MANAGEMENT OF THYROID STORM

Rossana Seno¹; Valerie Cluzet²

¹Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ²Infectious Disease/Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #3876178)

CASE: A 74-year-old male with Graves’ disease presented to the emergency room with one week history of intractable regurgitation and vomiting associated with diarrhea, 10-lb weight loss, palpitations and tremor. There was no recent history of travel, sick contacts or exposure to iodinated contrast. Two weeks prior, he had run out of propylthiouracil (PTU) and did not receive a refill. Past medical history was significant for recurrent benign esophageal stricture status post fourth balloon dilatation nine months ago. Starting two months ago, he had progressive dysphagia. In the ER, he was hypertensive, tachycardic (HR 136 bpm) but afebrile (Temp 98.1⁰F) and was breathing normally on room air. He was alert, cachectic, clinically dry and tremulous. Initial labs were consistent with hyperthyroid state, low TSH (<0.01 mcIU/ml), elevated FT4 (5.28 ng/dL), acute kidney injury and anion gap acidosis. He was admitted for impending thyroid storm (Burch-Wartofsky Scale 30) and possible recurrence of esophageal stricture. IV hydration, PTU and propranolol were promptly initiated. On hospital day 1, he had paroxysmal rapid atrial fibrillation (HR 170s) and progressed to thyroid storm (Burch-Wartofsky Scale 55). Propranolol was changed to IV metoprolol and amiodarone drip was started. PTU, however, could only be given orally since no other preparation was available. Esophagogastroduodenoscopy (EGD) and dilatation was planned once stabilized. On the 2nd hospital day, worsening organ failure was evident: his kidney function worsened, total bilirubin increased and he became hypoxic (SPO2 91%). After multidisciplinary discussion, decision was made to proceed with EGD. It showed a benign-appearing, intrinsic severe stenosis with an inner diameter of only 8 mm. Balloon dilatation was performed. After the procedure, he tolerated clear liquid and oral medications. On the 3rd hospital day, his kidney function improved, acidosis resolved and cardiac rhythm converted to sinus. On hospital day 4, diet was advanced to soft and he was discharged with plan for close follow up and repeat dilatation in one month.

IMPACT/DISCUSSION: Thyroid storm is a rare, life-threatening condition characterized by multiple organ dysfunction due to exaggerated thyrotoxic state. It is associated with mortality rate 12 times higher than those with thyrotoxicosis. Noncompliance or abrupt cessation of thionamides is the most common precipitating event. Prompt initiation of treatment geared towards controlling symptoms, thyrotoxicosis and underlying precipitating factor is crucial to improve outcome. This case highlights the complexity of the management of thyroid storm when confounded by severe esophageal stricture. Timely intervention toward the latter condition, despite risk of decompensation, had proven life-saving.

CONCLUSION: Thyroid storm is a life-threatening emergency that requires early recognition and prompt treatment. Identification and aggressive intervention of the precipitating factor is critical to improve outcome.

A CASE OF REFRACTORY MPOX, FOOD/HOUSING INSECURITY, AND QUESTIONABLE SULFA ALLERGY

Bhavya Ancha¹; Gregory Troutman³; Thomas Vazquez³; Timothy Buckey²; Patricia Takach²; Zsofia Szep³; Katherine Bar³

¹University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²Allergy/Immunology, Penn Medicine, Philadelphia, PA; ³Infectious DIsease, Penn Medicine, Philadelphia, PA. (Control ID #3874767)

CASE: A gentleman in his 50s with a PMH advanced HIV/AIDS, food/housing insecurity, and recent incarceration (with possible exposure to mpox while working for the prison’s medical waste disposal service) presented with diffuse cutaneous lesions of severe mpox. He had been diagnosed 7-8 weeks prior and treated with oral tecoviromat (an antiviral with activity against orthopox viruses that requires high fat/calorie diet for absorption) with initial improvement but had subsequent progression of disease in the setting of housing/food insecurity. He was treated at an outside facility with IV tecoviromat for 7 days with minimal improvement. Upon admission to the infectious disease service, his home HIV medications were continued. Due to relapse of his mpox and concern for refractory, drug-resistant mpox, treatment was initiated with IV tecovirimat and IV cidofovir (an antiviral used to treat cytomegalovirus that has in vitro activity against orthopox infections with limited clinical data). Due to nephrotoxicity associated with cidofovir, this infusion is preceded and followed by IV fluids and oral probenecid (a uric acid reducer with a sulfonamide group) for renal protection. During intake, the patient reported an allergy (acute respiratory symptoms) to trimethoprim-sulfamethoxazole (a sulfonamide antibiotic). The risk of allergy to sulfonamides called into question the safety of using probenecid and thus cidofovir. However, the patient’s advanced mpox disease in the setting of prolonged exposure to likely subtherapeutic levels of tecoviromat raised concern for drug resistance and the effectiveness of tecoviromat even at appropriate levels. After consultation, the allergy/immunology service recommended a graded probenecid challenge, which the patient tolerated. Thus, he received combination therapy with tecovirimat and cidofovir.

IMPACT/DISCUSSION: This case highlights lessons spanning treatment of resistant mpox and allergic cross reactivity of sulfonamide drugs. Firstly, people living with HIV account for most US cases of severe mpox and tend to have a higher incidence of drug allergies. Regarding sulfonamide antibiotics, delayed hypersensitivity reactions are most common. However, probenecid is a sulfonamide non-antibiotic, and existing data questions the allergic cross-reactivity between sulfonamide antibiotics and non-antibiotics Lastly, the lack of societal support in obtaining a high fat/calorie diet (needed for oral tecovirimat absorption) was a likely precipitant for progression and relapse of this patient’s mpox. This serves as a potent reminder of the importance of social determinants of health, how they drive healthcare outcomes, and our duty as providers to be acutely aware of them.

CONCLUSION: In conclusion, this case provides an interesting framework to review emerging therapies in mpox treatment, to discuss a common drug allergy and its potential interference with a now infrequently used medication, and to reflect on the disparities that dictate healthcare outcomes.

A CASE OF SCARLET FEVER IN AN ADULT PATIENT

Ariel Bar-Mashiah¹; Lauren Mitchell²

¹Medicine, Weill Cornell Medicine, New York, NY; ²Internal Medicine, Weill Cornell Medicine, New York, NY. (Control ID #3876743)

CASE: ES is a 42 year-old woman with history of migraines who presented to the ED with five days of nausea, vomiting, fever and rash.

The patient reported that five days prior she developed nausea, vomiting and headache that was similar to her prior migraines. She took Tylenol and the next day noticed a "rough-feeling" rash that started in her groin and soon spread through her entire body, most notably on her face, back and inner thighs. One day prior to presentation she developed a fever to 102.0 F, associated with chills, myalgias and watery diarrhea.

The patient reported that the rash was mildly itchy, not evanescent in nature, did not show evidence of desquamation and was without blisters, pustules or vesicles. The rash spared her palms and soles.

In the emergency department vitals were notable for T 38.7, HR 132, otherwise, vitals including BP were within normal limits. On physical exam, patient was found to have a "sandpaper-like rash" and beefy red tongue. A pelvic exam was done to assess for a foreign body, however, no foreign body was found. UA, EBV, CMV, and respiratory pathogen panel were negative. Of note, anti-streptolysin O antibody was positive (level 748). The patient was started on vancomycin and piperacillin/tazobactam. Upon starting antibiotics, the patient's rash improved significantly and she became afebrile within 24 hours. Given the rash and red tongue with improvement on antibiotics, infectious disease and dermatology teams believed this presentation was secondary to scarlet fever.

IMPACT/DISCUSSION: Scarlet fever is a diffuse erythematous eruption that generally occurs in association with pharyngitis in the setting of prior exposure to S. pyogenes, and is the result of a delayed-type skin reactivity to pyrogenic exotoxin. Patients usually develop a blanching "sandpaper-like" rash that starts in the groin (as was seen in our patient) or in the armpits that then spreads centrally. Additionally, the rash tends to spare the palms and soles. Another classic finding is the "strawberry tongue". Scarlet fever is a clinical diagnosis, although historically the appearance of anti-streptolysin O antibodies can help support the diagnosis. In adult patients, an elevated anti-streptolysin O level is considered > 200. In our patient with scarlet fever, the anti-streptolysin O level was >700. Although scarlet fever typically affects children between the ages of 5-15, it has been known to affect adults with school-age children at home. Notably, it is unusual to see scarlet fever in the absence of pharyngitis.

CONCLUSION: Scarlet fever is a clinical diagnosis that can be made upon seeing a blanching "sandpaper- like" rash that spares the palms as soles as well as a "strawberry tongue" usually in the setting of pharyngitis.

An anti-streptolysin O antibody level, while helpful, is not needed to make the diagnosis. Although scarlet fever is more commonly seen in children, adults with school-age children can also develop this classic manifestation.

A CASE OF SERUM SICKNESS-LIKE REACTION FOLLOWING STREPTOCOCCAL PHARYNGITIS

Lauren Mitchell²; Peggy B. Leung¹; Helene Strauss¹

¹Internal Medicine, Weill Cornell Medicine, New York, NY; ²Internal Medicine, New York Presbyterian/Weill Cornell, New York, NY. (Control ID #3875544)

CASE: A 35-year-old man with no past medical history presented to the emergency department with 10 days of rash and joint swelling.

Three weeks prior to presentation, the patient had a sore throat and a positive rapid strep test and was treated with a five-day course of azithromycin with resolution of symptoms. Ten days prior to presentation, he developed a rash over his legs and groin. He had no fevers. A few days later, he developed intermittent swelling and pain in various joints, including ankles. The patient had also recently been traveling throughout the United States and hiking. He had had multiple recent female sexual partners.

Exam was notable for non-blanching petechial rash over bilateral lower extremities and groin. The left ankle was swollen and tender to palpation with mild erythema. The patient was afebrile.

Labs were grossly normal except for elevated anti-DNase B and antistreptolysin O titers. CBC, BMP, LFTs, ESR, CRP, IgA, C3, C4, and UA were all within normal limits. RPR, HIV, viral hepatitis serology, urine chlamydia/gonorrhea, heterophile antibody, blood cultures, blood parasite smear, and testing for Lyme, RMSF, babesia, ehrlichia, and anaplasma were all negative.

An EKG and echocardiogram were unremarkable. The patient was thought to have a serum sickness-like reaction. His symptoms improved within 24 hours and he was discharged with ID follow-up.

IMPACT/DISCUSSION: Serum sickness reactions are type III hypersensitivity reactions, where antigen- antibody complexes form and deposit in tissues, causing an inflammatory reaction. Serum sickness-like reactions have a similar clinical presentation, but the pathophysiology of serum sickness-like reactions is not completely understood, and it is not known if antigen-antibody complexes are involved.

Medications are the most commonly described cause of serum sickness-like reactions, and the literature contains reports of antibiotics (including a case report of clarithromycin), monoclonal antibodies, and some antidepressants. Infections, including streptococcal infections, and various vaccines have also been reported as triggers. In this patient, the trigger could have been the streptococcal infection or the azithromycin.

The clinical presentation of serum sickness-like reactions is a milder version of serum sickness and can include arthralgias, lymphadenopathy, rash, and sometimes fever. Symptoms typically arise within 1-2 weeks after the exposure, and generally self- resolve within a few days to weeks. A wide infectious and inflammatory differential should be investigated before diagnosing serum sickness-like reaction.

CONCLUSION: Serum sickness-like reactions can be triggered by medications, infections, or vaccines. The pathophysiology of serum sickness-like reactions is not fully understood but may be distinct from serum sickness reactions.

Patients with serum sickness-like reactions present within 1-2 weeks of exposure to the offending agent with arthralgias, lymphadenopathy, rash, and sometimes fever.

A CASE OF SEVERE HYPOCALCEMIA IN A SLEEVE GASTRECTOMY PATIENT ON DENOSUMAB

Arathi Prabha Kumar¹; Muhammad Hassan Shakir¹; Brihant Sharma¹; Omar Z. Syed²; Maria Rose

Dominic²; Aayushi Sood³

¹Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA; ²Internal medicine , The Wright Center for Graduate medical education, Dunmore , PA; ³Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, Scranton, PA. (Control ID #3875847)

CASE: Patient was a 60 years old female with past medical history of obesity requiring laparoscopic sleeve gastrectomy converted later to Single anastomosis duodenoileostomy (SADI) 3 months prior (outpatient management with supervised dietary advancements and calcium and vitamin supplementation), chronic lower extremity lymphedema on as needed torsemide, spironolactone and metolazone, psoriatic arthritis on Etanercept, and osteoporosis secondary to chronic steroid use. She was on proton pump inhibitors for a long time. She had also had malabsorptive diarrhea since the SADI procedure. She received 2 doses of Denosumab 60 mg; 6 months and 5 days before the incident presentation. The second dose was after the SADI procedure. She presented to the hospital with weakness and tingling in bilateral lower extremities and an episode of dizziness and a fall. Orthostatic vital measurements revealed orthostasis. Rest of the vital signs were within normal limits. Physical examination was unremarkable. There was no Trosseaus or Chvostek's sign on examination. On EKG, QTc interval was 472 ms. PR interval was 150 ms; there were no T wave abnormalities. Initial labs showed a Calcium of 6.7 mg/dl and Magnesium level of 1.3 mg/dl, potassium of 3.1 mmolL and Phosphorus of 1.7 mg/dl. 25 hydroxy vitamin D was 39 ng/ml and PTH was 152 pg/ml. She was managed inpatient with fluid and electrolyte repletion. Echocardiography, telemetry and CT brain were all normal. Diuretics were held due to orthostasis. Hypocalcemia was refractory to replacement but eventually normalized to 8.4 on the day of discharge. She was discharged in stable condition. Repeat calcium levels on an outpatient basis are to be followed.

IMPACT/DISCUSSION: Denosumab, a RANK-Ligand inhibitor given every 6 months as a subcutaneous injection, significantly increases the risk of high grade hypocalcemia (serum calcium < 7.0 mg/dl), especially in patients with decreased renal function or renal failure, patients who have recently undergone thyroid surgery or are receiving other medications that increase calcium loss, such as loop diuretics which our patient was also taking. Denosumab can easily be missed during the admission medication reconciliation. Malabsorptive diarrhea after SADI is a recognized complication and depends, among other factors, on the common channel length. Malabsorption can cause vitamin D deficiency and hypocalcemia with secondary hyperparathyroidism. Management of hypocalcemia includes removal of factors that increase susceptibility, like diuretics. Daily supplementation calcium and vitamin D is recommended after gastric bypass and in patients receiving Denosumab, unless hypercalcemia is present.

CONCLUSION: Obesity can be a common denominator between gastric bypass surgery and osteoporosis treatment; both of these can lead to hypocalcemia as stated above. Careful risk stratification and adequate supplementation is required in these patients to anticipate and prevent hypocalcemia.

A CASE OF SEVERE HYPOMAGNESEMIA RELATED TO PROTON PUMP INHIBITOR USE Hussein Abu-Hashish, Esraa Askar, Regine Cherazard

Medicine, Forest Hills Hospital, Forest Hills, NY. (Control ID #3875243)

CASE: A 66-year-old man with a history of left upper extremity essential tremor, chronic obstructive pulmonary disease, hypertension, hyperlipidemia, renal cell carcinoma following nephrectomy with metastatic disease to the lungs presented to the emergency department with worsening tremors and leg weakness. One day prior to admission, the patient noted acute worsening of left-sided tremors and new tremors involving his right arm and bilateral lower extremities, limiting his ability to stand and ambulate. He denied recent vomiting, diarrhea or decreased oral intake. His medications included aspirin, doxazosin, cetirizine, rosuvastatin, albuterol, amlodipine, montelukast, and pantoprazole 40 mg. A physical exam revealed prominent tremors of all extremities. Admission serologic testing was significant for a critical magnesium level of 0.6 mg/dL. Electrocardiogram revealed normal sinus rhythm with frequent premature ventricular contractions. Within 24 hours of admission, he received 3 g magnesium sulfate intravenously. His serum magnesium levels stabilized at 2.1 mg/dL over several days with noted improvement in tremors, weakness, and gait disturbance. Magnetic resonance imaging of the brain was negative for intracranial metastatic disease. No serum magnesium levels were available within the prior 9 months of outpatient records.

IMPACT/DISCUSSION: PPI use is common as a first-line therapy for diseases involving increased gastric acid secretion and gastric ulcer prevention. The association between PPI use and hypomagnesemia was first documented in 2006. Studies demonstrate a causal relationship with dose and duration of PPI use and hypomagnesemia, though intermittent administration also carries some risk. Nevertheless, it remains unclear how PPIs affect magnesium absorption because there is limited magnesium solubility in the intestinal lumen. A proposed mechanism of action includes modifications in the expression and activity of essential transporter proteins which may further lessen the absorption pathways in the small intestine and colon. PPIs alter the gut microbiome composition, which may contribute to the occurrence of hypomagnesemia.

CONCLUSION: Providers must frequently reassess indications for ongoing PPI use and remain vigilant for potentially severe complications and electrolyte disturbances. Baseline laboratory assessments in patients with a history of prolonged PPI exposure or evidence of neuromuscular excitability should include magnesium serologies.

A CASE OF UNDIAGNOSED MYOCARDIAL BRIDGING OF THE LEFT ANTERIOR DESCENDING ARTERY

Chukwudumebi S. Uche, Tiana Dodd

Internal Medicine, University of South Florida, Tampa, FL. (Control ID #3875245)

CASE: A 45-year-old male with past medical history significant for hypertension, and hyperlipidemia presented to our ED for evaluation of a 1-week history of progressive sub-sternal exertional chest pain with radiation to his left upper extremity. He reports his pain was initially relieved with rest but states he now has pain at rest. Associated symptoms include exertional dyspnea, fatigue, and diaphoresis. He denied any tobacco, alcohol, or recreational drug use. He denied any family history of coronary artery disease (CAD). On presentation to the ED, he remained hemodynamically stable. Laboratory findings notable for serial troponin levels <0.01 ng/ml and BNP of 21 pg/ml. EKG without evidence of dynamic ischemic changes and chest x-ray with no acute findings. Given his progressive chest pain and concern for evolving ACS, pharmacologic therapy with aspirin 325 mg, IV unfractionated heparin, atorvastatin 80 mg, and nitroglycerin tabs were initiated in anticipation for urgent left heart catheterization (LHC). LHC demonstrated no evidence of obstructive CAD but was remarkable for a distal-LAD myocardial bridge. Pharmacologic therapy with metoprolol tartrate was initiated for symptomatic management.

IMPACT/DISCUSSION: Myocardial bridging (MB) occurs when a segment of an epicardial coronary artery tunnels through the myocardium resulting in an overlying muscular bridge. This congenital anomaly results in compression of the tunneled portion of the artery during systole, leading to disruption in coronary blood flow and filling, thereby precipitating angina, arrhythmias, and in severe cases, myocardial infarction.

On average, MB is present in 1 in 3 adults. The high prevalence of myocardial bridging makes it a frequent, but often forgotten cause of angina. Bridging of the left anterior descending artery (LAD) is the most common, as represented in our patient. MB is benign, and most patients are asymptomatic. However, patients with severe bridging can present with clinical manifestations indicative of myocardial ischemia and may present similarly to a patient with fixed obstructive CAD, as described in our case. Given the identical presentations of both pathologies, coronary angiography is the gold standard for diagnosing MB. Treatment modalities are indicated only for symptomatic patients or patients with objective signs of ischemia. Pharmacological therapy with beta-blockers or non-dihydropyridine calcium channel blockers is the recommended first-line therapy. Nitrates are contraindicated as they may worsen symptoms due to increased compression of the tunneled artery during systole. PCI or surgical management may be considered in medically refractory cases.

CONCLUSION: - Myocardial bridging (MB) should be considered in the differential diagnosis for substernal chest pain, as it is a common but often forgotten cause of angina.

- Prompt diagnosis and management of myocardial bridging is imperative to prevent detrimental cardiac complications.

- Nitrates can acutely exacerbate symptoms in MB.

CASE REPORT OF ANTI-GBM DISEASE WITH UNUSUAL LABS

Pablo Amador Mejia¹; Barath Rangaswamy¹; Roman Karkee²; Joud Enabi³; Edgar J. Sanabria⁴

¹Internal Medicine, Texas Tech University Health Sciences Center, Odessa, TX; ²Internal Medicine, Texas Tech University Health Sciences Center, Permian Basin, Odessa, TX; ³Internal Medicine, Texas Tech University Health Sciences Center Odessa Library, Odessa, TX; ⁴Cortés, Universidad Nacional Autonoma de Honduras, Tegucigalpa, Francisco Morazán, Honduras. (Control ID #3877337)

CASE: 85-year-old female with a history of hypertension presented with progressive fatigue, weight loss, decreased urine output. She also had nasal discharge and intermittent cough. She appeared cachectic. Labs were remarkable for proteinuria, anemia with hemoglobin 10.9 9/dl, creatinine 10.6 mg/dl, BUN 106 mg/dl potassium 5.6 mmol/L ,24 hour urinary protein was 621 mg, Urine Protein Electrophoresis showed elevated urinary free light chains kappa 189.83 mg/L and lambda 93.53 mg/L. Autoimmune disease testing revealed positive p-ANCA and ANA antibodies with a speckled pattern, positive dsDNA, positive SSA antibodies, negative anti-Smith antibodies, and negative anti-GBM ( Glomerular Basement Membrane ) antibodies.

Ultrasound of the kidneys demonstrated kidneys with normal size. Renal biopsy revealed focal necrotizing and crescentic glomerulonephritis with ~90% crescents, anti-GBM antibody mediated, severe tubular atrophy with interstitial fibrosis, and severe arteriolosclerosis. Intravenous methylprednisolone was started. She underwent hemodialysis. She also received epoetin alfa, calcitriol and sodium bicarbonate. After clinical improvement, patient was discharged with plans to receive rituximab as outpatient.

IMPACT/DISCUSSION: Anti-glomerular basement membrane (GBM) disease is a rare autoimmune vasculitis responsible for 5 - 10% of cases of acute renal failure presenting with rapidly progressive glomerulonephritis. Hence, early diagnosis and timely intervention are crucial to decrease morbidity and mortality associated with it. Detection of Anti GBM antibodies, commonly IgG circulating antibodies is one of the first steps in diagnosing this condition, and confirmation requires renal biopsy with a demonstration of linear IgG deposits along the glomerular capillaries. Although P-ANCA ( MPO-ANCA) is positive in 50% of patients, it is unusual for a patient with Anti-GBM disease to test positive for P-ANCA and not for Anti- GBM antibodies.

We report a patient with crescentic glomerulonephritis with anti-GBM antibody deposits on renal biopsy in whom the standard ELISA test was negative for circulating anti-GBM antibodies but positive for P-ANCA.

ELISA test has high sensitivity and specificity for anti-GBM antibodies. False-negative results, although rare, may be seen if the disease is caused by non-IgG immunoglobulins like IgA or IgM or if the overall antibody titer is lower than the detection level. ANCA-associated vasculitis and Anti-GBM disease have similar presentations and serological overlap, which may be challenging for clinicians to differentiate. Specific tests like Western blot and biosensor assay may detect Anti-GBM antibodies even when conventional tests are falsely negative. Renal biopsy gives the definitive diagnosis.

CONCLUSION: False negative results of anti GBM antibodies can occur and they may cause a diagnostic challenge for timely diagnosis of Anti GBM disease. Renal biopsy should not be delayed in the presence of clinical suspicion or uncertainty.

A CASE REPORT OF SOFT TISSUE AND WOUND INFECTION CAUSED BY ENTEROCOCCUS FAECALIS RESISTANCE TO VANCOMYCIN, LINEZOLID AND DAPTOMYCIN: THERAPEUTIC CHALLENGE

Sadia A. Tanami, Lochan Bellamkonda, Eman Alhussain, Falah I. Abu Hassan, Abhijit Gutal

Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX. (Control ID #3871751)

CASE: A 64-year-old male with a history of diabetes mellitus type 2 and hypertension was transferred from an outside facility for progressive worsening right lower extremity (RLE) cellulitis and gangrene of his right (R) fifth toe. Five days before the presentation, the patient experienced a penetrating injury from a nail to R fifth toe. The patient was prescribed oral trimethoprim/sulfamethoxazole and the laceration was sutured. However, the patient developed fever, local pain, and erythema to the R foot. He was subsequently admitted to an outside hospital and started on parenteral linezolid and ciprofloxacin. On initial presentation to our facility, a focused evaluation of RLE revealed a well-demarcated area of erythema, edema, warmth, and tenderness to the R mid-thigh and a necrotic R fifth toe. Laboratory studies revealed normal WBC count, ESR 64, CRP 190, and Hba1c 7.6%. The patient was started on empiric meropenem and vancomycin. Vascular surgery was consulted and performed local wound debridement with partial amputation of the gangrenous toe. Blood cultures returned negative, but the culture of wound tissue detected polymicrobial growth of Proteus vulgaris, klebsiella oxytoca, Morganella morganii, and Enterococcus faecalis (E. faecalis). Sensitivity results for the E. faecalis revealed resistance to vancomycin, linezolid, and daptomycin. However, the species was sensitive to levofloxacin, and he was started on 750mg daily. The patient’s symptoms improved clinically and discharged on oral antibiotics with wound and vascular team follow-up.

IMPACT/DISCUSSION: Enterococci are gram-positive facultative anaerobes commonly found in the gastrointestinal tract of a variety of organisms including mammals. They are reported to be the third leading cause of nosocomial infection in the world. The organism is also notorious for its high level of resistance to many commonly used antibiotics due to their intrinsic features and natural inheritance to develop acquired resistance. Multidrug-resistance enterococci (MDR) display a wide range of antibiotic resistance through modification of drug targets, inactivation of therapeutic agents, overexpression of efflux pumps, and a complex cell envelope adaptive response that assists survival in the human body and the nosocomial environment. Among MDR enterococci, vancomycin-resistant species is of particular concern. In these cases, linezolid is often recommended for treatment but daptomycin is available as another option.

CONCLUSION: This is the first case report to our knowledge where E. faecalis is resistant to vancomycin, linezolid, and daptomycin, all three major antibiotics, which added a clinical dilemma for the medical provider. Unfortunately, we do not have the genetic details of this specific strain. Proper compliance with infection control measures and good stewardship combined with targeted antibiotics is necessary to prevent antibiotic resistance among enterococcus isolates.

A CASE STUDY ON MANAGING EXPECTATIONS IN A PATIENT WITH HYPONATREMIA Priyanka Sridhar¹; Hong Yu Wang²; Geetika Arora¹; Patricia Dharapak¹

¹Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY; ²Medicine, Mount Sinai Beth Israel Hospital, New York, NY. (Control ID #3874792)

CASE: A 34-year-old man with hypertension on chlorthalidone and recent COVID-19 infection treated with Paxlovid presented with three days of shortness of breath and diarrhea. On exam he was alert, neurologically non-focal and underweight. Initial labs showed severe hyponatremia(<100 mmol/L) and hypokalemia(2.3 mmol/L). Serum osmolality was low(199 mOsm/kg) and urine osmolality and random urine sodium were inappropriate(486 mOsm/kg, 50 mmol/L respectively). Cortisol and TSH levels were normal. He was admitted to the ICU for hypertonic saline infusion and careful correction of severe, subacute SIADH from chronic thiazide diuretic use compounded by COVID-19 infection. Over 9 days, the serum sodium was slowly corrected with a delicate balance of desmopressin and salt tablets. He remained asymptomatic and was discharged home with a sodium of 132 mmol/L. Three days later, the patient returned with worsening fatigue, slow speech and involuntary clenching of the hands and jaw. Serum sodium was 137 mmol/L. Contrast brain MRI showed symmetrically increased T2 signal affecting the bilateral basal ganglia with mild diffusion weighted hyperintensity without post-contrast enhancement consistent with osmotic demyelination syndrome(ODS). He declined plasmapheresis, Baclofen and Klonopin were given for dystonia and he was discharged to an acute rehabilitation facility. Two months later, follow-up brain MRI remains unchanged but the patient is clinically improved and has no residual gross neurologic or physical deficits.

IMPACT/DISCUSSION: The prevalence of ODS is 0.25-0.5%. Risk factors include serum sodium ≤105-110 mmol/L, hyponatremia >2-3 days, malnutrition, hypokalemia, female gender, alcohol use disorder, liver cirrhosis and rapid correction. The onset of clinical manifestations is delayed and range from dysarthria, dysphagia and movement disorders to seizures, obtundation and coma. Pontine and/or extra-pontine demyelination on MRI with a corroborative clinical presentation are diagnostic. Given the variable reported long-term neurologic outcomes of patients with ODS, employing protective strategies in hyponatremia management are paramount. Sodium rise should be < 8 mmol/L in a 24-hour period and <18 in any 48-hour period. Concurrent desmopressin use can mitigate over-correction. Management strategies for ODS include acute re-lowering of sodium within 8-10 hours of symptom onset and supportive care. Plasmapheresis offers some benefit by removing pro-inflammatory myelinotoxins. Our patient had at least 4 identified risk factors and despite careful and appropriate correction of hyponatremia, ODS still developed.

CONCLUSION: We present a case of severe, subacute SIADH whose management was complicated by ODS. Theoretical medicine forms the basis for guideline directed practice, but real-world outcomes can deviate from expectations. Each case of sodium correction should be delicately approached because practice guidelines offer risk-reductive strategies but do not eliminate the risk of ODS.

A CASE YOU DON’T WANT TO MISS: IMPENDING THYROID STORM

Martha Dillon¹; Rachel A. Zielinski¹; Nicole Bambara²; Areeka Memon¹; Aleena Rajpoot¹; Matthew Tichauer³

¹Internal Medicine-Primary Car, UConn Health, Farmington, CT; ²University of Connecticut School of Medicine, Farmington, CT; ³Hospital of Central Connecticut at New Britain, New Britain, CT. (Control ID #3875531)

CASE: 21-year-old female with past medical history of intermittently treated Graves’ disease presented to an outside facility with headache, nausea, and diarrhea. Social history positive for housing insecurity and sick contacts at her shelter. Vitals revealed fever of 101 degrees Fahrenheit, 30 breaths per minute, and tachycardia of 140 beats per minute. Significant labs included elevated alkaline phosphatase 207, white blood cell count 4.0, Thyroid stimulating hormone (TSH) 0.02, and a free thyroxine (T4) of 4.00. Patient tested negative for pregnancy. Chest x-ray was clear of any acute cardiopulmonary process. Impending thyroid storm was diagnosed due to a Burch and Wartofsky's score of 35. Patient was then transferred to our hospital for ICU level of care. Repeat labs showed rising free T4 6.45. Patient started on propylthiouracil (PTU), propranolol and hydrocortisone. With treatment, her symptoms began to resolve and the patient was discharged. During follow up, patient endorsed some tremors and heat intolerance in addition to improved palpations. Once biochemically euthyroid, patient will go for definitive therapy.

IMPACT/DISCUSSION: Due to a mortality rate of 10 -30%, high clinical suspicion of thyroid storm is necessary. This acute complication can be precipitated by infection or interrupted treatment, as illustrated by our patient. Additional triggers include surgery, trauma, parturition and an acute iodine load. Due these risk factors, hospitalized patients or those with limited healthcare access have higher incidences than the general public. Symptoms include tachycardia, arrhythmias, coma, hypotension, hyperpyrexia, anxiety, altered mental status, gastrointestinal symptoms, and acute liver failure. These are reflected in the Burch and Wartofsky point scale - a diagnostic aid to distinguish between thyroid storm, impending storm, and less probable. In addition to ICU monitoring, treatment often focuses on symptoms control and preventing the conversion to biochemically active T3. Propranolol controls the increased adrenergic symptoms as well as inhibiting type 1 deiodinase. Glucocorticoids to reduce T4 to t3 conversion as well as promote vasomotor stability. Iodine solutions block release of further thyroid hormones. Thionamides block synthesis of de novo hormone. Bile acid sequestrants can also be used in severe cases to reduce enterohepatic recycling. Due to the high mortality rate and risk of major complications, it is crucial to recognize early stages to begin aggressive treatment.

CONCLUSION: Clinicians must have a high clinical suspicion of impending or overt thyroid storm in a patient with symptoms of severe thyrotoxicosis as there is a mortality rate up to 30% despite available treatments. It is crucial to recognize early stages to begin aggressive treatment for the best outcomes, and often involves ICU monitoring, propranolol, glucocorticoids, and thionamides. After acute treatment, clinicians can consider thyroidectomy or radioiodine treatment to prevent recurrence.

A CHEST PAIN CHALLENGE

Grace Alexander¹; Paul Lindower¹; Katherine Harris²; Ruchi Sharma¹

¹University of Iowa Hospitals and Clinics, Iowa City, IA; ²Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA. (Control ID #3858530)

CASE: A 32 year old previously healthy male presented to the emergency department with acute non- exertional chest pressure with radiation to the back and jaw three days after receiving his third COVID-19 vaccine, a Pfizer-BioNTech, and 6 months after his initial two series Astra-Zeneca COVID-19 vaccines. Past medical history was notable for symptomatic COVID-19 infection 1.5 years ago, without cardiac involvement. He had no family history of early cardiac disease, never smoked tobacco, and had an allergy to penicillin. He took no daily medications. Vitals 157/92-82-16-98% on room air. No cardiac murmur or rub. No elevated jugular venous pressure or lower extremity edema. Initial high sensitivity troponin was 897 which peaked at 1,215 two hours later. Electrocardiogram revealed diffuse ST segment elevations. Transthoracic echocardiogram revealed a normal left ventricular size and function without pericardial effusion. Cardiac magnetic resonance imaging revealed mid apical and lateral wall subepicardial enhancement. He was treated with colchicine and Ibuprofen. He discharged after three symptom free days with plan to continue for 3 months. At follow up visit C-reactive protein was <0.5 from 4.3 during hospitalization and the patient was instructed to resume his usual activities.

IMPACT/DISCUSSION: Myocarditis is a rare but serious adverse event that can happen after mRNA based COVID-19 vaccination. It is three to five times more frequent following the second dose compared to the first; however patients with prior COVID-19 infection are at higher risk following the first dose. COVID-19 vaccine-associated myocarditis most often occurs in males aged 12-24, and as men increase in age, the reported incidence decreases. This case demonstrates the most common clinical course of COVID-19 vaccine–associated cases of myocarditis. Symptom onset is within seven days of vaccination, most often day 2-3, which contrasts with the more indolent clinical course of viral myocarditis. An overwhelming majority of cases require hospitalization. Symptoms most commonly resolve prior to discharge from the hospital. Diagnostically, most cases have a grossly normal echocardiogram. Cardiac magnetic resonance imaging reveals the extent of myocardial involvement, most often showing edema and late gadolinium enhancement, similar to findings in nonvaccine myocarditis. The optimal duration of exercise restriction in adults post- myocarditis is uncertain. The normalization of C-reactive protein at follow up visits can be used as a tool to aid clinicians in deciding timing of resuming activity.

CONCLUSION: While COVID-19 vaccine-associated myocarditis is most often seen in adolescent males, it can also occur in adults. The clinical course is favorable, with rapid onset of symptoms and rapid resolution. Cardiac magnetic resonance imaging is an essential, non-invasive, high sensitivity imaging test used for diagnosis of myocarditis. C-reactive protein can function as an indicator of active disease at follow up.

A CHIROPRACTIC CRACK IN THE BACK, TRIGLYCERIDES IN THE PLEURAL SACK: AN UNCOMMON CASE OF TRAUMATIC CHYLOTHORAX

Allison Heymann¹; Shamroz Farooq³; Katherine Gavinski²

¹Medical School, University of Pittsburgh Schools of the Health Sciences, Pittsburgh, PA; ²General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ³Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #3876633)

CASE: A 31-year-old woman with psoriasis presented with one month of dyspnea on exertion, cough, and recurrent right-sided pleural effusion. She initially sought care after five days of productive cough; she was treated with amoxicillin for presumed bronchitis. Her symptoms progressed and she presented to the ED where a CXR revealed a small right sided pleural effusion. She was given doxycycline for suspected pneumonia. With no improvement in her symptoms for weeks, she re-presented to the ED where a CT chest revealed a large right sided pleural effusion with diffuse ground glass opacities. A thoracentesis yielded 2L of exudative fluid with negative gram stain and cytology. Rheumatologic labs were unremarkable. Her symptoms improved with thoracentesis and her findings were attributed to multifocal pneumonia. She discharged with levofloxacin. Ultimately, her symptoms returned days later and she presented again to the hospital.

Inpatient evaluation demonstrated normal vitals and an exam with reduced breath sounds and dullness to percussion over the right lower lung. Aside from her presenting complaints, her review of systems was unremarkable. Chest imaging demonstrated a recurrent large right-sided pleural effusion. A pigtail catheter was placed which yielded 6L of chylous fluid over the course of a week. She denied any history of chest trauma but disclosed an extensive family history of cancers and rheumatologic conditions. Repeat gram stain and cytology of pleural fluid were negative. Autoimmune labs were unremarkable. CT of chest, abdomen, and pelvis was negative for malignancy. Lymphoscintigraphy revealed a multi-part thoracic duct leak. Further investigation into the patient’s recent history revealed two trips to the chiropractor for spinal realignment that coincided with the onset of her symptoms.

IMPACT/DISCUSSION: Although traumatic chylothorax is rare without any obvious chest trauma or iatrogenic insults, this case serves as an excellent example of how premature closure and availability bias can prevent a broad-based approach to identifying the etiology of a pleural effusion. Pneumonia is a common cause of dyspnea, cough, and unilateral pleural effusion. However, faced with discordant data (lack of systemic signs and symptoms, non-response to antibiotics, chylous, sterile pleural fluid), providers continued to treat her symptoms and effusion as infectious. On repeat evaluation, her compelling rheumatologic and cancerous family history persuaded providers to seek out an autoimmune disease or malignancy as a cause. While this was an appropriate workup, it blinded providers from revisiting the patient’s history to understand if trauma was still a possibility.

CONCLUSION: - Chylous pleural effusion is either traumatic or non-traumatic in nature; a careful review of a patient’s recent history may help identify an unexpected source of trauma

- Thoughtful problem representation can help avoid anchoring and allow clinicians to maintain a broad differential diagnosis

A CHRONIC CAUSE OF ACUTE CHEST PAIN

Zachary Zins¹; Mark Troyer²

¹Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #3865861)

CASE: 43M hx ESRD 2/2 Goodpasture's syndrome s/p kidney transplant presents with chest pain. Chest pain began 1 day ago, described as sharp, sub-sternal, radiates to back, worsens with deep breathing + exertion, not relieved with rest. Initially felt like pulled muscle, but steadily worsened over 24 hours to 8/10 severity. Pain initially improved with sitting up, is now constant, w/ lethargy + LE edema.

ROS negative for fever, congestion, cough, SOB, or recent URI. Patient vapes, no tobacco/alcohol/drug use. Medical history: ESRD 2/2 Goodpasture's syndrome s/p kidney transplant, HTN

Meds: cyclosporine, sirolimus

Physical exam: VS: 174/116, 117, 26, 98.2. Alert, NAD. Lungs CTA. CV: no m/r/g, bilateral 1+ LEE. L AV

fistula w/ palpable thrill. A+Ox3.

Labs w/ phos 12.1, Cr 14.7 [baseline 2], hgb 8, BUN 159, hs-trop 192, BNP 3824, 7.17 pH, CO2 20.4, D-dimer 5.6

EKG: new R-axis, known LVH, no ST/TW changes. CXR: Hazy opacities in the left base, bilateral pleural effusions. Renal US: Increased echogenicity in transplanted kidney. No hydronephrosis.

Hospital course: Patient was started on heparin empirically as severe AKI limited CTPE. TTE showed pericardial effusion, chest pain resolved with HD, patient was diagnosed with uremic pericarditis. IS levels <30. Anti-GBM membrane (-). Renal biopsy showed chronic, active, antibody-mediated rejection + 50% IF/TA, for which patient was started on a prednisone taper, + received a 2nd kidney transplant 6mo later.

IMPACT/DISCUSSION: We present a case of chest pain, found to be chronic rejection of a transplanted kidney leading to uremic pericarditis. Uremic pericarditis is an inflammatory reaction to uremia (usually >60mg/dL) in the pericardium. Prevalence is 2-21% in HD patients. It typically presents as positional chest pain especially when lying down; fever + shortness of breath may be present. EKG changes typically show diffuse concave ST elevations + PR depressions. A pericardial friction rub is often present on physical exam. Severe cases can develop into pericardial effusion + tamponade. Diagnosis is primarily clinical: EKG is necessary to differentiate from STEMI. Treatment is directed at removing the underlying urea through HD; refractory cases may require pericardiocentesis.

This was a unique case of uremic pericarditis caused by chronic allograft rejection. Chronic rejection is important to consider when evaluating a transplant patient with worsening renal function. Chronic rejection, the leading cause of graft rejection, is mediated by several mechanisms including fibrosis, chronic inflammation, & humoral + cellular immune reactions. Histology often shows interstitial fibrosis + tubular atrophy. At 1 year post-transplant, more than 80% of transplant biopsies have at least some evidence of chronic rejection.

CONCLUSION: Uremic pericarditis is an important cause of chest pain in ESRD patients.

Chronic allograft rejection is an important cause of renal failure in transplant recipients, with increasing prevalence over time from transplant.

A CLASSIC PRESENTATION OF DENGUE VIRUS EVALUATED IN THE OUTPATIENT SETTING IN A NON-ENDEMIC AREA

Nicole Rueb¹; Jennifer Michener¹; Susan M. Nikels²

¹Internal Medicine, University of Colorado, Denver, CO; ²GIM, University of Colorado Denver, Aurora, CO. (Control ID #3869340)

CASE: A 53-year-old female presented to clinic for fever and rash for 1 week. She had a pruritic rash on her trunk, abdomen, and all extremities including her palms and soles. She described the rash as “hive like”. She experienced midday fevers up to 102F. She noticed firm, tender inguinal lymph nodes. She described cramping pain in her hands and feet. Denied abdominal pain, vomiting, diarrhea or dysuria. Denied any new animal or environmental exposures. She had traveled to see family in Singapore and returned to Denver 5 days prior. Physical exam positive for a non blanching maculopapular rash on abdomen and bilateral lower extremities, an area of erythematous plaques on her right upper extremity, palmar erythema and bilateral palpable, tender inguinal lymph nodes. CBC showed a WBC of 2.4. CMP unremarkable. Covid, syphilis, and HIV negative. Rapid Malaria antigen negative. Zika PCR and Dengue IgG studies pending. Urine culture for leptospirosis pending.

IMPACT/DISCUSSION: Differential diagnosis included Dengue versus Chikengunya virus. Leptospirosis is also endemic to the region. Given the patient's history and water exposure, a urine culture was ordered and was negative. Dengue IgG drawn at urgent care was unequivocal but Dengue IgM drawn at the clinic appointment was positive. Patient counseled on ED precautions as she was returning to Singapore. Dengue virus is carried by the Aedes aegypti mosquito, a vector found in 150 different countries. Cases have increased due to travel leading to presentations of the virus in non-endemic areas such as our case. Initially, our patient’s presentation aligned with both Chikengunya and Dengue virus. Her presenting symptoms including hemorrhagic symptoms, lymphopenia, made the exact diagnosis indistinguishable. Since our patient’s symptoms were self limited, making a diagnosis distinguishing Dengue from Chikengunya did not change our management. However, since the IgG antibody test done prior was unequivocal, an IgM was sent.

Dengue IgM can be positive 4 days from infection. IgG positivity depends on primary or secondary infection. A primary infection has a low titre-IgG response of 7 days post infection. A secondary infection has a rapid antibody response of 4 days.

CONCLUSION: Dengue virus presents in three different phases: febrile, critical and convalescent. Patients who are reinfected with Dengue less than 18 months post primary infection are more likely to progress to the critical phase: a systemic vascular leak syndrome including plasma leakage and shock. Dengue, Chikengunya, and Zika virus present with similar symptoms and cannot be differentiated without testing. Without symptom progression, patient’s are likely managed similarly in the outpatient setting. Since our patient had never experienced these symptoms prior, this was likely a primary Dengue infection. With return to the endemic region, our patient was counseled on ways to minimize risk of a secondary infection to prevent progression to a severe illness.

A COMPLEX CASE OF MENTAL VOID, RHEUMATOID, AND HIGH DOSE STEROIDS

Rya Glasshof¹; Monica H. Klaybor²; Pranav Shah^2,3

¹Medicine, Medical University of South Carolina, Charleston, SC; ²Internal Medicine, Medical University of South Carolina, Charleston, SC; ³Internal Medicine, Ralph A. Johnson VA Medical Center, Charleston, SC. (Control ID #3876581)

CASE: A 77-year-old male with a history of Parkinsonism, longstanding rheumatoid arthritis on chronic 10mg of prednisone daily, and recent HSV meningitis/encephalitis presents from home nonverbal and obtunded. Per family, within the course of one week patient went from his baseline intact neurological exam to unresponsive. On admission he was afebrile, tachycardic to 120 beats/minute, normotensive, and oxygenating well on RA. Although obtunded, patient withdrew to pain and was protecting his airway. Patient was found to have high titers of RF (1868 ID/mL) and CCP antibodies (>300 U/mL), ESR >100 mm/hr, CRP 13 mg/dL, WBC of 14.9 K/cumm. Lupus and anti-phospholipid panels were negative. Anti-nuclear antibody was positive at 1:160 with negative ENA panel. Blood and urine cultures showed no growth. Lumbar Puncture was negative for infectious etiologies. CSF autoimmune antibody testing were not collected. Electroencephalography showed no seizure activity and was notable for generalized slowing and generalized periodic discharges. MRI brain revealed areas of patchy incomplete suppression of sulcal CSF signal on FLAIR with slight dural thickening. Patient was initially started on ampicillin, acyclovir, cefepime, and vancomycin for empiric treatment of meningitis/encephalitis without improvement. Given negative infectious workup, antibiotics and acyclovir were discontinued. Given concerns for autoimmune encephalitis, high dose intravenous hydrocortisone was initiated. Within two days the patient was conversant and interactive with continued neurologic improvement each day.

IMPACT/DISCUSSION: Autoimmune encephalitis (AE) is a broad term comprising non-infectious immune-mediated inflammatory disorders of the brain and spinal cord. It is thought to be due to antibody production against onconeuronal antigens, neuronal surface or synaptic antigens, and oligodendrocytes or astrocytes. In some patients with AE, no antibodies can be identified. There have been many advances in laboratory testing, however these panels take time to result. Thus, diagnostic criteria for this condition are largely based on neurologic assessment, neuroimaging, and CSF testing. AE can rarely develop as an extra- auricular manifestation of RA. In our patient, with longstanding seropositive RA, rheumatoid arthritis pachymeningitis is a possibility. Rheumatoid meningitis (RM) encompasses a wide range of symptoms, including headache, seizures, and coma. The MRI findings could be consistent with dura thickening seen in pachymeningitis. AE syndromes are classically treatment responsive, however, overall prognosis is highly variable.

CONCLUSION: This case highlights a rare and challenging diagnosis of AE. Infectious and metabolic causes must be ruled out prior to considering a diagnosis of autoimmune encephalitis. Positive CSF serologies can aid in diagnosis and management but should not delay immunosuppressive therapy in the setting of clinical suspicion.

A CONFLUENCE OF AUTOIMMUNITY: A CASE OF ISAACS SYNDROME RELATED TO GBS AND IGG-4 RELATED DISEASE

Manjari Daniel, Karlen Ulubabyan, Amy Guzdar, Jaclyn Vargas

School of Medicine, University of California San Diego, La Jolla, CA. (Control ID #3877298)

CASE: A 35-year-old male with unremarkable medical history was admitted after recent viral infection with symptoms of subacute progressive lower extremity weakness, asymmetric bilateral facial nerve palsy, diffuse myalgias and muscle fasciculations. Neurologic workup included spinal tap yielding lymphocytic pleocytosis without albuminocytological dissociation, brain MRI notable for asymmetric enhancement of facial nerves, and EMG consistent with multifocal motor polyneuropathy with axonal and demyelinating features. After an extensive workup, the patient was diagnosed with Guillain-Barre Syndrome (GBS), underwent 5 days of intravenous immunoglobulin with subjective improvement, and was subsequently discharged home.

He was re-admitted the following month for progressive worsening of initial symptoms and superimposed pneumonia. A second workup yielded myokymic discharges and neuromyotonia consistent with peripheral nerve hyperexcitability syndrome on EMG and positive anti-neurofascin antibodies. Rheumatologic studies demonstrated voltage-gated K+ channel (VGKC) antibodies and elevated polyclonal IgG4. Ultimately, he was diagnosed with Isaacs Syndrome secondary to IgG4 Related Disease (IgG4-RD) and GBS. Inpatient treatment involved prednisone, rituximab, and pain management which led to more sustained improvement in symptoms.

IMPACT/DISCUSSION: This case represents a complex picture arising from three coalescing autoimmune disorders and adds to the scarce literature investigating the relationship between Isaacs Syndrome, IgG4-RD, and GBS.

Of these three, GBS is most frequently encountered and presents as acute polyneuropathy due to autoimmune damage to peripheral nerves². Conversely, IgG4-RD is a recently defined condition, where IgG4-positive plasma cells invade tissue in any organ system resulting in autoinflammatory lesions and dysfunction, requiring histopathological identification for diagnosis⁵. Isaacs Syndrome is an even rarer presentation of acquired neuromyotonia characterized by peripheral nerve hyperexcitability, diffuse stiffness and fasciculations, and distinct EMG patterns⁴. The underlying pathophysiology is believed to be autoimmunity, as nearly half of patients demonstrate VGKC antibodies¹. While nearly a quarter of Isaacs Syndrome patients have a co-occurring autoimmune disorder, there have been rare associations with GBS³. Existing literature reports symptom response and improvement in Isaacs Syndrome with plasmapheresis or steroids¹.

In this case, ongoing multidisciplinary collaboration and discussion of study results achieved a more accurate diagnosis and symptom improvement, highlighting the limitations of initial diagnoses and the dynamic nature of managing multifactorial chronic illness.

CONCLUSION: ● GBS may present without albuminocytological dissociation and can coincide with other autoimmune processes.

● IgG4-RD is a rare autoimmune inflammatory process that can affect multiple tissues.

● Isaacs Syndrome is a rare clinical entity which may be associated with GBS.

ACQUIRED HEMOPHILIA A: RARE DISEASE MANIFESTING AS PERSISTENT HEMATURIA Amber Kuta, Karina S. Shendrik, Linda Youn, Alena Yarema

Internal Medicine Residency Program, St Bernard's Medical Center, Jonesboro, AR. (Control ID #3876651)

CASE: Our patient is a 71 year old African American female nursing home resident with advanced dementia who presented from an outside facility for urological evaluation for gross hematuria. At the outside hospital labs showed prolonged APTT which was not addressed at that time. Cystoscopy showed no pathology in the bladder. CT scan showed no kidney or ureter pathology. Hematuria was attributed to infection and patient was discharged. Patient returned requiring admission to the intensive care unit due to hypotension, profound anemia, continued hematuria and increased ecchymosis. Coagulation studies obtained and showed prolonged APTT. Patient was never on any antiplatelet or anticoagulation. No signs of gastrointestinal (GI) bleeding and computed tomography (CT) scans did not show sources of internal blood loss. Mixing study, lupus anticoagulant, factor VIII, IX, and XI inhibitors levels were ordered. Mixing studies results suggested the presence of an inhibitor. Our factor VIII inhibitor testing showed a Factor VIII inhibitor level (Bethesda) of 846 and Factor VIII activity was less than one.

IMPACT/DISCUSSION: Hemophilia A is a deficiency of factor VIII that is congenital; however patients may develop inhibitors to factor VIII later in life which is considered acquired hemophilia A. Acquired factor VIII inhibitor (FVIII) is a bleeding disorder caused by autoantibodies against the coagulation factor VIII that inhibit its activity in the coagulation cascade. This inhibition leads to new onset bleeding, most commonly mucocutaneous. Coagulation studies shows a normal prothrombin time (PT) and thrombin time (TT) with a prolonged activated partial thromboplastin time (APTT). The incident rate of acquired inhibitors/autoantibodies is about one case per million per year. (1) The typical initial study for prolonged APTT is a mixing study. It is important to rule out nonspecific inhibitors such as heparin contamination and lupus anticoagulant as these are the two most common causes of a prolonged aPTT. (2) With over two million patient referrals to urology each year, hematuria is considered relatively common. Current guidelines suggest initially obtaining thorough history and physical exam, urinalysis and identifying potential non-malignant or gynecological sources. Further investigation if source is unidenitfied is based on risk stratification.

CONCLUSION: Hematuria is a common presentation that we see inside and outside of the hospital. In our patient, it was not until the patient came in with profound anemia, multiple ecchymosis, and continued hematuria, requiring intensive care that her coagulation abnormality was considered. In a patient that can’t provide good history or their only current complaint is hematuria the current evaluation and guidelines do not recommend coagulation studies. The benefit of early coagulation studies in evaluating patients with hematuria should be further explored. We urge physicians to broaden their differential diagnosis and think unconventially.

ACUTE DYSTONIA DUE TO PROCHLORPERAZINE USE IN THE SETTING OF NEWLY- DIAGNOSED IDIOPATHIC INTRACRANIAL HYPERTENSION

Keely Coxon, Jerry Koh, Delaney C. Goulet

Internal medicine, Washington State University-Providence Everett Regional Medical Center, Everett, WA. (Control ID #3871920)

CASE: A 35-year-old female with history of hypertension, anxiety, depression, OSA and obesity (BMI 42) presented with a thunderclap headache, nausea, vomiting, reported nuchal rigidity, photophobia and word- finding difficulty.

Differential diagnosis included subarachnoid hemorrhage, meningitis, migraine, idiopathic intracranial hypertension (IIH), reversible cerebral vasoconstriction syndrome (RCVS), seizure or stroke.

Vitals included: temp 36.7C, pulse 103, respiratory rate 22, O2 sat 99%, and blood pressure 169/128. Neurologic exam was unremarkable (no cranial nerve deficits; normal sensation and reflexes; 5/5 strength). She had no nuchal rigidity on exam. Labs demonstrated a mild leukocytosis and hypokalemia, normal calcium and mildly elevated troponin. MRI brain and MRI venogram of the head were negative for ischemia, hemorrhage, and thrombus. Neurology temporarily deferred lumbar puncture due to administration of aspirin.

The patient’s initial symptoms quickly improved, apart from nausea and a mild headache. She was given PRN prochlorperazine and ketorolac. Several hours later, she complained of throat tightness and muscle spasms. She then developed involuntary contractions of her right upper extremity (posturing), lower extremities and neck muscles. There was no swelling of her lips or tongue, and no wheezing or stridor, but she could only phonate weakly. Diphenhydramine was given, out of concern for anaphylaxis. Within minutes, the patient returned to baseline.

Over the next couple of days, she experienced recurrent episodes, each resolving with diphenhydramine. Given her underlying psychiatric history, it was initially assumed she was manifesting panic attacks or conversion disorder. However, acute dystonia that resolved with diphenhydramine eventually raised concern for EPS.

Lumbar puncture performed on hospital day five revealed an elevated opening pressure consistent with IIH. IMPACT/DISCUSSION: The patient’s initial complaints differed from symptoms that emerged during her hospitalization. The new symptoms of acute dystonia could have been easily attributed to panic attacks, conversion disorder or even anaphylaxis.

Review of the literature reveals numerous case reports of similar episodes of acute dystonia with anti-emetic use, which are relieved using anticholinergics. It is estimated that EPS will occur in 0.5-1% of patients receiving metoclopramide or prochlorperazine. Anticholinergic therapy should be continued until symptom resolution, if not several days beyond. Our patient’s dystonic events subsided after stopping prochlorperazine.

Adjunctive benztropine was not required.

CONCLUSION: In conclusion, a high degree of suspicion for the association between medication administration and onset of symptoms was required to discern an acute dystonic reaction caused by prochlorperazine from more common neurologic and psychiatric etiologies, including initial presenting symptoms of IIH. This case highlights the importance of remaining vigilant about drug-induced movement disorders.

ACUTE HEMOLYTIC ANEMIA DUE TO VITAMIN B-12 DEFICIENCY

Nkolika U. Nwankwo^1,2; Runa Shrestha^1,2

¹Internal Medicine Residency Program, Mercy Hospital Fort Smith Area, Fort Smith, AR; ²Medicine, Arkansas College of Osteopathic Medicine, Fort Smith, AR. (Control ID #3838721)

CASE: In this article we present the case of a 66-year-old female with past medical history of coronary artery disease presented to the emergency room with worsening generalized weakness, poor appetite, and shortness of breath. On arrival at the emergency department, blood pressure was 107/92, heart rate 79bpm, respiratory rate 20cpm, oxygen saturation 100% on room air and temperature was 98.5F. Laboratory results showed severe anemia with hemoglobin of 4.1, leukopenia with white blood cell count of 2.0 and thrombocytopenia with platelet count of 179. Peripheral blood smear showed RBCs with nonspecific anisopoikilocytosis. Hemolytic markers were also found to be elevated and B12 levels was markedly reduced. Methylmalonic acid was elevated at 23,616. Iron panel showed serum iron levels elevated at 116, TIBC reduced at 187, iron percent saturation elevated at 89. Coombs’s test was also negative.

CT abdomen and pelvis showed abnormal liver with increased attenuation, gallstones, right renal cysts, left small complex cyst, no hepato-splenomegaly. Patient received about 3 units of packed red cells and was started on B12 injections. Subsequently pancytopenia resolved with hemoglobin increasing to 7.8. Patient was discharged to follow up with hematology, at follow- up patient reported her symptoms had resolved. Hemoglobin level was normal at 13.2, white cells 4.7 and platelets 194.

IMPACT/DISCUSSION: Vitamin B12, a water-soluble vitamin containing a metal ion cobalt, plays a vital role in DNA synthesis, erythropoiesis and neurologic functions. According to the national health and nutrition examinations studies [NHANES] from 1999-2002, vitamin B12 deficiency [serum vitamin B12 < 200pg/mL] varied by age group showing increasing prevalence with age. Most cases of vitamin B12

deficiency in resource- rich settings are related to malabsorption from pernicious anemia, gastric bypass surgeries, gastritis, than dietary deficiency which is more commonly seen in resource-poor settings. Vitamin B12 deficiency is a common cause of macrocytic anemia, however it can also cause intramedullary hemolysis that can present as acute hemolytic anemia. Vitamin B-12 deficiency typically presents with vague and nonspecific symptoms [e.g., Fatigue, irritability, and cognitive decline] which may be attributable to macrocytic anemia. The development of symptoms depends on the rate of development of the deficiency, the severity, the hemoglobin level, and the patient's overall health. B-12 deficiency leads to ineffective DNA synthesis leads to the development of megaloblastic anemia, cytopenia, and dysplasia. Therefore, severe B-12 deficiency may present with pancytopenia and hemolysis.

CONCLUSION: It is important for primary care physicians, mid-level providers, hospitalists to be aware of the increasing incidence of vitamin B12 deficiency and associated complications to prevent unnecessary and potentially harmful medical interventions. Also, at risk patients will recieve prompt testing and management.

ACUTE INTERMITTENT PORPHYRIA LEADING TO POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME (PRES): A RARE CAUSE OF ABDOMINAL PAIN AND SEIZURES

Malek Ayoub¹; Janki P. Luther¹; Caline Mattar²

¹Internal Medicine, Washington University in St Louis, St Louis, MO; ²Infectious Disease, Washington University in St Louis, St Louis, MO. (Control ID #3875513)

CASE: 26 yo female initially presented to the urgent care with a 5-day history of severe generalized abdominal pain, which was attributed to her upcoming menstrual cycle. She then presented to the ED, with similar symptoms. Laboratories were unremarkable. The right upper quadrant US was unremarkable. The Obstetrics team was consulted, who thought a gynecologic cause such as Pelvic Inflammatory disease and Fitz-Hugh-Curtis syndrome was unlikely. She was discharged without any specific diagnosis. She then presented to the ED multiple times, with an extensive workup including 3 abdominal CT scans, which were remarkable for lymphadenopathy and a corpus luteum cyst. Enteritis and autoimmune conditions were also considered in the setting of a previously low positive ANA(1:80) but her autoimmunological labs were unremarkable. GI team was consulted, who recommended a pantoprazole trial and a bowel regimen. Pelvic US demonstrated a possible ruptured corpus luteum cyst. Her pain was attributed to multiple cysts rupturing, causing prolonged pain. She returned to the ED with severe abdominal pain, hyponatremia(127mEq/L), nausea, vomiting, tachycardia, and hypertension. During her hospital stay, she began to have seizures with transient bilateral cortical blindness. MRI brain showed symmetric parenchymal edema in the occipital and posterior parietal lobes concerning for PRES. Given her new symptoms, urine PBG level was obtained and was elevated to 126 (< 1.3 mcmol/L). She was started on high glucose (300 g) per day and hematin in a dose of 4 mg/kg/d for 4 days. Her urine PBG decreased to 20.6 mcmol/L after the 4^th dose of hematin. Her abdominal pain resolved, and she was discharged with a follow-up with hematology.

IMPACT/DISCUSSION: AIP is a rare autosomal dominant metabolic disorder caused by a partial deficiency in the enzyme porphobilinogen deaminase (PBG deaminase), which leads to a build-up of PBG in the cytoplasm. AIP affects around 1 in 75,000 people, often females between the ages of 20 and 40. The most common clinical feature is abdominal pain. Other symptoms such as autonomic dysfunction, and electrolyte imbalances are common. Diagnosis is made by a 24-hour urine collection, which will reveal elevated levels of PBG during an attack. Usually, the attacks are triggered by starvation, a low carbohydrate diet, drugs, and menstruation. During the attack, the color of the urine might turn red or port wine due to the porphyrins present. Treatments of AIP consist of a high carbohydrate diet with the use of intravenous dextrose, and hematin. PRES has only been reported in a handful of patients and is characterized by headaches, seizures, and visual loss with parenchymal edema in the occipital and parietal lobes.

CONCLUSION: The clinical presentations of AIP are nonspecific and may mimic common surgical and medical conditions which can result in the underdiagnosis and misdiagnosis of this disease. The delay in diagnosis and treatment can increase mortality and morbidity despite proper management.

ACUTE LUPUS FLARE IN THE SETTING OF CLOVES SYNDROME

Tyler Bendrick¹; Alexander Sipe¹; Ashley Scholtens³; Naomi Habib²; Jaya Raj¹

¹Internal Medicine, Creighton University School of Medicine Phoenix Regional Campus, Phoenix, AZ; ²Internal Medicine, St Joseph's Hospital and Medical Center/Creighton University Medical School, Phoenix, AZ; ³Internal Medicine, Creighton University School of Medicine, Omaha, NE. (Control ID #3872201)

CASE: A 27-year-old Mexican female with a history of developmental delay who presented with a 1-week history of left anterior neck pain with associated swelling. She noted painless increasing left anterior neck swelling for the past year. She had undergone a surgery in Mexico 4 years prior, where “a fat mass” in the same area was removed. Physical exam showed an erythematous region over her lateral left neck extending towards the base of the occipital scalp, and no gross skeletal abnormalities. Labs were remarkable only for a platelet count of 42,000. CT angiogram of the neck showed a L neck arteriovenous malformation (AVM) with sequelae suggestive of prior attempted resection and fat graft, and extremely dilated venous drainage and associated dural venous sinus thrombosis (Figure 1). These clinical signs, combined with developmental delay and lipomatous mass, led to the diagnosis of CLOVES.

On hospital day 3, the platelet count decreased to 9,000 with symptoms of vaginal bleeding, and she was transferred to the ICU. Further workup showed a positive DAT and undetectable ADAMTS13 levels, with a positive ANA (1:2560, speckled pattern), elevated dsDNA, and low C3/C4. The patient was started on pulse dose IV methylprednisolone and plasma exchange for 8 days. Due to severity, patient was started on a planned regimen of 4 weekly doses of Rituximab. She was ultimately diagnosed with systemic lupus erythematosus (SLE) with manifestations of thrombotic thrombocytopenia purpura (TTP).

On hospital days 15 and 19, after stabilization of her hematologic abnormalities, she was able to undergo exploratory cranial surgery showing a left petrosal dural arteriovenous fistula, with successful staged embolization. She was discharged 1 week later on a prednisone taper with final diagnosis of AVM in the setting of CLOVES syndrome, complicated by TTP in the setting of SLE flare.

IMPACT/DISCUSSION: CLOVES is a rare congenital disorder presenting with congenital lipomatous overgrowth, vascular malformations, epidermal nevi and scoliosis/skeletal/spinal anomalies. The syndrome is caused by the activation of mosaic mutations in the P13K/AKT/mTOR pathway, which plays an important role in immunomodulation and is also involved in the pathogenesis of systemic lupus erythematosus (SLE). The upregulation of PI3K contributes to T cell proliferation, causing the immunodysregulation seen in both CLOVES and SLE While the initial workup did not focus on pathophysiology outside of CLOVES, we maintained a high level of suspicion for hypercoagulability disorders given the unusual location of her sinus vein thrombosis. These considerations ultimately led to the workup and diagnosis of TTP and SLE, in addition to CLOVES. There have been no other reported cases of both conditions presenting in the same patient.

CONCLUSION: Our case highlights the importance of maintaining a broad differential in the workup of patients presenting with complex manifestations of rare disease.

ACUTE MYELOID LEUKEMIA (AML) PRESENTING AS ACUTE RESPIRATORY DISTRESS SYNDROME THE VALUE OF A PERIPHERAL BLOOD SMEAR

Lemchukwu Amaeshi¹; Kristin A. Swedish²; Dharmarajan S. Thiruvinvamalai³

¹Internal Medicine, Montefiore Health System, Bronx, NY; ²Medicine, Division of General Internal Medicine, Montefiore Medical Center, New York, NY; ³Medicine - Geriatrics, Montefioe Medical Center (Wakefield Campus), Bronx, NY. (Control ID #3873536)

CASE: A 34-year-old man presented with dyspnea. On exam, he was tachypneic, tachycardic, hypotensive, and had diffuse lung crackles. He was intubated for acute hypoxic respiratory failure thought to be due to multifocal pneumonia and admitted to the intensive care unit. A chest CT scan revealed radiographic features consistent with acute respiratory distress syndrome (ARDS). We started broad-spectrum antibiotics and dexamethasone. However, infectious workup was negative. Connective tissue disease (CTD) and pulmonary- renal syndrome were considered because he developed hematuria, proteinuria, and elevated inflammatory markers; however, these were ruled out with negative autoimmune workup. He developed worsening monocytic leukocytosis - his presenting white cell count WBC was 13,800 cells/mm3 with a monocyte count of 5,500 cells/mm3, which rose to WBC 67,000 cells/mm3 with monocytes 36,600 cells/mm3 five days later. At that time, we suspected acute leukemia complicated by ARDS. A peripheral smear revealed marked atypical monocytosis 73% and promonocytes making up 8% of the total cellularity. Flow cytometry was consistent with AML. Unfortunately, he was too hemodynamically unstable to undergo a bone marrow aspiration for confirmation. He died shortly thereafter from cardiopulmonary failure.

IMPACT/DISCUSSION: This case presents a patient with unique presentation of AML. AML is a heterogeneous group of acute leukemias characterized by clonal proliferation and impaired differentiation of myeloid precursors into mature cell lines. Patients with AML typically present with signs and symptoms of bone marrow failure. Non-infectious ARDS is an uncommon manifestation of AML. Although we could not make a definite diagnosis of AML with bone marrow aspiration, the worsening monocytosis, peripheral smear, and flow cytometry findings were consistent with AML. AML is diagnosed with greater than 20% blasts or blast equivalents, such as promonocytes, in bone marrow or blood. In our patient, even though the circulating promonocytes from his complete blood count did not reach the cut-off for diagnosis of acute leukemia, his counts would likely have been higher in bone marrow. AML is an uncommon cause of ARDS, which is most commonly due to pneumonia, sepsis, and aspiration. Our patient had extensive infectious workup, which was non-revealing. There have been case reports of AML causing ARDS. Hyper-leukocytosis and direct endothelial damage from leukemic cells are independent risk factors for developing ARDS in AML. Our patient likely developed ARDS from a combination of these two pathophysiological processes.

CONCLUSION: AML is an uncommon cause of ARDS; however, our patient did not present with the classic clinical features of AML, which may explain the late diagnosis.

ACUTE MYOSITIS SECONDARY TO EPSTEIN-BARR VIRUS IN THE ABSENCE OF INFECTIOUS MONONUCLEOSIS

Adam J. Tuchinsky, Angela Montalvo

Internal medicine, UPMC Central PA, Harrisburg, PA. (Control ID #3867743)

CASE: The patient was a twenty-two-year-old African American male, with no significant past medical history who presented to the emergency department with complaints of about 1-week duration of weakness. No history of recent exercise, travel, or any traumatic events. The patient’s chief complaint was soreness across his chest, weakness, body aches, nausea, vomiting, and fevers. CK level of 452,458 U/L and a creatinine of 7.23. Urine drug screen was negative. Consequently, the patient was admitted for nontraumatic rhabdomyolysis, and acute kidney injury.

Due to the patient’s developing uremic symptoms, declining renal function, and increasingly aberrant electrolytes, the decision for urgent hemodialysis was made and a temporary hemodialysis catheter was inserted by an interventional radiologist.

All serological tests were negative except for Epstein-Barr virus. The patient had a full renal recovery during his hospital course and was weaned off hemodialysis. On day 10 of hospitalization, the patient was discharged without incident and scheduled for outpatient follow-up with infectious disease, nephrology, and his primary care provider.

IMPACT/DISCUSSION: Our patient presented with serve AKI secondary to rhabdomyolysis. To further work the patient’s underlying diagnosis, we considered the broad differential for rhabdomyolysis. This was, “Excessive exercise, trauma, seizures, alcohol, drug abuse and infections.” Interestingly, our patient denied any excessive exercise, seizures, or trauma. The patient denied excessive alcohol ingestion and the urine drug screen was negative. Another differential which was investigated was inflammatory myopathies, however, myositis panel was negative.

EBV is a well-documented cause of acute viral myositis oftentimes precipitated by influenza A/B, enteroviruses, and other viruses. A literature search and review describing AKI with EBV was published in the New England Journal of Virology. The authors found only 38 cases of symptomatic, primary EBV infectious mononucleosis which were complicated by AKI. Of those patients 47% of cases required renal replacement therapy, and 7 of the cases were associated with myositides. Interestingly, our case demonstrates an even rarer scenario: acute viral myositis secondary to EBV - in the absence of infectious mononucleosis. In our review of the literature, we did not discover any published reports demonstrating AVM secondary to EBV, causing rhabdomyolysis in the absence of infectious mononucleosis.

CONCLUSION: Our case aligns with an acute infection given that anti-VCA is positive both for IgM and IgG, anti-EA is positive, and importantly EBNA is negative. The differential diagnosis for cause of rhabdomyolysis is vast. In our case we were both, able to rule out other causes, and demonstrate acute EBV infection. An additional unique point is that this EBV infection was without mononucleosis.

ACUTE ONSET, NON-EPILEPTIC, LEUCINE-RICH GLIOMA-INACTIVATED 1 (LGI-1) ANTIBODY ASSOCIATED LIMBIC ENCEPHALITIS

Pushpendra Patel, Michael Vaysblat, Bernardo A. Acevedo-Mendez

Internal Medicine, Northwell Health, New Hyde Park, NY. (Control ID #3875224)

CASE: A 53-year-old male with a past medical history of paroxysmal atrial fibrillation, hypothyroidism, and obstructive sleep apnea presented with acute onset behavioral and cognitive impairment. Symptoms began when the patient drove his mother to the hospital after she was diagnosed with metastatic lung cancer. While waiting in the hospital parking lot, he became acutely disoriented, forgetting why he came to the hospital.

The patient's wife was able to reorient him briefly, but episodes of confusion and memory loss persisted, prompting her to bring him to the hospital two days later. On presentation, the patient was only oriented to person. Initial workup for stroke, including CT angiography of the head and neck, was negative. He had no focal deficits on examination. He was afebrile without nuchal rigidity, photophobia, or rash. Lab work was only significant for sodium level of 125. Toxicology and infectious workups were negative. Video EEG was negative for epileptiform abnormalities. His MRI Brain showed mild diffusion restriction and FLAIR hyperintense signals diffusely in the hippocampus. Paraneoplastic workup, including AFP, HCG, CT of the chest, abdomen, pelvis, and ultrasound of the testes was negative. CSF studies were grossly normal. An encephalitis panel was positive for Leucine-rich Glioma-Inactivated 1 (LGI-1) antibodies with a titer of 1:640.

IMPACT/DISCUSSION: Our patient had an acute onset encephalopathy that appeared to be triggered by emotional distress; however, the presentation was inconsistent with transient global amnesia and dissociative identity disorder. A primary psychiatric disorder was ruled out when LGI-1 antibodies and diffuse hippocampal lesions were discovered. Autoimmune limbic encephalitis (LE) with LGI-1 antibodies was recently described in the past decade, with a reported prevalence of 0.83 per million. LGI-1 LE is a clinical syndrome, which involves subacute onset of cognitive impairment, seizures (90% of cases), and insomnia. Hyponatremia has commonly been reported. This case describes an atypical presentation of a rare disease. Literature review on LGI-1 LE reveals that drug-resistance epilepsy is the most prominent presenting feature. In this patient, several EEGs, including a 24-hour study, were negative for epileptiform abnormalities. Most patients present with the full clinical syndrome. There are only a few reported cases where patients develop isolated encephalopathy.

CONCLUSION: Atypical presentations of rare conditions present a diagnostic challenge and can be frustrating to clinicians, patients, and family. In this case, it was important to thoroughly investigate organic causes of the patient's encephalopathy and not attribute his symptoms to a primary psychiatric etiology. Our patient had mild to moderate improvement in cognitive impairment with steroids, intravenous immunoglobulin therapy, and rituximab treatment. An MRI at 6 months showed mild improvement in hippocampal lesions and continues to recovery with close outpatient followup.

ACUTE ONSET HEART FAILURE: LEFT VENTRICULAR NON-COMPACTION, CORONARY ARTERY DISEASE OR BOTH?

Utsav Aiya¹; Avijit Deb¹; Rakin Rashid¹; John J. Finley²

¹Internal Medicine, Mercy Fitzgerald Hospital, Darby, PA; ²Interventional Cardiology, Mercy Fitzgerald Hospital, Darby, PA. (Control ID #3877375)

CASE: A 36-year-old male with asthma presented with progressive shortness of breath. Vital signs revealed SBP 174 mmHg, HR 115 beats per minute and RR 20 breaths per minute. Labs was notable for BNP of 435. EKG showed sinus tachycardia, and CXR noted cardiomegaly and pulmonary edema. Chest CT angiography ruled out pulmonary embolism but revealed mild-moderate bilateral pleural effusions with enlarged left atrium and ventricle respectively. The patient was given diuretics and admitted for new onset heart failure.

Transthoracic echocardiogram showed severe left ventricular dilatation and left ventricular ejection fraction (LVEF) of 20 – 25% that was confirmed via contrast while also ruling out left ventricular thrombus. Subsequent coronary catheterization was notable for complete occlusion of the left circumflex artery and 50 – 60% eccentric stenosis of the mid to distal left anterior descending artery warranting follow-up cardiac MRI for wall viability. MR noted markedly dilated chambers, global hypokinesis and diffuse thinning of myocardial walls, most prominent along the left ventricular apex and lateral wall with disorganized appearance and a non-compacted to compacted ratio of 3.5 suggestive of cardiac non-compaction. Lateral wall hibernating myocardium was not excluded given known circumflex occlusion. Percutaneous coronary intervention was performed with successful balloon angioplasty and placement of a drug-eluting stent in the left circumflex artery. Patient was discharged on guideline-directed heart failure therapy, dual-antiplatelet therapy, wearable defibrillator, and rivaroxaban. Repeat outpatient echocardiogram showed LVEF recovery to 35% and aspirin was discontinued.

IMPACT/DISCUSSION: Left ventricular non-compaction (LVNC) is a rare congenital cardiomyopathy estimated to affect 8 - 12 per 1 million individuals each year. Patients may present at any age and the clinical manifestations inculde heart pump failure, arrhythmias, and thromboembolic phenomenon. Echocardiography is routinely used initially as the non-invasive investigation of choice. Cardiac MR is increasingly used for its ability better distinguish between compacted and non-compacted layers. Coronary angiography is rarely required the diagnosis of non-compaction, but is necessary in the setting of ischemic cardiomyopathy as described here.

Management of symptomatic patients includes guideline-directed heart failure therapy. Some patients may benefit from an implanted cardiac defibrillator for severe ventricular tachyarrhythmias to prevent sudden death. Hypertrabeculation predisposes patients with reduced left the ventricular function at risk for clot formation and patients should be started on oral anticoagulation once the diagnosis of LVNC is confirmed.

CONCLUSION: This is a rare case of both LVNC and CAD leading to a mixed ischemic and non-ischemic cardiomyopathy in which advanced imaging modalities played a pivotal role in helping diagnose a life- threatening condition that may have been missed otherwise.

ACUTE ONSET IGA VASCULITIS IN AN OTHERWISE HEALTHY ADULT WITH NO EVIDENCE OF SYSTEMIC INFLAMMATION.

Raphael J. Crum¹; Christopher Miao²; Nathaniel W. Scarberry²; Stephanie Gambino²

¹Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #3869890)

CASE: A 31-year-old man with unremarkable past medical history presented to the hospital with a 2-week history of worsening petechia and purpura on his bilateral lower extremities. Two weeks prior to presentation, he began noticing a non-blanching, non-pruritic, and petechial rash on his bilateral medial ankles that expanded distally to the dorsum of his feet and proximally up to his knees. In addition to the rash, he endorsed arthralgia and edema of his bilateral ankles. The patient tried over-the-counter topical steroid creams and oral antihistamines with no relief of the rash or arthralgia. ROS was notable for a chronic cough and mild headaches, but otherwise 12-point ROS was negative. Medical, surgical, and family histories were unremarkable and non-contributory. He worked in a water-treatment plant and did not smoke or use illicit substances but endorsed occasional alcohol use.

All vital signs were within normal limits. Physical exam was notable for bilateral ankle tenderness and decreased range of motion, multiple non-blanching, erythematous petechiae on bilateral ankles extending to the dorsa of both feet and shins as well as some lesions on medial thighs. Tender purpura was observed on the dorsum of each foot. CBC and BMP were notable for an elevated white cell count to 12.4 but otherwise grossly negative. Urinalysis was negative for hematuria or proteinuria. Auto-immune workup resulted in a negative rheumatoid factor, non-reactive ANA titer, a borderline normal vs. elevated CRP to 1.2, and C3/C4 complement levels within normal limits.

A punch biopsy was performed and revealed leukocytoclastic vasculitis with areas of red blood cell extravasation, fibrinoid necrosis of the blood vessel wall with perivascular neutrophil-rich infiltrate, and immunofluorescent labeling positive for perivascular IgA deposition consistent with a diagnosis of IgA- vasculitis (formerly Henoch-Schoenlein purpura).

IMPACT/DISCUSSION: IgA vasculitis is a small-vessel vasculitis caused by deposition of IgA immune complexes in the gastrointestinal system, joints, skin, and kidneys. IgA vasculitis is the most common etiology of small-vessel vasculitis in pediatric patients but is far less common in the adult population with more than 90% of cases occurring in patients less than 10 years of age. The European League Against Rheumatism (EULAR) diagnostic criteria defines IgA Vasculitis as presence of purpura or petechiae on lower limbs with one of the four following criteria: acute arthritis/arthralgias, acute and diffuse abdominal pain, histopathology showing leukocytoclastic vasculitis with IgA deposits, or renal involvement with hematuria or proteinuria.

CONCLUSION: While IgA vasculitis is a rare occurrence in the adult population, especially in the absence of any inflammatory markers or abdominal pain, IgA vasculitis should be considered in the differential diagnosis of acute onset lower extremity petechiae and purpura in an adult with arthralgias.

ACUTE PERICARDITIS SECONDARY TO CONCOMITANT INFECTION BY COCKSACKIE VIRUS AND STAPHYLOCOCCUS AUREUS

Dania Kaur, Abhinav Vyas, Sarah Elsayed, John W. Scarborough

Department of Internal Medicine, North Alabama Medical Center, Florence, AL. (Control ID #3876860)

CASE: A 33-year-old female with a significant past medical history of intravenous drug use with methamphetamine presented to our facility complaining of shortness of breath and pleuritic chest pain for three weeks with a flu-like prodrome one week back. The chest pain was worse lying flat. Shortness of breath was present at rest and exertion and associated with position changes. Initial vitals showed a blood pressure of 116/59 mmHg, heart rate of 96 bpm, respiratory rate of 32 breaths/min, and temperature of 97.8. She was saturating at 96% oxygenation. Labs showed WBC of 57.6, H&H 12.3 mg/dL and 36.5%, creatinine 1.6 mg/dL, BUN 86 mg/dL, lactate 3.8. A Computed Tomography scan of the chest without contrast showed moderate to large pericardial effusion, almost 2.5 cm in thickness, and bibasilar pleural effusions. Electrocardiogram showed sinus rhythm with low-voltage QRS. We started the patient on ibuprofen 600 mg 3 times daily and colchicine 0.6 mg twice daily. However, her condition continued to deteriorate despite starting her on appropriate therapy. The cardiothoracic surgery and cardiology were consulted, and a joint decision was made to drain the pericardial fluid through the subxiphoid window approach. It was also decided to start the patient on broad-spectrum antibiotic coverage owing to the deterioration in clinical status. Serology for ANA, anti-CCP and double-stranded DNA, EBV DNA PCR, and coxsackie A and B antibodies were sent. Serology was positive for coxsackie A and B antibodies. The pericardial effusion, which was drained, revealed culture positive for methicillin-sensitive Staphylococcus aureus(MSSA). The blood cultures were negative. Since it was MSSA, the patient was started on cefazolin 2 g IV every eight hours for four weeks. She was safely discharged in the next three days.

IMPACT/DISCUSSION: Acute pericarditis is a painful inflammation of the fibrinous covering of the heart called the pericardium. The most common etiology other than idiopathic is secondary to viral infection however can also be caused by bacterial infections and systemic diseases. Few cases have been reported in the literature regarding concomitant bacterial and serology-positive viral pericarditis. Mainstay management of acute pericarditis involves non-steroidal anti-inflammatory drugs and colchicine. By timely initiating antibiotics in our patient, we prevented complications like tamponade, which happens in approximately 23% of patients developing pericardial effusion secondary to acute pericarditis.

CONCLUSION: We should have a low threshold for initiating antibiotics in patients who fail to respond to mainstay management of acute pericarditis in the first few days without waiting for a culture report.

Physicians should also remember that although viral infection is the most common cause of acute pericarditis in a developed nation like the US, concomitant bacterial infection can also occur and cause acute pericardial effusion, especially in patients with a history of drug abuse.

ACUTE THROMBOEMBOLISM AFTER COVID-19 VACCINATION IN THE SETTING OF MAY- THURNER SYNDROME.

Ayesha Iqbal¹; Fadila Noor¹; Valerie Cluzet²

¹Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ²Medicine/Infectious Diseases, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #3873919)

CASE: 44-year-old woman presented with fever, chest pain and left lower extremity (LLE) pain and swelling five days after receiving J&J COVID-19 vaccination. On arrival to ED, vital signs were within normal limits. Initial lab work was notable for normal complete blood count but D-dimer was elevated to 3571ng/ml. Initial EKG showed sinus tachycardia at 128 bpm. Chest x-ray revealed hyperaerated lungs. Ultrasound Doppler of LLE showed no evidence of DVT. CTA chest identified numerous filling defects in the bilateral pulmonary arterial tree including both upper lobes and both lower lobes. Patient was started on therapeutic enoxaparin and was admitted for bilateral pulmonary embolism. Echocardiogram showed normal EF without RV strain. To assess for iliocaval DVT in the setting of persistent leg swelling and discoloration, patient underwent CT abdomen and pelvis venogram which showed May-Thurner syndrome with compression of left common iliac vein by the right common Iliac artery. There was an acute thrombus within the left common iliac vein extending into the IVC. The patient underwent mechanical thrombectomy and stenting of the common external iliac vein. She was transitioned from enoxaparin to apixaban and was discharged home in stable condition on hospital day seven.

IMPACT/DISCUSSION: Although our patient was diagnosed with May-Thurner Syndrome at the time of presentation, the timing of thrombosis raises the query if COVID vaccination enhanced the risk of thrombosis. There is not enough evidence yet to confirm that J&J vaccination increases the risk of thromboembolism in patients who are already at increased risk, such as those with anatomical risk factors. J&J vaccine-associated thrombotic events are thought to be related to autoantibodies against PF4 platelet antigen, similar to HIT. According to one observational study, post-vaccination thromboembolism was more pronounced in those with previous history of thromboembolism, HIT and COVID-19 infection . Our patient’s platelets were normal at baseline, but her symptoms started within five days of getting vaccination, which raises suspicion that J&J vaccination predisposes the patients for thrombotic events, especially when they are already at risk.

CONCLUSION: Deep venous thrombosis (DVT) can occur in the setting of hypercoagulability, venous stasis and prolonged immobilization. There are other rare causes of DVT, like May-Thurner Syndrome, in which an anatomical variant of the right common iliac artery compresses the left common iliac vein. The J&J vaccine against COVID-19 is associated with thromboembolism which can occur at different sites, including cerebral, splanchnic and ophthalmic veins. People who are at increased risk for thromboembolism should be monitored closely after J&J vaccination for thrombosis.

A DETRIMENTAL DUO: COVID-19 THERAPY-INDUCED TACROLIMUS TOXICITY WITH GASTROINTESTINAL BLEEDING

James Z. Todd¹; Byung Soo Yoo²

¹Internal Medicine, Atrium Health, Charlotte, NC; ²Gastroenterology, Atrium Health, Charlotte, NC. (Control ID #3875886)

CASE: A 73-year-old female with a history of breast cancer, doxorubicin-related cardiomyopathy status post orthotopic heart transplant on tacrolimus presented to the emergency department with dyspnea, nausea, and vomiting. Four days prior, she tested positive for COVID-19 and was started on nirmatrelvir-ritonavir outpatient. Given her transplant history, tacrolimus level was checked which revealed a level of greater than 60 ng/mL. All of her medications were reviewed for potential interactions and both nirmatrelvir-ritonavir and tacrolimus were held. Her hospitalization was complicated by melena and an acute decline of hemoglobin from 11.3 g/dL to 6.3 g/dL. She denied any NSAID use prior to admission and she did not receive any during her hospitalization. An H. pylori stool antigen was also negative. Gastroenterology was consulted, and an upper endoscopy revealed scattered gastritis with hemorrhage and ulcerations. She was then started on supportive therapy and proton pump inhibitors. Subsequently, tacrolimus levels returned to therapeutic levels and a repeat upper endoscopy four days later showed resolved gastritis and ulcerations. Her gastrointestinal bleeding was determined to be from tacrolimus-induced gastrointestinal toxicity.

IMPACT/DISCUSSION: Nirmatrelvir-ritonavir has quickly caught on as a preferred treatment for symptomatic patients with mild to moderate COVID-19 infection in the outpatient setting. Early clinical trials indicated an 89% relative risk reduction of hospitalizations or death in unvaccinated patients, but it is not without risks. Ritonavir is a strong CYP3A4 inhibitor and can increase serum levels of CYP3A4 substrates such as tacrolimus. A multi-center Spanish study in 2020 described a persistent elevation of tacrolimus levels in 71.4% of patients on liponavir-ritonavir for COVID-19. Nirmatrelvir-ritonavir-induced tacrolimus toxicity has been well described and often presents as acute kidney injury.

To our knowledge, this is the first description of gastrointestinal bleeding due to nirmatrelvir-ritonavir- induced tacrolimus toxicity. Gastrointestinal toxicity is a known adverse effect of tacrolimus and can manifest as diarrhea, ulceration, or even perforation. Our patient had no prior gastrointestinal disease, developed her symptoms following initiation of nirmatrelvir-ritonavir with elevated tacrolimus levels, and had endoscopic evidence of improvement and symptom resolution following discontinuation. This case clearly illustrates the importance of completing a thorough review of medication interactions and monitoring for signs of toxicity, particularly when starting a novel medication.

CONCLUSION: ● Nirmatrelvir-ritonavir is a potent CYP3A4 inhibitor and a thorough medication review should be performed prior to prescribing this.

● Tacrolimus toxicity can adversely affect the gastrointestinal system and lead to bleeding.

A DIAGNOSTIC DILEMMA COMPLICATED BY SAMPLING BIAS: MUCINOUS ADENOCARCINOMA WITH SUPERIMPOSED CRYPTOCOCCAL INFECTION

Mallory Brosious, Benjamin D. Goodman, Naa-irah Muhammad

Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #3876499)

CASE: A 66-year-old male with history of type 2 diabetes mellitus and coronary artery disease presented with subacute shortness of breath and pleuritic chest pain. He was recently evaluated at an outside hospital for these symptoms and transferred for additional advanced evaluation. Chest radiograph revealed a right- sided pneumothorax, and chest computed tomography (CT) scan was significant for a large right-sided hydropneumothorax and extensive pulmonary cavitary lesions bilaterally. Multiple samples of the pleural fluid were collected without significant findings. Prior to transfer, multiple biopsies of the cavitary lung lesions were obtained without yielding a diagnosis. On the fifth bronchoscopy, pathology results revealed adenocarcinoma with mucinous features and fungal cultures were significant for cryptococcus neoformans. The mucinous adenocarcinoma origin was unable to be identified on pathology, but a CT scan of the abdomen and pelvis showed an atrophic pancreas, but no definitive masses. Carbohydrate antigen 19-9 was significantly elevated. This, in conjunction with the CT findings, make a pancreatic origin the most likely source.

IMPACT/DISCUSSION: Pulmonary cryptococcosis is an invasive fungal infection caused by Cryptococcus neoformans or Cryptococcus gattii. This infection is known to occur in immunocompetent or immunocompromised patients. More severe disease is often seen with immunocompromised hosts, and those with malignancy are at increased risk for cryptococcosis. The findings on chest radiograph or chest CT for pulmonary cryptococcosis and metastatic disease to the lungs are similar. For this reason, it is important to obtain biopsies and cultures of areas of concern when the definitive diagnosis remains in question to determine a diagnosis and treat accordingly.

This case also highlights the phenomenon of sampling bias. Sampling bias occurs when a sample is collected in such a way that it fails to collect a representative sample and systematically favors one outcome over another. In total, the patient had five bronchoscopies with biopsies before a final histological diagnosis was made. It is of paramount importance to emphasize the need of obtaining an adequate tissue sample from multiple sites in order to attain the highest yield for a quick and accurate diagnosis. One exam finding that made the diagnosis more difficult was that the patient did not have visual evidence of a lesion while performing the bronchoscopy. A retrospective study from 2008 of patients with a diagnosis of lung cancer showed that the diagnostic yield of non-visible lesions via biopsy is 25%.

CONCLUSION: Cryptococcosis is a fungal infection that can lead to pulmonary manifestations which can mimic lung cancer on imaging. The diagnosis of lung cancer can be difficult due to sampling bias. In order to increase the diagnostic yield of a biopsy, an adequate sample size from multiple sites should be obtained.

A DIAGNOSTIC ENIGMA : AN URGENT INTERVENTIONAL APPROACH TO A PATIENT WITH DECOMPENSATED HEART FAILURE AND CHRONIC KIDNEY DISEASE WITH WELLEN'S SYNDROME

Rajeev V. Seecheran, Abhiram Challa, Rhythm Vasudeva, Kevin Kadado, Wassim Shaheen

Internal Medicine, University of Kansas School of Medicine Wichita, Wichita, KS. (Control ID #3875249)

CASE: A 71-year-old male with heart failure with reduced ejection fraction and stage 3b chronic kidney disease presented with chest pain and fluid overload. Initial ECG demonstrated sinus rhythm and troponin of 163 ng/ml. The patient had progressively worsening chest pain, rising troponin indices and the development of anterior biphasic T-wave inversions.

The patient became progressively dyspneic within several hours and underwent urgent coronary angiography with deranged kidney function, which demonstrated thrombus formation of the distal apical segment of the LAD with spontaneous reperfusion. The patient did not require stent placement and was continued on medical management with tirofiban, heparin and ticagrelor. The patient was considered at high risk for contrast-induced nephropathy (CIN) and, due to fluid status, could not be given intravenous fluid.

IMPACT/DISCUSSION: Wellen’s syndrome is described as a rare and ominous electrocardiogram finding of biphasic T-wave inversions or symmetrical T - inversion in precordial leads in patients presenting with anginal symptoms and portends critical proximal left anterior descending (LAD) coronary artery stenosis.

CONCLUSION: Prompt recognition of Wellen’s Syndrome is crucial and serves a prognostic role for impending infarction of the proximal LAD, particularly in high at-risk populations, such as in this case, to minimize the risk of CIN and for timely intervention to prevent acute anterior wall myocardial infarctions.

A DIFFICULT CASE OF NEW-ONSET SEIZURES IN THE PRESENCE OF SEVERE HYPERTENSION – WHEN TO CONSULT YOUR FRIENDLY NEUROLOGIST?

Navedeep Kaur¹; Hector I. Roman Perez¹; Tazeen Rizvi¹; Isaac Bourgeois²

¹Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL; ²Neurocritical care, Advocate Christ Medical Center, Oak Lawn, IL. (Control ID #3876969)

CASE: A 57-year-old male with past medical history of recently diagnosed hypertension and Type II Diabetes Mellitus presented with acute onset dizziness, ataxia, headache, nausea and vomiting. Initial triage was significant for elevated blood pressure of 228/127 and bloodwork showing glucose of 256 mg/dL. Physical exam demonstrated lack of eye contact with difficulty tracking and dysmetria. CT Head and MRI Head without contrast were read as having no acute intracranial pathology. Treatment was started for hypertensive emergency. The following day, the patient showed signs of encephalopathy and had a witnessed seizure with post-ictal state demonstrating left-sided hemineglect and cortical blindness with confabulation of vision (Anton Syndrome). The patient was sent for a STAT MRI, which reported no intracranial abnormalities and no findings to explain seizure activity. The Neuro Critical Care Unit was consulted and bedside review of MRI images by the neurointensivist were read as subtle cortical hyperintensity and expansion in the right lobe, corresponding to the patient’s clinical symptoms of hemineglect and cortical blindness, and consistent with findings seen in posterior reversible encephalopathy syndrome (PRES).

IMPACT/DISCUSSION: PRES is a diagnosis based on clinical presentation, risk factors and radiographic findings. It presents with variable neurological symptoms, but commonly includes vision changes, headache, nausea, altered mentation and seizures. In our case, the patient presented with hypertensive emergency and neurologic symptoms consisting of headache, ataxia, dysmetria. A thorough work-up to rule out stroke, infectious and metabolic etiologies of his symptoms was negative. However, with the new onset seizure, our suspicion for PRES increased. Although repeat MRI reported no concern for PRES, the patient’s clinical picture was concerning and we sought out further evaluation from Neurology. PRES was not reported on the formal radiographic readings, however, the neurologist evaluated the images and diagnosed PRES based on their interpretation of the MRI, leading to timely and accurate diagnosis. This case illustrates the importance of avoiding anchoring on radiographic findings when clinical suspicion of a diagnosis is high and consulting specialists to delineate subtle or atypical presentations, ultimately decreasing morbidity and mortality.

CONCLUSION: PRES is a disorder of cerebrovascular autoregulation and endothelial dysfunction. Some of the triggering factors are hypertension, kidney disease, autoimmune conditions, and infectious processes. Most of these triggers are also associated with encephalopathy, seizures, and headaches which confounds PRES's typical symptomatology. As an internist, one of the main driving forces for medical management is the clinical degree of suspicion. This case provides a great example of when to consult a specialist for additional input, especially when the diagnostic findings are vague and require a higher degree of expertise.

A DIZZYING DISPLAY: AN EVALUATION OF NEW VERTIGO

John Marsiglio¹; Matthew Mulligan²

¹Internal Medicine, University of Utah Health, Salt Lake City, UT; ²General Medicine, The University of Utah School of Medicine, Salt Lake City, UT. (Control ID #3869909)

CASE: A 25-year-old female with history of postural orthostatic tachycardia syndrome (POTS) with episodic presyncope, and migraines presented with migraine and vertigo for 2 weeks unresponsive to home medications. Unlike prior migraines this was more posterior, and continuous with visual aura. Prior migraines did not have associated vertigo. Neurologic exam including head impulse and Dix-Hallpike maneuvers were unremarkable. MRI brain was unremarkable, audiometry, and video nystagmography were normal. The patient was diagnosed with vestibular migraine based on clinical presentation and negative testing. Symptoms improved with meclizine and resolved at week 6 with nonpharmacologic prevention.

IMPACT/DISCUSSION: Dizziness is frustrating for patients and physicians alike. It is important to define it as either vertigo (sensation of motion), presyncope, disequilibrium (imbalance) or mixed. The differential for vertigo is broad and broken into central or peripheral causes. Central causes include TIA, stroke, and vestibular migraine while peripheral causes include benign paroxysmal positional vertigo (BPPV), vestibular neuronitis (VN) and Meniere's disease. A clear history is important to establish time course. Only BBPV has brief episodes. VN has a single episode lasting days. Meniere’s disease and vestibular migraines both have recurrent episodes lasting minutes to hours. Infarction results in persistent symptoms for days but rarely lasts longer than a week.

Diagnosis of vestibular migraine uses the International Classification of Headache Disorders (ICHD-3) criteria. It requires at least 5 episodes of moderate to severe vestibular symptoms lasting 5 minutes to 72 hours, at least 1 migrainous feature in 50% of episodes, recurrent or history of migraines and symptoms not better explained by another diagnosis. Physical exam maneuvers that aid diagnosis include the Dix-Hallpike (BPPV) and head impulse test (peripheral vs central cause). Further tests are not necessary but helpful in atypical presentations. In this patient further testing was indicated given the constant symptoms.

Acute treatment uses antihistamines such as meclizine and/or antiemetics. Nonpharmacologic prevention centers on lifestyle modifications including regular exercise, stress management, avoidance of triggers and improving sleep and treating comorbidities (depression or anxiety). Given a lack of high-quality studies pharmacologic prevention is based on general migraine prevention with beta blockers, calcium channel blockers, antiseizure medications, or antidepressants (TCAs or SSNRIs) depending on comorbidities.

CONCLUSION: The challenge to evaluating dizziness lies in the broad differential diagnosis, which can be narrowed primarily based on history. Vestibular migraine is an uncommon but important cause of dizziness, and is diagnosed based on episodic vertigo symptoms associated with migrainous features. Antihistamines are first line for acute treatment and prevention centers around general migraine prevention.

ADMINISTRATION OF IN HOSPITAL CHEMOTHERAPY TO OVERCOME ACUTE RIGHT VENTRICULAR (RV) DYSFUNCTION SECONDARY TO A MASS EFFECT

Hadeel N. Sahar

Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX. (Control ID #3876531)

CASE: A 51-year-old female with history of metastatic left breast cancer (triple negative) to numerous sites including the liver, anterior chest wall, retroperitoneal adenopathy, pericardial, pulmonary, and osseus metastases. She was treated heavily with multiple lines of chemotherapy in the past, and most recently was on phase 1 clinical trial, however with further disease progression. She was sent from the breast medical oncology clinic for admission because of obstructive hyperbilirubinemia secondary to her metastatic cancer. Patient admitted to the hospital medicine department and underwent successful ERCP and stenting to the biliary duct. Over her hospital stay she complaint of worsening shortness of breath that get worse on lying down and better with sitting. Her most recent CT scan showed a 4.9 cm lesion in the left anterior chest previously measured 4.0 cm, tumor invades the ventral pericardium and abuts the right ventricle and other pericardial metastases result in narrowing of the pulmonary veins. She is now becoming hypotensive, and cardiology was consulted. Echo was done with findings of small pericardial effusion and no evidence of tamponade. Cardiology has advised to keep the patient on intravenous (IV) fluids since she is becoming hypotensive that is likely secondary to the mass compressing the right ventricle. At some point the patient didn't want the IV fluids and subsequently her blood pressure dropped again. Her condition was discussed further with breast medical oncology and cardiology in regards for the consideration of in hospital chemotherapy to overcome organ dysfunction, and therefore patient received IV liposomal doxorubicin overnight. Patient tolerated chemotherapy well. On the 4th to 5th day post chemotherapy, her blood pressure started to improve, with reported improvement of her shortness of breath.

IMPACT/DISCUSSION: This case highlighted the presence of an acute right ventricular dysfunction in the presence of metastatic cancer affecting the RV contractility and subsequently cardiac output manifesting as hypotension. The patient received IV fluids that helped to maintain her blood pressure tentatively at lower normal ranges, however without treating the actual underlying cause for her RV dysfunction. Treating the underlying cause was necessary in this case to raise the blood pressure and subsequently helped to alleviate the underlying reason for the RV dysfunction that could be fatal if left untreated.

CONCLUSION: Hospitalists can play an essential role in the management of a very specific presentation in a cancer patient. Alertness to RV dysfunction in this case and discussing the management plan with cancer medicine and cardiology was imperative to prevent further vital organ dysfunction and possible death. This case may also have an impact on the hospitalist's awareness with regards to the indications of chemotherapy in a hospitalized patient with a solid tumor.

A FATAL CASE OF RAPIDLY PROGRESSIVE CATASTROPHIC ANTIPHOSPHOLIPID SYNDROME WITH UNDIAGNOSED GASTRIC ADENOCARCINOMA

Ying Yin Zhou¹; Melanie Li¹; Madina Ray²

¹Internal Medicine, NYU Langone Health, New York, NY; ²Rheumatology, NYU Langone Health, New York, NY. (Control ID #3874819)

CASE: A 42-year-old otherwise healthy man presented with 2 years of intermittent nausea, vomiting, and abdominal pain that acutely worsened in the past 3 weeks, associated with new-onset headache, dizziness, and blurry vision. He reported a 20-lb weight loss, otherwise denied fevers, rashes, arthritis, recent travel, or history of bleed or thrombosis. Exam showed heart rate 105 and right upper quadrant abdominal tenderness. Laboratory studies showed platelet 21,000/uL, white blood cell 13,700/uL, prothrombin time 19.7 seconds, lactate dehydrogenase 3,325 U/L, and D-Dimer 10,000 ng/mL. Hemoglobin, creatinine, haptoglobin and ADAMTS13 levels were normal. No schistocytes were seen on peripheral smear. Antiphospholipid antibody testing was positive for lupus anticoagulant. Initial CT brain showed acute parietal and occipital lobe infarcts with a punctate white matter focus of hemorrhage. Abdominal CT angiography on hospital day 3 showed acute bilateral renal infarcts and gastric wall thickening. Acute inferior STEMI ensued and was treated medically with beta blocker and statin, cardiac catheterization deferred due to severe thrombocytopenia. Broad-spectrum antibiotics were continued for suspected sepsis, however infectious workup including bacterial, tick-borne, and viral etiologies only revealed a urinary tract infection. Given a high clinical suspicion for catastrophic antiphospholipid syndrome (CAPS), the patient was started on plasmapheresis, high dose steroids, and subsequently rituximab, intravenous immunoglobulins (IVIG), and platelet transfusions. Heparin was started cautiously at 300 u/hr with platelets at 46,000/uL. However, repeat CT brain showed temporoparietal lobe infarct with increased hemorrhage and heparin was held. Patient unfortunately expired from cardiac arrest on day 13. Autopsy revealed gastric adenocarcinoma.

IMPACT/DISCUSSION: CAPS is a rare but fatal, rapidly progressive condition characterized by thromboses in multiple organ systems. The most common precipitating factors are infection, surgery and malignancy. Only two gastric cancer-associated CAPS cases have been reported. Malignancy can further increase thrombotic risk as seen in this case. Establishing the diagnosis of CAPS is difficult, especially as the first manifestation of antiphospholipid syndrome. Acute CAPS can also resemble sepsis or other primary thrombotic microangiopathies. Current knowledge supports treatment with heparin anticoagulation, high dose steroids, and plasmapheresis and/or IVIG along with precipitating factor treatment in patients with clinical suspicion of CAPS. Rituximab and eculizumab have reported success in refractory cases, however, the mortality of CAPS remains extremely high despite therapy. Severe thrombocytopenia is uncommon and can delay early initiation of anticoagulation which has a significant effect on survival.

CONCLUSION: This case highlights the importance of early recognition and aggressive treatment of CAPS. Workup for an underlying malignancy is warranted.

AGAMMAGLOBULINEMIA IN A PATIENT WITH LUPUS

Asma Bahrami¹; Alec Rezigh²; Rashmi Thimmapuram¹

¹Internal Medicine, Baylor College of Medicine, Houston, TX; ²General Internal Medicine, Baylor College of Medicine, Houston, TX. (Control ID #3874244)

CASE: A 25-year-old male with systemic lupus erythematosus (SLE) presented to the emergency room with supraventricular tachycardia and left knee pain and swelling in the setting of recent left knee septic arthritis and osteomyelitis managed with washout, debridement, synovectomy at a neighboring hospital. Synovial biopsy was notable for chronic inflammation and hemosiderin, but no organisms were identified. He was treated empirically with antibiotics.

He was diagnosed with systemic lupus erythematosus (SLE) thirteen years prior to admission via serologic workup and renal biopsy. He was treated with hydroxychloroquine, prednisone, and rituximab, but taken off two years later and lost to follow-up. Between then and the time of presentation, he reported three instances of pneumonia and development of a chronic cough. Prior chest imaging had revealed bronchiectasis. In the two years prior to presentation, he had morning stiffness and joint pain in the bilateral shoulders and right knee. He developed right knee septic arthritis which was treated with washout and antibiotics. No organism was ever identified.

With recurrent infections without a clear predisposition, further investigation was initiated. Immunoglobulin levels were profoundly low, raising suspicion for common variable immunodeficiency (CVID) versus a complication of his prior rituximab therapy. Due to the severity of agammaglobulinemia, he was initiated on intravenous immunoglobulin (IVIG) therapy. He was empirically treated with doxycycline and levofloxacin for septic arthritis due to difficulty with obtaining samples with repeat arthrocentesis. Several months later, he continues to do well on IVIG therapy with no recurrent infections to date.

IMPACT/DISCUSSION: Immune dysregulation is involved in the pathophysiology of both autoimmune disorders and primary immune deficiencies, and they commonly co-exist. Up to 38 percent of individuals with CVID have a coexisting autoimmune condition, and of those up to 20 percent develop autoimmune conditions prior to their diagnosis of CVID. CVID is defined by significant reductions in immunoglobulin (Ig) G with concurrent reductions in either IgA, IgM or both. However, secondary hypogammaglobulinemia or agammaglobulinemia may develop in patients with autoimmune conditions either related to the disease itself or its treatments, such as rituximab or other immunomodulators. This is distinct from CVID which is a primary defect.

This patient had negative serologic titers despite prior history of SLE likely due to his primary or secondary immunoglobulin deficiency. Understanding the relationship between autoimmunity and immunodeficiency and learning when to initiate an immunodeficiency workup can help with diagnosis and management of our patients.

CONCLUSION: Clinicians should maintain a moderate degree of suspicion for primary immune deficiency in patients with autoimmune disorders such as SLE and vice versa.

AIDS AND PAROTID TUBERCULOSIS, NOT FORGOTTEN

Hannah Li, Joseph D. Cooper, Dennis W. Adams

Santa Clara Valley Medical Center, San Jose, CA. (Control ID #3872964)

CASE: A 46 year-old man from Malaysia with no known medical history presents with a 3-week history of an enlarging right neck mass. He has no other symptoms other than a dry cough over the past few months. He mentions having a right lower molar infection two years ago. Surgery was recommended at the time; however, he declined and was treated with oral antimicrobials. He was last sexually active five years ago, during which he had unprotected sex with men and women. On physical examination, he has a fever of 101.5 degrees and a 3-inch right submandibular mass that is mobile and tender to palpation. He is breathing comfortably with no stridor. Initial bloodwork is significant for elevated CRP of 7.5. CT scan of the neck shows a complex cystic and solid mass in the inferior right parotid. He is started on broad-spectrum antibiotics and seen by ENT who performs an FNA biopsy of the mass. Further workup reveals an AIDS diagnosis with a CD4 count < 35 and HIV viral load of 178,395 copies. Interferon-gamma release assay is positive. Expectorated sputum for acid fast bacilli (AFB) returns negative on three occurrences, and chest X-ray is non-concerning for infection. FNA cytology demonstrates mixed, predominantly neutrophilic inflammation with rare epithelioid granulomata. AFB smears are positive, so he is started on rifampin, isoniazid, ethambutol, and pyrazinamide. M. tuberculosis (MTB) is later confirmed on tissue PCR.

IMPACT/DISCUSSION: TB is a necrotizing granulomatous disease that most commonly affects the lungs, however extra-pulmonary forms make up to 20% of all active TB cases. Involvement of the parotid gland is rare, with less than 200 cases documented worldwide. Due to its low incidence, nonspecific symptoms, and radiographic findings that often mimic malignancy, parotid TB difficult to identify. Therefore, histopathological examination of parotid gland tissue is paramount for diagnosis. Historically, most cases have been diagnosed through parotidectomy; however, recently it has become standard to use the less- invasive option of FNA cytology. On histology, TB typically manifests as granulomatous inflammation, however in some immunocompromised patients it elicits suppurative inflammation with a lack of granulomas. Our patient’s histology findings generated a broad differential for parotitis, including infection, sialolithiasis, and benign lymphoepithelial cysts. When the classic granulomatous pattern of TB is not seen, tissue MTB PCR may be needed to confirm diagnosis, but should not delay treatment. In our case, early consultation of ENT directly from the emergency room led to prompt biopsy of the parotid gland, however treatment was initiated prior to PCR confirmation due to high clinical suspicion for parotid TB.

CONCLUSION: The hallmark for diagnosis of parotid TB is histological confirmation, however among immunocompromised patients this may present atypically. Subsequent PCR confirmation may take weeks to result, and should not delay treatment.

A LIVER INJURY WHO DONE IT

Lena J. Volpe¹; Reeti Gulati¹; Trisha Kaundinya¹; Deepa Daryani²; Kelley Wachsberg²

¹Northwestern University Feinberg School of Medicine, Chicago, IL; ²Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #3875209)

CASE: A 67-year-old male with a history of bipolar disorder and polysubstance abuse presented with one week of dark urine. He was otherwise asymptomatic. He endorsed unprotected intercourse and denied injection drug use. Prior to admission he had restarted taking valproate, though intermittently, and recently completed a course of cephalexin for cellulitis. Exam was notable for scleral icterus and painless 5mm palmar lesions. Labs revealed an elevated ALT (1953 U/L), AST (1427 U/L), alkaline phosphatase (219 U/L), total bilirubin (11.3 mg/dL), LDH of 352 U/L, and INR of 1.2. Valproate and acetaminophen levels were negative. A urine drug screen was positive for cocaine. Other labs included a +treponemal Ab/+RPR, +HCV antibody and quantitative HCV PCR of 1,410,000 IU/mL. Hepatitis B, HIV, autoimmune serologies and ceruloplasmin were unremarkable. Iron studies included a ferritin of 12,993 ng/mL, IBC of 304 mcg/dL, Fe of 304 mcg/dL, and a 100% transferrin saturation. MRI showed no biliary dilation and changes consistent with secondary hemochromatosis. Liver biopsy revealed an acute hepatitis pattern and fibrosis consistent with acute autoimmune hepatitis, toxin exposure and/or acute viral hepatitis. Warthin-Starry stain was negative. During admission, N-acetylcysteine and IM penicillin were started. Transaminases improved and HCV titers declined to 20,400 IU/mL by the time of discharge.

IMPACT/DISCUSSION: Marked transaminitis has a finite differential and commonly results from acute viral hepatitis, ischemic injury, drug-induced liver injury, or autoimmune hepatitis. Syphilitic hepatitis was considered though commonly presents with a cholestatic liver injury pattern without severe transaminase elevation. The leading diagnosis was DILI secondary to valproate or cephalexin in a patient predisposed by underlying HCV. Idiosyncratic DILI is dose-independent and hepatocellular injury with an elevated bilirubin is typical for valproate toxicity. Cephalosporins rarely cause clinically apparent liver injury. While cocaine use can cause ischemic injury it was not felt causative. Secondary hemochromatosis in this case was attributed to HCV-associated hepatic iron accumulation, which may have predisposed the patient to DILI or worsened DILI insult. Acute HCV infection alone is possible given that the rise and fall of HCV titers tracked with transaminase improvement. However, HCV is not commonly a singular cause of liver failure without co-infection with HBV. Liver biopsy is used to help elucidate an etiology in cases such as this though was not definitive for our patient.

CONCLUSION: Our case highlights the challenge in distinguishing a clear cause for acute liver injury in patients with possible DILI who present with concurrent HCV infection and emphasizes the need to consider both etiologies in patients with multiple risk factors. Further research is needed to determine whether HCV predisposes to DILI or whether DILI can exacerbate chronic HCV infection.

ALL THAT IS INFLAMED IS NOT INFECTED: A CASE OF GRANULOMATOSIS WITH POLYANGITIS CAUSING MIDDLE EAR EFFUSION AND MULTIPLE CRANIAL NEUROPATHIES

Laura Nichols^1,2

¹Internal Medicine, University of North Dakota, Fargo, ND; ²Internal Medicine, Sanford Health, Fargo, ND. (Control ID #3867945)

CASE: A 35 year old female with no significant past medical history presented with history of new right- sided ophthalmoplegia and ptosis. She began experiencing right ear pain, approximately 4 months prior and was treated with multiple courses of antibiotics as well as tympanostomy tube placement for otitis media and possible mastoiditis noted on CT. Four days prior to admission, she had onset of vertical diplopia, ptosis and worsening right-sided headache. Outside MRI, MRV and MRA were performed, which showed persistent right mastoid opacification without evidence of stroke or venous thrombosis. There was concern for petrous apicitis; therefore, broad spectrum antibiotic coverage was initiated. On transfer, repeat MRI revealed enhancement of the right V3 nerve root, probable bilateral cranial nerve XII enhancement within the hypoglossal canals as well as asymmetric tissue expansion from the right nasopharynx into the right parapharyngeal fat with encasement of the right carotid artery. CMP and CBC showed no abnormalities. CRP was elevated to 186.8 mg/L and ESR was elevated at 97 mm/hr. Urinalysis was positive only for presence of moderate blood with 21-30 RBC/hpf. CT chest, abdomen, pelvis was performed, which was negative for lymphadenopathy but showed scattered subpleural opacities. Cerebrospinal fluid had no abnormalities. Autoimmune serologic revealed positive cANCA with a titer of >1:640 and positive PR-3 antibodies (>8.0 AI). Rheumatology was consulted given the presumptive diagnosis of granulomatosis with polyangitis (GPA) manifesting as middle ear inflammation and cranial neuropathies. Renal biopsy confirmed presence of pauci- immune focal segmental necrotizing and crescentic glomerulonephritis. The patient was started on high-dose solumedrol as well as rituximab infusion with rapid clinical improvement.

IMPACT/DISCUSSION: The current case illustrates a rare presentation of GPA with progressive cranial neuropathies. Peripheral neuropathies are a relatively common manifestation of GPA at around 20-25%. However, multiple, progressive cranial neuropathies as a primary manifestation are reported in a minority of patients. The current case also provides an excellent example of the mechanisms of cranial neuropathy in GPA. While our patient primarily had unilateral symptoms related to compressive neuropathy, she also had evidence of radiographic involvement bilaterally of the hypoglossal nerve without evidence of compression, likely consistent with nerve injury from vascular inflammation and occlusion. The case also provides an important clinical reasoning reminder that the presence of inflammation does not always indicate infection and that expansion of the differential diagnosis is necessary when empiric treatment as failed.

CONCLUSION: Progressive cranial neuropathies as illustrated in this case are a rare complication of GPA, but given the implications for patient debility, it is important for the internist to recognize this presentation of GPA for early diagnosis and treatment.

ALTERED MENTAL STATUS: IS NCSE ON YOUR DIFFERENTIALS?

Noor Dweik¹; Tarek Shihab¹; Anass Dweik²; Tarek Naguib³

¹Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ²Internal medicine, Texas Tech University Health Sciences Center School of Medicine Amarillo, Amarillo, TX; ³Internal Medicine, Texas Tech University Health Sciences Center - Amarillo, Amarillo, TX. (Control ID #3876072)

CASE: Introduction

Nonconvulsive status epilepticus (NCSE), originally described in patients with chronic epilepsy, is now recognized in other populations, especially the critically ill. The threshold of 10 minutes is used to define NCSE as status epilepticus without prominent motor symptoms.

Case Presentation

A 47 years old female with diabetes, hypertension, peripheral vascular disease, and cerebrovascular accident with residual aphasia presented with altered mental status. Son reported history of seizures, and finding mother unresponsive with froth on mouth. No history of alcohol or illicit drugs besides marijuana. She took clonazepam with unclear compliance. Blood pressure was 213/96. WBCs was 16K/mcL and potassium was 3.3 mmol/L. GSC was 11, continuous lip smacking, blinking, and bilateral Babinski sign were noted.

Nicardipine drip controlled blood pressure, but AMS remained unchanged. Empiric therapy for meningoencephalitis was started.

Workup for autoimmune and infectious diseases was negative. Blood glucose was normal. MRI showed chronic left MCA territory and lacunar infarcts in the bilateral centrum semiovale, corona radiata, body of the corpus callosum, and left thalamus. EEG showed ongoing ictal activity and confirmed electrographic status epilepticus in the frontal, parietal, and temporal lobes. Initiating benzodiazepines and levetiracetam was followed by a slow recovery.

IMPACT/DISCUSSION: Our patient had focal status epilepticus, with impairment of consciousness, previously referred to as complex partial status epilepticus and is more appropriately referred to as focal status epilepticus with impaired awareness. Seizures most commonly originate from the temporal or frontal lobe. In addition to impaired consciousness, manifestations can include confusion, aphasia, amnesia, behavioral changes, and automatisms. The cause of NCSE in our patient was likely hypertensive encephalopathy in addition to clonazepam withdrawal. Hypokalemia may suggest a role for aldosteronism and possible primary aldosternism, seizures, and neurologic abnormalities (PASNA). Other causes include infections, autoimmunity, drugs, or aftermath of convulsive status epilepticus. There is controversy whether to treat NCSE as aggressively as convulsive status epilepticus, but there are no randomized studies for treatment decisions. Therapy includes initial intravenous benzodiazepines with a non-coma-inducing intravenous anti-seizure medication; and treating the underlying cause.

CONCLUSION: The etiologies of NCSE are varied. Up to two-thirds of the patients have a remote history of seizures or epilepsy. Potential relation to PASNA needs explored. Diagnosis of NCSE requires a high index of suspicion. Focal status epilepticus with impairment of consciousness typically has a good response to initial therapy, but clinical improvement may be delayed.

A LYMPHOMA WITH NO MASS; A 75 YEAR OLD FEMALE DIAGNOSED WITH DIFFUSE LARGE B CELL LYMPHOMA

Mariko Aoyama¹; Tetsuya Hoshi²; Kaito Nakamura³; Kaihei Masuda²; Keita Hibako²; Megumi Sano²; Yoshimoto Serizawa²; Taku Shimizu⁴; Satoshi Oota⁵

¹General internal medicine, Teine Keijinkai Byoin, Sapporo, Hokkaido, Japan; ²General Internal Medicine, Teine Keijinkai Byoin, Sapporo, Hokkaido, Japan; ³Department of General Internal Medicine, Teine Keijinkai Byoin, Sapporo, Hokkaido, Japan; ⁴Hematology, Teine Keijinkai Byoin, Sapporo, Hokkaido, Japan; ⁵Pathology, Teine Keijinkai Byoin, Sapporo, Hokkaido, Japan. (Control ID #3872035)

CASE: A 75 year old female with a significant history of hypertension, osteoporosis and allergic rhinitis presented with fever, reduced appetite, night sweats, coughing and dyspnea that worsened over 3 weeks. As there was no improvement with acetaminophen, the previous clinic took a chest computed tomography (CT) scan 3 days before admission that showed ground glass opacities (GGOs); she was suspected of atypical pneumonia and was started on azithromycin. However, her symptoms did not improve and was admitted to our hospital for further investigation. She denied sick contacts, and multiple COVID-19 tests were negative. On admission, her physical examination demonstrated fever (99.5 Fahrenheit) , tachypnea and fine inspiratory crackles on the right lower lung. There was no lymphadenopathy. Blood tests showed an elevated

CRP, LDH(874U/L) and hypoalbuminemia. The sputum culture, blood cultures were negative. Her symptoms and fever did not alleviate, but a repeated CT scan 7 days later showed her GGOs had disappeared. We decided to work her up as a fever of unknown origin and performed an extensive laboratory exam, which showed high s-IL2-R(8975U/mL) and ferritin (212ng/mL) levels. During the hospital course, she developed blurred vision, and the ophthalmologic examination revealed chorioretinitis. Elevated s-IL2-R and LDH levels, in addition to systemic symptoms including fever and night sweats suggested lymphoma but without lymphadenopathy; therefore, we suspected intravascular lymphoma. A random skin biopsy revealed involvement of diffuse large B cell lymphoma within and around the blood vessel lumen.

IMPACT/DISCUSSION: There is a rare form of diffuse large B cell lymphoma called intravascular lymphoma, which is characterized by the predominant growth of large malignant cells within the lumen of blood vessels. Since there are no pathognomonic features, one must suspect the disease based on the patient presentation, physical exam and laboratory findings. In this patient, we initially suspected atypical pneumonia and admitted the patient for observation after appropriate use of antibiotics. However, the onset of ophthalmologic symptoms suggested a systemic disease such as malignant lymphoma, and prompted further investigation including biopsies that led to the diagnosis. When investigating fever of unknown origin, laboratory findings that point towards hematological malignancies include anemia, leukopenia, thrombocytopenia, hypoalbuminemia. In our case, marked elevations of LDH, s-IL-2R levels also suggested malignant lymphomas. Definite diagnosis of such patients often requires pathohistological examinations. Examination of unaffected organs, especially random skin biopsies are useful as in this case, with a suggested sensitivity of up to 78%.

CONCLUSION: In patients with elevated LDH and s-IL2R, lymphoma should be suspected even in the absence of lymphadenopathy. Furthermore, biopsy of seemingly unaffected organs such as the skin can lead to the diagnosis in such patients.

A MASS OF COMPLICATIONS FROM AN UNEXPECTED UNDERLYING DIAGNOSIS IN AN IMMUNOCOMPETENT PATIENT

Kandice Roberts¹; Rachel Presti²

¹Internal Medicine, Washington University in St Louis, St Louis, MO; ²Internal Medicine, Division of Infectious Diseases, Washington University in St Louis School of Medicine, St Louis, MO. (Control ID #3877229)

CASE: A 37-year-old man with history of obesity presented to the hospital with 2 weeks of progressive odynophagia, dysphagia, productive cough, and a new right submandibular mass that was initially soft and tender but became firm and painless. He endorsed weight loss of 127 pounds in 8 months, attributed to dietary modifications. He denied, dyspnea, fever, and night sweats.

Vitals were normal other than tachycardia to 109. Physical exam revealed a palpable mass in the right submandibular region, diffuse submandibular lymphadenopathy, and occasional rhonchi. Labs were notable for strep DNA positivity on pharyngeal swab. CBC and CMP were normal. Influenza, COVID-19, RSV, and mono testing was negative. CT scan of the neck and chest showed mass-like fullness in the right Peri tonsillar

region with loss of the parapharyngeal fat and encasement and narrowing of the right internal and external carotid arteries, submandibular lymphadenopathy, enlarged hilar lymph nodes, and a mass-like consolidation in the superior segment lower lobe of the left lung. He received IV Unasyn, Vancomycin, and dexamethasone without benefit.

His course was complicated by multiple syncopal, hypotensive, and bradycardic episodes attributed to impingement of the carotid sinus by the mass. Laryngoscopy showed severe airway narrowing, resulting in awake tracheostomy. He then developed Serratia and Klebsiella bacteremia leading to MICU transfer for fluids, pressors, and IV antibiotics. Multiple biopsies of the nasopharyngeal mucosa were read as reactive tissue. PET/CT imaging was pursued given a high concern for malignancy and showed FDG avid pharyngeal and right parapharyngeal soft tissue thickening, FDG avid consolidation in the left lung, hypermetabolic left hilar and mediastinal lymph nodes, and FDG uptake throughout the bone marrow and spleen. Transbronchial biopsy revealed granulomas and histoplasma antibody titer of 1:64. He was treated for disseminated histoplasmosis with ambisome.

IMPACT/DISCUSSION: Histoplasmosis is caused by the endemic mycosis, Histoplasma capsulatum. It can be found anywhere in the United States but is most prevalent in the Ohio and Mississippi River valleys.

Risk factors for disseminated infection include primary immunodeficiencies, AIDS, extreme ages, and immunosuppressive drugs. Construction, farming, and spelunking have also been associated with an increased risk for infection, as the mold grows best in soils with a high nitrogen content. Approximately 90% of exposed individuals will remain asymptomatic or have self-limited symptoms. Clinical manifestations are

widely variable and nonspecific. This case demonstrates the ability of H. capsulatum to cause life-threatening symptoms, even in an immunocompetent patient.

CONCLUSION: Disseminated histoplasmosis should be considered in a patient with systemic symptoms regardless of immune status, especially in highly endemic areas. Prompt diagnosis is important for the avoidance of life-threatening complications.

AMIODARONE-INDUCED PNEUMONITIS MASKED BY HEART FAILURE EXACERBATION James Yang

Internal Medicine, University of Massachusetts Chan Medical School - Baystate Regional Campus, Springfield, MA. (Control ID #3871381)

CASE: 65 year old female with history of pulmonary fibrosis of unknown etiology, atrial fibrillation (Afib) on warfarin, coronary artery disease with stent, ischemic cardiomyopathy, ventricular tachycardia with AICD presented with shortness of breath, subsequently admitted to intensive care unit for cardiogenic shock. Vitals were significant for blood pressure of 89/47, but despite fluids, the patient's pressure dropped to 68/25. O2 saturation was in the mid 80s. Labs were significant for pro-BNP 18k, negative troponin, and positive urinalysis. CT chest showed pulmonary edema and upper lobe predominant fibrosis with traction bronchiectasis. Hospital course was complicated by Afib with rapid ventricular response (RVR) and worsening oxygen requirement. Afib with RVR was Initially treated with amiodarone drip but due to continued RVR, the patient underwent ablation, which was partially successful. Given partial success, amiodarone was continued. Hypoxemia was attributed to volume overload, however, despite volume optimization, the patient continued to require higher oxygen with chest x-ray concerning for acute respiratory distress syndrome (ARDS) in the setting of known pulmonary fibrosis. Second CT chest showed exacerbation of interstitial lung disease (ILD). Pulse dose methylprednisolone 1000 mg IV daily for 3 days was started due to concern for rapidly progressive ILD with highest suspicion for amiodarone pneumonitis.

ILD serologies (RF, CCP, ANA, DSDNA Ab, Smith/RNP Ab, Sjogren's Ab, Scleroderma Ab, Jo1 Ab, Aldolase) and hypersensitivity pneumonitis panel were negative. Subsequently, oxygen was weaned from 50L 50% FiO2 high flow nasal cannula down to 4L nasal cannula. Amiodarone has been discontinued and the patient was eventually discharged on 3L oxygen via nasal cannula, 80 mg prednisone daily and Atovaqueon daily for PJP prophylaxis.

IMPACT/DISCUSSION: Amiodarone-induced pneumonitis is a serious complications of the drug. Common risk factors include male gender, age, and pre-existing lung disease. It can occur any time after the initiation, but patients who have been taking 400mg or more for at least two months are at highest risk. Diagnosis is made with clinical presentation and imaging such as chest X-ray and CT. Lung biopsy is the gold standard. Treatment is to stop amiodarone and in symptomatic patients, starting systemic glucocorticoids. This case is unique in that amiodarone pneumonitis was masked by heart failure exacerbation. Further, the patient responded quickly with pulse dose steroids, in fact, the oxygen requirement decreased from 50L 50% FiO2 high flow nasal cannula to 4L nasal cannula in a few days. In retrospect, if amiodarone pneumonitis was on the differential, early treatment with systemic glucocorticoids may have helped this patient’s clinical course and resulted in a quicker recovery.

CONCLUSION: When patients with amiodarone use and a history of pre-existing lung disease presents with hypoxemia, amiodarone pneumonitis should be on the differential.

A MOUTHFUL OF POSSIBILITIES: AN INTERESTING PRESENTATION OF MUCOCUTANEOUS HSV-1

Anisha S. Das

Department of Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #3876949)

CASE: A 57-year-old female with past medical history of intellectual disability and recently diagnosed AML was admitted to the hospital for cholecystitis. History was also notable for dysphagia. Over the past month, the patient had progressive difficulty swallowing solids primarily with initiation. Other symptoms included the sensation of residual food remaining in the pharynx, regurgitation, coughing, and choking. Physical exam revealed white, dorsal, multifocal, circular tongue and left lower lip lesions with a heaped appearance. The lesions were non-tender to palpation. Labs were notable for a white blood cell count of 1.9, hemoglobin of 11.3, platelets of 71, and absolute neutrophil count of 590. EGD revealed normal appearing oropharynx, larynx, and esophagus. Proximal and distal esophagus biopsies were normal. There was mild nonspecific erythema throughout the stomach. Gastric body and antrum biopsies were normal. Duodenum was normal in appearance. ENT obtained biopsies of the tongue and lip lesions. Pathology was consistent with herpetic ulceration. Treatment was valacyclovir 1 gram twice daily until the lesions resolved. Due to the patient's moderate neutropenia, treatment was followed by acyclovir prophylaxis.

IMPACT/DISCUSSION: It can be challenging for many experienced clinicians to accurately diagnose and manage oral lesions as the differential is broad. Recognizing the relationship between systemic diseases and oral manifestations can help narrow the differential. In AML, common oral manifestations include but are not limited to mucosal pallor due to anemia, spontaneous bleeding and petechial hemorrhages due to thrombocytopenia, and gingival hyperplasia and oral ulcerations from neutropenia or leukemic infiltration. Due to neutropenia, patients are also at risk of developing periodontal bone loss and bacterial, viral, and fungal infections. Common infections include candidiasis and herpes. Antiviral medications for the treatment of mucocutaneous HSV-1 infection include acyclovir, valacyclovir, and famciclovir. Treatment should be initiated as early as possible from symptom onset. In initial infection, dosing depends on the agent. Treatment duration typically ranges from 5-10 days or until lesions resolve. Suppressive therapy should be considered for patients with severe disease or frequent recurrences.

CONCLUSION: This case highlights that the broad differential for oral lesions can be narrowed based on a patient's systemic disease, such as AML. This case also discusses the management of mucocutaneous HSV-1 in immunocompetent and immunocompromised individuals.

A MYSTERIOUS CASE OF CAVITARY LUNG LESION IN A HEALTHY YOUNG MALE

Lutfor Nessa¹; Kristina M. Cross²; Sai Siva Mungara¹; Barath Rangaswamy¹

¹Internal Medicine, Texas Tech University Health Sciences Center Permian Basin, Odessa, TX; ²School of Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX. (Control ID #3876985)

CASE: A 23-year-old male with history of type 1 diabetes mellitus on insulin and mild Intermittent Asthma on rescue inhaler presented with a 2-week history of right lower pleuritic chest pain associated with 2-days of high-grade fever and cough with green, foul-smelling sputum. He denied any recent travel history and sick contacts but had COVID-19 infection one month before his presentation. He smokes marijuana daily. Vital signs were normal, including SP02 96% on room air. Physical examination revealed decreased breath sounds in the right lower lobe (RLL). Labs showed leukocytosis (18.4) with neutrophilic dominance (74%) and HbA1C of 6.1. CTPE showed cavitary lung lesion in the RLL measuring 5.5 cm with viscous exudate and reactive right hilar lymphadenopathy. An IR-guided chest tube was placed for abscess drainage, and biopsy showed extensive eosinophilic tissue necrosis. Special stains failed to demonstrate the presence of any microorganisms. Blood cultures, Sputum cultures, including AFB and fungal cultures, were negative. However, the Chlamydia Pneumoniae IgG titer was 1:256. Vasculitis workup, including Anti-MPO, C-ANA, and p-ANCA, were negative. Patient was treated with broad-spectrum antibiotics, including MRSA coverage with vancomycin, ampicillin-sulbactam, and fluconazole for fungal coverage. A repeat CT Chest after five days of IR-guided chest tube placement and IV antibiotics showed RLL abscess decreased significantly in size. Patient clinically improved except for mild pleuritic chest pain on the seventh day of hospitalization and was discharged home.

IMPACT/DISCUSSION: The differential diagnosis for a cavitary lung lesion is vast, which includes complications from bacterial pneumonia, septic emboli, mycobacterial infection, fungal infection, granulomatosis with polyangiitis (GPA), sarcoidosis, and cystic lung diseases. In this case, the patient’s geographic location in West Texas predisposes him to fungal infections, but he was negative for antibody titers. The patient was positive for Chlamydia IgG, which increases the risk of delayed cavitary lung lesions. Delayed cavitary lung lesions after COVID-19 infection have also been reported previously. It is important to note that GPA can have a difficult clinical course and sometimes can be presented as progressive cavitary

lung lesions even in the absence of renal involvement or positive ANCA serologies. It may take several months to diagnose GPA after symptom onset.

CONCLUSION: Broad differential diagnosis and thorough workup are warranted in a patient with cavitary lung lesions. This case supports the management strategy of deploying adequate empiric antibiotics and antifungal therapy early in the course. Even with extensive workup and multi-specialty engagement, we could not identify the specific cause in our patient.

A MYSTERIOUS CASE OF FOOT DROP

Mark E. Heslin

Joseph Park, Victor Cotton. Internal Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #3876425)

CASE: A 59-year-old male with a past medical history of hepatitis b virus (HBV) presented to the ED with subacute bilateral lower extremity numbness and pain. Six weeks prior to admission, he developed left groin pain and a testicular ultrasound showed left sided orchitis. Five weeks prior to admission, he developed bilateral lower extremity numbness and pain and presented to an outside hospital (OSH). He reported that the numbness was in his right leg below the knee. Then, one week later, he developed the same numbness in his left leg. He also reported abdominal pain, low grade fevers, fatigue, and unintentional weight loss. He had a CT A/P that was notable for colitis. He also had an MRI head, which was unremarkable. He was started on steroids and discharged on a steroid taper. After discharge from OSH, he reported improvement in the numbness, however he was unable to ambulate without a walker, therefore he presented to the ED of this hospital.

His focused neurological exam was notable for bilateral common peroneal neuropathy. An MRI lumbar spine was obtained, which unremarkable. Labs were notable for a hemoglobin A1c 5.4, negative HIV, normal ESR and CRP, and normal vitamin levels. Autoimmune serologies were notable for an ANA 1:40, negative p-ANCA, negative c-ANCA, C3 91 (88-201 mg/dL), C4 19 (16-47 mg/dL), negative cryoglobulins, negative rheumatoid factor, and negative anti-CCP antibody. A CTA C/A/P was obtained, which showed a small wedge-shaped infarct in the left kidney. A presumed diagnosis of polyarteritis nodosa (PAN) was made and the patient was started on prednisone with immediate improvement in symptoms. The patient followed up with rheumatology one month after discharge and was started on azathioprine and continued prednisone.

IMPACT/DISCUSSION: PAN is a medium-vessel vasculitis with a prevalence of 2-33 per million. Given its rare prevalence, unclear pathogenesis, and lack of specific serologies, the diagnosis of PAN is frequently delayed. PAN presenting as orchitis is rare. Furthermore, orchitis is rarely encountered by internists in the inpatient setting, therefore making this case of PAN especially difficult to diagnose. PAN has a poor prognosis if left untreated with a five year survival of 13%. Unfortunately, our patient will likely have permanent neuropathy due to misdiagnoses. Misdiagnosis is one of the most important safety problems in healthcare today and it is estimated that 33% of patients have been impacted by diagnostic errors. Cognitive biases, like confirmation and anchoring bias, play a major role in the misdiagnosis of rare diseases. It is vital that physicians are aware of these biases to improve diagnostic accuracy and ultimately, the lives of our patients.

CONCLUSION: PAN is a rare disease with varied clinical presentations Orchitis occurs in ~20% of patients with PAN

Cognitive biases perpetuate the misdiagnosis of rare diseases

AN ALMOST FATAL DOG BITE

Jawairia Sahar Mirza¹; Murali Ranjani Behara²; Austin Saugstad¹; Syed Hassan²

¹Internal Medicine, Creighton University School of Medicine Phoenix Regional Campus, Phoenix, AZ; ²Dignity Health Cancer Institute, Phoenix, AZ. (Control ID #3875598)

CASE: A 60-year-old homeless male with history of COPD and syphilis was hospitalized after presenting with a presyncopal episode. On arrival, the patient was found to be septic. Laboratory data was suggestive of macrocytic anemia with a hemoglobin of 12.7 g/dL. The initial platelet count was 42,000/uL, which quickly trended down to 4,000/uL. Additionally, LDH was elevated with undetected haptoglobin levels, and a peripheral smear showed several schistocytes up to 20/hpf. An infectious work-up was completed, with blood cultures growing gram-negative rods and RPR returning negative. As a result, the patient was started on broad spectrum antibiotics. Due to concerns for thrombotic thrombocytopenic purpura (TTP), urgent plasmapheresis was planned, though the patient left against medical advice. Three days later, the patient was readmitted with complaints of lower extremity rash. Repeat lab analysis was completed and was consistent with findings of severe thrombocytopenia and hemolytic anemia. Additionally, the patient was noted to have an acute kidney injury with creatinine of 5.3 mg/dL. Plasmapheresis was immediately initiated. He was continued on broad spectrum antibiotics with cefepime and metronidazole. ADAMST13 activity levels were found to be 23%. Following plasmapheresis, some improvement was noted in the platelet count, but with relatively elevated levels of ADAMST13 levels, plasmapheresis was discontinued. Blood cultures from the first admission, after 18 days of incubation period, grew capnocytophaga species. The patient later reported a dog bite on the left arm, which was subtle, obscured, and was not noticed on the first admission. The patient’s antibiotic regimen was changed to Unasyn with improvement in patient’s lab parameters. Ultimately the hemolysis resolved, and the patient’s platelet count and creatinine normalized. He was discharged home in a stable condition.

IMPACT/DISCUSSION: Here we present a case of capnocytophaga-induced sepsis complicated by thrombotic microangiopathy. Our patient’s initial clinical presentation was concerning for TTP, thus plasmapheresis was initiated, for this potentially life-threatening condition. This presentation is more often seen in immunocompromised patients and those with asplenia, however has also been reported in immunocompetent patients. Capnocytophaga is a gram negative, facultative anaerobe usually found in the saliva of dogs and cats. It is a very slow growing organism and takes an average of 5-7 days to be detected in the culture media. Mortality from sepsis due to this organism is close to 30%.

CONCLUSION: Capnocytophaga is a rare cause of sepsis, presenting as a diagnostic challenge due to delayed culture growth and non-specific clinical symptoms. Quality history taking is the key to unlocking the events preceding the onset of symptoms and revealing potential infectious exposure risks. Lifesaving treatment such as plasmapheresis should be promptly initiated in suspected cases even when the diagnosis is not yet confirmed.

ANAPLASMOSIS MYOPERICARDITIS

Jane Ehret^1,2; Olushola Ogunleye^1,2; Winifred C. Akabusi^1,2; Benoit Bewley³

¹Internal Medicine, Nuvance Health, Lagrangeville, NY; ²Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ³Cardiology, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #3873972)

CASE: A previously healthy 50-year-old male, who was diagnosed with Anaplasmosis by his primary care doctor two days earlier, presented to the hospital with one day of chest pain and dyspnea. Vital signs and examination were unremarkable. He had an elevated troponin T of 662 ng/L. ECG showed diffuse ST elevations. Coronary angiography revealed normal coronary arteries. He was diagnosed with Anaplasmosis myopericarditis and started on doxycycline, colchicine, and aspirin. His symptoms resolved, but his hospital course was complicated by non-sustained ventricular tachycardia. Six weeks later, a cardiac MRI was performed. It showed no myocardial edema on T2-weighted imaging; however, late gadolinium enhancement imaging revealed a small region of subepicardial enhancement at the basal inferolateral wall, consistent with recent myocarditis.

IMPACT/DISCUSSION: Myopericarditis (MP) is characterized by pericardial inflammation (pericarditis) with extension to the myocardium. Myocardial involvement is identified either by significantly elevated troponin or evidence of myocardial inflammation on cardiac MRI. The clinical presentation is similar to that of acute pericarditis or acute coronary syndrome.¹ Therefore, this entity should be considered after ruling out immediately life-threatening conditions.

MP can be idiopathic or secondary to infection, autoimmune disease, uremia, radiation, trauma, or myocardial infarction. Most infectious etiologies are viral, but other infectious organisms have been implicated. Tick-borne illnesses, such as Anaplasmosis, are rarely associated.²

Anaplasmosis is a febrile illness caused by Anaplasma phagocytophilum, a bacterium transmitted by ticks of the Ixodes spp. in the Northeast and Midwest regions of the United States.³ Known cardiac complications of Anaplasmosis include heart failure, arrhythmias, and pericardial effusions.^4,5 To our knowledge, only two other cases of MP associated with Anaplasmosis have been reported.^5,6

Our patient met the diagnostic criteria for MP with his clinical symptoms, ECG findings, and elevated troponin level. The absence of edema or inflammation on cardiac MRI does not exclude MP in this case, as it was done six weeks after presentation instead of the recommended two-week time frame. After six weeks of treatment, any previous edema or inflammation had resolved. However, the focal region of subepicardial enhancement at the basal inferolateral wall on late gadolinium imaging confirmed the diagnosis.

This case occurred in a region endemic to Anaplasmosis. Fortunately, the patient’s PCP had already made the diagnosis two days earlier. Having this information allowed for prompt antibiotic therapy and an excellent outcome.

CONCLUSION: Myopericarditis is a rare complication of Anaplasmosis. The diagnosis should be considered when patients in endemic areas present with chest pain and elevated cardiac biomarkers, after ruling out acute coronary syndrome. Early and appropriate antibiotic therapy is crucial for patient recovery.

AN ARROW THROUGH THE HEART: RECOGNIZING PACEMAKER LEAD PERFORATION Gilgamish Maloul¹; Susan B. Glick²

¹Medical College, Rush University Rush Medical College, Chicago, IL; ²Internal Medicine, Rush Medical College, Chicago, IL. (Control ID #3875198)

CASE: An 85-year-old woman presented with exertional dyspnea and chest discomfort for 6 years. She became short of breath when walking from one room to another or walking up and down the stairs. The dyspnea was accompanied by substernal chest tightness. She slept on one pillow and denied PND, edema, and cough.

Shortly before symptom onset, a pacemaker was placed for second degree AV block type II. Periprocedural echo revealed a trivial pericardial effusion. Troponin I was 0.20. CT angiogram was unremarkable and stress EKG showed no ischemia. The patient consulted several electrophysiologists who provided differing opinions about the etiology of her symptoms. Pacing was adjusted but led to worsened symptoms.

Past medical history was significant for anxiety, HCL, dilated aortic root, PSVT and IBS. She was a never smoker, did not drink alcohol or use recreational drugs. Family history included a brother with a pacemaker due to syncopal episodes.

On examination, she was well-appearing. BP 145/69 HR 78 RR 16 T 97.4°F. Physical examination including HEENT, neck, pulmonary, cardiac, abdominal, neurologic and extremities was normal.

CBC revealed MCV 101, though was otherwise normal. CMP, TSH and CRP were normal. LDL 131.

A repeat echo and CT angiogram were performed and revealed the RV lead extending through the ventricular free wall and lying in the epicardial or pericardial space. The pacemaker lead was replaced with resolution of the patient’s symptoms.

IMPACT/DISCUSSION: Lead perforation may occur at the time of pacemaker placement or much later. The incidence of pacemaker lead perforation is unknown. However, CT scan findings suggest the prevalence is 6%. Cardiac perforation by an implantable device is associated with significantly increased risk of major complications and mortality, with UpToDate reporting odds ratios of 27.5 and 17.7, respectively. It may also result in pacemaker malfunction due to pacing or sensing failure.

Periprocedural pacemaker lead perforation is recognizable to internists by the post-procedure quartet of chest discomfort, dyspnea, pericardial effusion and a troponin leak. Other symptoms include diaphragmatic stimulation, hiccups, and abdominal pain, though many are asymptomatic.

Whether lead perforation can be diagnosed by imaging depends on the extent of perforation and the location of the lead. In our patient, initial chest x-ray, chest CT scan and echocardiogram failed to elucidate the diagnosis. However, her diagnosis was ultimately made by follow up echocardiogram and CT angiography. This highlights the difficulty of making the diagnosis even with imaging.

CONCLUSION: This case shows the importance of considering lead perforation in the differential of a patient presenting with chest discomfort and/or dyspnea after permanent pacemaker placement. Had these symptoms been recognized earlier as possible signs of perforation, a cardiac CT could have been ordered and the patient might not have had to endure her symptoms for six years.

AN ATYPICAL PRESENTATION OF TYPICAL HEMOLYTIC UREMIC SYNDROME IN AN ADULT

Michele Fang, Katherine Oakden

Internal Medicine, Penn Medicine, Philadelphia, PA. (Control ID #3869483)

CASE: A 38 year-old woman presented with a three day history of bloody diarrhea, abdominal pain, anorexia, and nausea. She denied any sick contacts and did not eat any raw vegetables, undercooked meat, frozen dinners, or restaurant food.

The patient was afebrile and had left lower quadrant pain to deep palpation. WBC was 15.5, and CT abdomen and pelvis showed severe colitis. The patient was treated with antibiotics, fluids, and analgesics. Her clostridium difficile testing was negative. Then on day 3, patient worsened with increased abdominal pain, decreased urine output, acute kidney injury, and had a marked drop in platelets and hemoglobin. Antibiotics and narcotics were discontinued. An ADAMSTS 13 level was sent and was not consistent with thrombotic thrombocytopenic purpura (TTP), but her stool culture returned positive for Escherichia coli 0157:H7.

The patient’s presentation was consistent with typical hemolytic uremic syndrome (HUS). Adult and pediatric hematology, nephrology and infectious disease were consulted. Ultimately, eculizumab was given along with meningitis vaccination. Despite eculizumab, the patient had worsening mental status requiring intubation and hemodialysis, but the hemolysis improved.

IMPACT/DISCUSSION: Diarrhea is a fairly common presentation encountered by hospitalists. However, when bloody diarrhea is noted, stool cultures should be ordered, and antibiotics and narcotics should be held if patients are clinically stable until shiga-toxin producing bacteria are ruled out given risk of triggering HUS.

Given that HUS has similar findings to TTP, an ADAMSTS 13 should be routinely checked as part of the work up as if the ADAMSTS 13 were positive, patient would have been a candidate for plasmapheresis. Typical HUS has a relatively good prognosis with a low mortality and with an evolution to chronic renal failure in only 10% of cases. Factors of poor prognosis include the presence of neurological symptoms and need of renal replacement therapy as in our patient (1).

Eculizumab is a humanized monoclonal antibody and terminal complement inhibitor that binds to the human C5 complement protein to block the generation of C5a and C5b-9 (2). It is approved in atypical HUS, but case reports suggest it may reduce hemolysis, improve renal function and neurological deficits in those with typical HUS with elevated soluble C5B9 levels (2). Hospitalists need to be aware that the medication increases susceptibility to encapsulated bacteria. Patients who have not received meningitis vaccination will need penicillin prophylaxis and be started on a vaccine schedule.

CONCLUSION: Stool cultures should be checked and antibiotics should be held in patients with colitis unless patients are hemodynamically unstable. ADAMSTS13 should be checked to rule out TTP when HUS is considered. Hematology and renal should be consulted early. Eculizumab may be used in typical HUS with neurological involvement and elevated soluble C5B9 levels.

ANCHORING ON CONSTIPATION: A DELAYED DIAGNOSIS OF METASTATIC OVARIAN CANCER

Tatiana Requijo, Rex Hermansen, Jennifer Weintraub

Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3876465)

CASE: A 57-year-old post-menopausal woman with chronic constipation presented to the Emergency Room with anuria for one day. Urine output had decreased over two weeks, with worsening of constipation that was ongoing for years, with negative colonoscopy. The patient had up-to-date cancer screenings.

Vitals were normal. Exam revealed abdominal distension and diffuse tenderness. Labs resulted with newly elevated creatinine (8.3) and K (6.0). Urinalysis was unremarkable. A renal ultrasound showed bilateral hydronephrosis. A Foley catheter was placed, laxatives were ordered, and she was given a working diagnosis of acute kidney injury due to urinary obstruction caused by severe constipation.

Subsequent cross-sectional abdominal imaging showed a large adnexal mass following the left ureteral course, with extensive uterine, cervical, and bladder metastases, diffuse lymphadenopathy, and peritoneal carcinomatosis. Tumor markers CA-125 and HE4 were elevated. Endometrial biopsy confirmed high-grade ovarian serous carcinoma.

The patient required urgent placement of bilateral percutaneous nephrostomy catheters for full renal recovery. Upon discharge, she began treatment with neoadjuvant carboplatin/paclitaxel prior to surgery.

IMPACT/DISCUSSION: This case illustrates how anchoring bias delayed the diagnosis of metastatic high- grade ovarian cancer. The patient had a longstanding history of constipation, requiring daily laxatives. She had presented to Gastroenterology with progressive abdominal discomfort and bloating weeks prior, and, since the presumed etiology was constipation, a colonoscopy was obtained, rather than cross-sectional imaging to look for alternate causes. When the colonoscopy was normal, she was diagnosed with irritable bowel syndrome with constipation.

It was not until the patient presented with urinary obstruction that the correct diagnosis was made. Common etiologies of obstructive uropathy include renal stones, ureteral stricture, and urinary tract trauma; however, gynecologic cancer is an important alternate cause. There is limited data on gynecologic etiologies of urinary obstruction, with case reports about large cysts or extrinsic endometriosis, but not malignancy.

Rarely, obstructive uropathy can be a complication of chronic constipation. It is important to recognize that constipation is a symptom, not a diagnosis. Primary causes include defecatory dysfunction, and secondary causes include structural abnormalities like cancer. In a case of urinary obstruction alone, but especially with constipation, malignancy should be high on the differential. Ovarian, uterine, and endometrial cancer should all be considered.

CONCLUSION: For general internists, it is essential to recognize gynecologic malignancy as a rare but important cause of chronic constipation and post-renal acute kidney injury. Keeping gynecologic cancer on the differential for constipation may improve outcomes for these conditions with often delayed diagnoses and poor prognoses.

AN IMAGING MISADVENTURE: A RARE CASE OF ABDOMINAL PAIN

Anisha S. Das, Nicholas S. Faraci, Gregory M. Olenginski

Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #3877049)

CASE: A 67-year-old woman with a history of chronic kidney disease stage 3a and diverticulosis presents with subacute fatigue, anorexia, and epigastric discomfort.

The patient’s symptoms began with a month of fatigue and later developed dull, achy epigastric discomfort associated with early satiety and anorexia four days prior to presentation. She had subjective fevers and chills, but no night sweats.

On examination, temperature was 38.4 C, BP 84/53 mmHg, HR 134 bpm, and abdomen was mildly tender in the epigastrium. Laboratory investigation revealed a white blood cell count of 20.9 K/mL, lactate 2.2 mMol/L, serum creatinine 2.2 mg/dL (baseline 1.2 mg/dL), and normal liver chemistries. Contrast-enhanced CT scan of the abdomen and pelvis demonstrated acute uncomplicated sigmoid diverticulitis and intrahepatic biliary ductal dilation with associated narrowing/effacement of the right portal vein concerning for cholangiocarcinoma. She was resuscitated with crystalloid, started on IV antibiotics, and admitted to the hospital.

The patient’s sepsis improved with resuscitation and IV antibiotics. Magnetic resonance cholangiopancreatography was obtained to better characterize the biliary system, given concern for cholangiocarcinoma, and demonstrated no biliary ductal dilation but rather pylephlebitis and thrombosis of the right posterior portal vein and its branches.

Serial blood cultures remained negative. She was discharged home to finish a 4-week course of piperacillin- tazobactam and 3-6-month course of apixaban pending follow-up imaging.

IMPACT/DISCUSSION: This case highlights a rare complication of intraabdominal sepsis –pylephlebitis, or septic thrombophlebitis of the portal vein.

The diagnosis of pylephlebitis requires demonstration of portal vein thrombosis, and commonly fever and bacteremia. Imaging (CT scan, ultrasonography, or MRI abdomen) is required to confirm the presence of portal vein thrombosis, but is not sufficient by itself. CT is favored over ultrasound as it can identify the precipitating focus of infection.

Antibiotic therapy is the foundation of pylephlebitis treatment. Culture-directed therapy is preferred when available. Empiric antibiotic regimens should cover likely organisms, which are often polymicrobial (gram- negative aerobes and anaerobes). Proposed regimens include: (1) metronidazole + 3rd generation cephalosporin OR fluoroquinolone, (2) piperacillin-tazobactam OR ampicillin-sulbactam, (3) carbapenem. Duration of therapy is at least 4-6 weeks with at least 2-3 weeks of parenteral therapy followed by oral agents.

CONCLUSION: Pylephlebitis, or septic thrombophlebitis of the portal vein, is a rare complication of intraabdominal sepsis. The diagnosis is made clinically by the combination of symptoms and fever with imaging confirmation of portal vein thrombosis. Management focuses on an extended course of IV antibiotics.

AN INTERESTING CASE OF HYPOTHYROIDISM INDUCED RHABDOMYOLYSIS

Omar Z. Syed¹; Khalid Ahmed²; Elmkdad Mohammed²; Muhammad Hassan Shakir²; douglas Klamp²; Aayushi Sood²

¹Internal medicine , The Wright Center for Graduate medical education, Dunmore , PA; ²Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, Scranton, PA. (Control ID #3871890)

CASE: A 37 year old Female with a past medical history of Iron deficiency anemia presented with generalized weakness for 3 weeks and nonproductive cough for 3 days. She also had associated ambulatory dysfunction and anorexia, however denies any recent trauma, falls or prolonged immobility. Her vitals were within normal limits. On the physical exam, she was ill-appearing and pale. She was noted to have lower extremity proximal muscle tenderness bilaterally but otherwise was unremarkable. Investigations were significant for elevated LFTs ( ALT 179, AST 631, Bili total 2.1) and CK of 20,507. Autoimmune work-up revealed positive ANA test but was otherwise unremarkable.

Viral panel was positive for adenovirus. Supportive therapy including IV fluids was initiated. The pain was not improving and on further questioning she admitted to a remote history of thyroid disorder, which elicited a thyroid panel that was significant for a TSH of 43 along with low free T4 and positive thyroid peroxidase antibodies. Patient was started on levothyroxine and her subsequent CK, LFTs and thyroid levels normalized within weeks. Prior to discharge her symptoms significantly improved and she was discharged.

IMPACT/DISCUSSION: Hypothyroidism causing Rhabdomyolysis is considered a rare clinical scenario. Hypothyroidism is defined as the lack of adequate thyroid hormone production which is manifests in a broad category of symptoms and confirmed with elevated TSH values. Rhabdomyolysis is the dissolution of skeletal muscle characterized by elevated muscle cell contents, myoglobin, sarcoplasmic proteins and electrolytes in the circulation. Patients usually have an elevated creatinine kinase (CK) and clinical manifestations include muscle pain or muscle cramps.

Previous literature indicated an association between hypothyroidism and muscle involvement. Only a few cases proved an association between hypothyroidism and rhabdomyolysis. Initially no cause could be identified regarding the elevated CK levels in this patient. She did not have immediate recollection of her thyroid history and she denied any history of statins or other medications associated commonly with the above lab abnormalities. Therefore, hypothyroidism was thought to be the underlying cause of rhabdomyolysis, which was confirmed on laboratory evaluation. Also as seen in previous studies, there has been an inverse relationship shown between CK and thyroid enzymes. We suggest that hypothyroidism should be considered in the differential of rhabdomyolysis and physicians should not hesitate to investigate via thyroid function tests. Additionally, studies have proven that elevated CK levels and LDH should prompt testing for thyroid disorders, especially hypothyroidism.

CONCLUSION: The diagnosis of Hypothyroidism should be included in the differential for patients who present with rhabdomyolysis of unclear etiology. Prompt testing for thyroid function and initiation of appropriate therapy should be considered.

AN INTERESTING CASE OF INCIDENTAL FINDING OF RIGHT ATRIAL MYXOMA IN A MALE PATIENT.

INTRODUCTION: ATRIAL MYXOMAS ARE MORE COMMON ON THE LEFT SIDE AND FOUND MOSTLY IN FEMALES. SYMPTOMS OCCUR THROUGH A VARIETY OF MECHANISMS INCLUDING OBSTRUCTION OF CIRCULATION THROUGH THE HEART VALVES AND INVASION OF MYOCARDIUM LEADING TO CONDUCTION ABNORMALITIES AND THEREFORE ARRHYTHMIAS.

Aisha Abdul Sattar, Henal Patel, Adetola Isola, Ibrahim Ahmed, Harsha Sai Sreemantula

Internal Medicine, Mercy Fitzgerald Hospital, Darby, PA. (Control ID #3877018)

CASE: Case Description: A 57-year-old AA male with history of cardiomyopathy, CHF, paroxysmal atrial fibrillation, DM, and HTN arrived to our cardiac catheterization lab for cardiac ablation. He was scheduled for elective cardiac ablation as his cardiomyopathy was felt to be mostly related to his atrial fibrillation and longstanding poor rate control.

On presentation to our hospital, his only symptoms were dyspnea on exertion. A pre ablation Transesophageal echocardiogram (TEE) was done to rule out left atrial appendage thrombus, which incidentally revealed a pedunculated mass in the right atrium that measured 1.2 x 0.8 cm. The mass was attached to the inferior portion of the inter-atrial septum by a thin stalk, likely representing a right atrial myxoma, however presence of thrombus could not be completely excluded.

Ablation was held and further investigation including CT angiogram and Cardiac MRI was approached. Anticoagulation was started. CT angiogram revealed: "Heterogeneous density which has the appearance of contrast admixture artifact in the atrial appendages and right atrium. No atrial mass is seen. Right lower lobe nodular lesion measuring 14 x 13 mm". Cardiac MRI could not be performed due to claustrophobia. Ablation was held due to the risk of dislodgement of myxoma. Alternative approach was taken for the management of A Fib with rate and rhythm control with metoprolol succinate and Dofetilide with EKGs monitoring, and electrolyte repletion. Rhythm converted to sinus by the second day and he was discharged with outpatient cardiology follow up and repeat TEE in 4-6 weeks.

IMPACT/DISCUSSION: Discussion

The subject case is significant for the following reasons 1) the location of the atrial myxoma was in the right atrium and 2) the atrial myxoma was in a male patient. Atrial myxomas are a rare form of sporadic cardiac tumors. They account for approximately 30-50% of all cardiac benign neoplasms with a predominance for middle-aged women. Atrial myxomas have a tendency to reoccur; however, it has been shown that excisions of myxomas arising from the interatrial septum reduces the risk of recurrence.

TEE is superior over TTE in diagnosing an atrial mass. Cardiac MRI is preferred to assess the morphology, characterization, and potential for malignancy. Cardiac arrhythmias and impaired contractility can occur due to the obstruction of blood flow through the heart and invasion of myometrium. The atrial mass can also fragment from the mass and embolize in the setting of atrial fibrillation. Due to this occurrence, anticoagulation is necessary.

CONCLUSION: This report highlights an unusual case of atrial right sided myxoma in a male as an incidental finding in the process of ruling out left atrial appendage thrombus. He will require close clinical follow up.

AN INTERESTING CASE OF RECURRENT POSTPRANDIAL CARDIOGENIC SYNCOPE CAUSED BY TYPE III HIATAL HERNIA

Ammad J. Chaudhary¹; Mobeen Haider²; Ahmed Oudeif¹; Samantha Koerber¹; Yousra Khalid²; Jonathan Prostak¹

¹Internal Medicine, Henry Ford Health System, Detroit, MI; ²Internal Medicine, Carle Foundation Hospital, Urbana, IL. (Control ID #3877180)

CASE: 92 years-old female with past medical history of medium-size hiatal hernia (HH) presents with recurrent episodes of syncope, immediately after heavy meals, for 4 weeks. Patient denied any prodromal symptoms, bowel/bladder incontinence, tongue biting, or seizure-like activity. On presentation patient was hemodynamically stable, orthostatics negative, physical exam was unremarkable. EKG & cardiac telemetry were unremarkable. Lab work was remarkable for baseline anemia (Hb:8g/dl). CT brain did not show any acute changes. A CT scan chest, abdomen & pelvis showed a large HH with a largely intrathoracic stomach adjacent to left atria (LA) without gastric outlet obstruction.

IMPACT/DISCUSSION: Syncope is a sudden & brief loss of consciousness with spontaneous recovery.

Detailed history & physical exam are pivotal in diagnosis. The differential diagnosis of syncope is broad. It includes neurologic & cardiovascular differentials. Precipitating factor aids in diagnosis. Deglutition syncope is either a neurally mediated syncope precipitated by vagal nerve stimulation during swallowing or caused by pressure on LA as a result of pressure from HH. HH is the protrusion of abdominal organs, mostly the stomach, into the mediastinum through diaphragmatic esophageal hiatus. It is usually asymptomatic & discovered incidentally. Type III HH is when both fundus & gastroesophageal junction herniate through the hiatus.

In this case, the patient had no orthostatic hypotension, arrhythmias, or seizures, however, the history of HH & symptoms precipitated by large meals led to the hypothesis of deglutition syncope. In our patient, the size & location of HH led to postprandial cardiogenic syncope, by pressure on the LA compromising cardiac output. Symptomatic LA compression is a rare clinical condition causing left ventricular inflow obstruction resulting in low output, with symptoms such as syncope, and retrograde increase in pressure throughout the pulmonary vessels with subsequent dyspnea. Given poor surgical candidacy & patient preference, the patient was discharged on proton pump inhibitors along with the advice of eating small & frequent meals. The patient is compliant with recommendations with no recurrence of syncope.

CONCLUSION: Recurrent syncope in patients with a history of HH should prompt differential for HH leading to deglutition syncope.

HH usually remains asymptomatic and sometimes is difficult to diagnose due to its various clinical presentations, the most common being gastroesophageal reflux, and less commonly chest pain, discomfort, or anemia. There are some unusual presentations that could be life-threatening.

Management for HH is acid suppression & diet modifications. Surgical intervention is reserved for persistent symptoms/life-threatening emergencies.

AN INTERESTING PATIENT WITH BOTH HEADACHE AND RIGHT VISION IMPAIRMENT. Soichiro Matsuo¹; Yoko Yamamoto³; toshiaki Furuta³; Yasuteru Sugino⁴; Kazuo Komamura²; Mitsunori Iwase²

¹Internal medicine, Toyota Kinen Byoin, Toyota, Aichi, Japan; ²Cardiology, Toyota Memorial Hospital, Toyota, Aichi, Japan; ³Otolaryngology, Toyota Kinen Byoin, Toyota, Aichi, Japan; ⁴Respiratory, Toyota Kinen Byoin, Toyota, Aichi, Japan. (Control ID #3875920)

CASE: A 73-year-old man with a history of diabetes mellitus (HbA1c was 8.9%) and glaucoma developed severe headache, right ocular pain, and nausea, five days before visiting our hospital. When he arrived at the hospital, his left eye was normal, but the right eye had a visual acuity as low as a hand motion and a disorder in ocular movement. There were no neurological deficits other than visual acuity and ocular motility. No lesions were noted in the head CT. Therefore, the patient was judged to have little urgency and consulted the ophthalmologist. The ophthalmologist performed a facial MRI. Since it showed a hyperintense area in the right optic nerve sheath on T2-weighted imaging and a mass-like lesion and bone destruction in the right sphenoid sinus, the patient was referred to otolaryngologists. They found a black mass in the right sphenoid sinus by nasal fiberscope, and diagnosed the optic neuritis due to fungal sinusitis. The fungal mass in the right sphenoid sinus was removed by endoscopic sinus surgery, and they started antifungal medication postoperatively. They used liposomal amphotericin B assuming mucormycosis. His light perception did improve 2 days after surgery. Since filamentous fungi were identified according to pathology, they considered the sinusitis to be caused by Aspergillus infection. His visual impairment continued to improve steadily and eventually recovered to the same level as before the onset of the disease, and he was discharged on the 22nd day after admission.

IMPACT/DISCUSSION: The causes of sinusitis can be classified as viral, bacterial, fungal, and allergic. The fungal sinusitis is rare (less than 1%) and is classified as either invasive or noninvasive. Especially the mortality rate for invasive fungal sinusitis is as high as around 10-20%. However, it is often difficult to distinguish between fungi and bacteria using imaging studies, and there is invasive fungal sinusitis in which the levels of fungal antigens and β-D-glucan are not elevated. Therefore, a definitive diagnosis of invasive fungal sinusitis requires the detection of a fungal mass by nasal fiberscope.

In this case, invasive fungal sinusitis due to immunocompromised status may be attributed to poorly controlled diabetes mellitus. A nasal fiberscope was performed promptly to confirm the presence of fungi in the sinus cavity. The fungal mass was confined to the sphenoid sinus and the right orbital tip, and there was no extensive intracranial or orbital extension. There was no invasion into the spinal fluid. Fungal sinusitis is one of the most easily overlooked diseases but fatal. Early intervention and treatment can greatly affect the patient's prognosis and quality of life.

CONCLUSION: Sinusitis is one of the common causes of headaches and requires attention, especially in the elderly or diabetic patients. Since invasive fungal sinusitis is a disease with poor prognosis, both accurate diagnosis and prompt treatment are important.

AN INTERESTING PRESENTATION OF FROIN SYNDROME AS A GUILLAIN-BARRE SYNDROME MIMIC

Mobeen Haider¹; Yousra Khalid¹; Ammad J. Chaudhary²; Abdul Basit Nawaz¹; Saba Akram¹; James Kumar¹

¹Internal Medicine, Carle Foundation Hospital, Urbana, IL; ²Internal Medicine, Henry Ford Health System, Detroit, MI. (Control ID #3877011)

CASE: A 66-year-old female with a past medical history significant for migraines & invasive lobular breast cancer status post bilateral mastectomy, chemotherapy & radiotherapy presented with worsening migraine headaches, nausea, projectile vomiting & progressive bilateral lower extremity weakness for 3 weeks. The patient was recently treated with Azithromycin for Campylobacter gastroenteritis four weeks ago. The patient was hemodynamically stable. Physical exam was significant for irritability, decreased power (3/5) & absent reflexes bilaterally in the lower extremities. Lab work was remarkable for mild leukocytosis. Brain imaging (CT & MRI) revealed disproportionate lateral ventriculomegaly with obstructive hydrocephalus. A CT abdomen pelvis & MRI thoracolumbar spine were unremarkable. Lumbar puncture (LP) revealed an elevated opening pressure of 38 mmHg, glucose:41 & total protein: 295 mg/dl(elevated). Cerebrospinal fluid(CSF) cytology revealed xanthochromia, elevated RBCs >3000 & WBC: 38 (0-10) with 44% lymphocytes, 2% neutrophils & malignant cells morphologically resembling invasive lobular carcinoma. The patient was initially started on broad-spectrum antibiotics & later discontinued when infectious etiologies were ruled out. Given mild symptoms & low concern for GBS, intravenous immunoglobulin & plasmapheresis were not done. The patient was started on steroids. However, given the inadequate response to treatment patient was referred to a high-level care facility where the patient was admitted to the intensive care unit. Neurology, neurosurgery, & infectious disease services were on board & repeat workup was consistent. The patient received five days of high-dose steroids.

IMPACT/DISCUSSION: Differential diagnosis in such cases should be broad including metastatic disease, infectious processes, Guillain-Barre syndrome (GBS), & rare Froin syndrome. Symptoms of Froin syndrome include back pain, lower extremity neurological symptoms (sensory deficit, weakness, brisk/absent reflexes), & symptoms of elevated intracranial pressure (headache, irritability, nausea & vomiting). GBS was a differential in our case given the recent history of diarrhea and the patient’s presentation with progressive weakness, & areflexia. However, in our patient, neurological symptoms did not progress beyond the lower extremities and elevated ICP pressures were more consistent with a diagnosis of Froin syndrome. Treatment of Froin syndrome is focussed on conservative management with the treatment of the underlying cause.

CONCLUSION: Froin syndrome, first described by Georges Frion in 1910, is a rare condition with xanthochromia, elevated protein levels & hypercoagulability in CSF. Elevated protein levels lead to stagnation leading to the activation of coagulation factors. It can be secondary to obstructive, infectious, or neoplastic processes.

AN INTRIGUING PRESENTATION OF STREPTOCOCCUS INFANTARIUS BACTEREMIA Taibah Chaudhary, Kanishq Rajan Jethani, Sarasija Natarajan, Ravleen Kaur

Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA. (Control ID #3876885)

CASE: A 54-year-old female with past medical history significant for COPD, paroxysmal atrial fibrillation, breast cancer post radical mastectomy and a 40-pack-year smoking history presented with generalised weakness and left upper extremity erythema. Examination showed left forearm erythema and tenderness. Labwork was significant for leukocytosis. Venous thrombosis was ruled out and empiric treatment for sepsis secondary to left upper extremity cellulitis was initiated. Her condition initially deteriorated into acute on chronic hypoxic hypercapnic respiratory failure requiring BiPAP, hypotension and uncontrolled atrial fibrillation briefly requiring amiodarone. CT of the left upper extremity showed patchy soft tissue edema suggestive of phlegmon/myositis. Surgical intervention was deferred. Blood cultures grew Streptococcus infantarius, bovis group in ¼ bottles, sensitive to ceftriaxone. With continued antibiotic therapy, hemodynamic and respiratory parameters stabilised with symptomatic improvement. Abdominal ultrasound and echocardiogram ruled out hepatobiliary and cardiac sources of bacteremia. Colonoscopy was significant for 4 tubulovillous adenoma polyps, sized 10-12 mm in the ascending and transverse colon that were resected. Repeat blood cultures confirmed eradication of bacteremia and the patient was discharged with recommendations for followup colonoscopy.

IMPACT/DISCUSSION: Group D streptococci account for approximately 5% of streptococcal bloodstream isolates in hospitalised patients, most commonly associated with infective endocarditis and colonic bacteremia. Evidence for screening colonoscopy in patients with bacteremia is primarily based on epidemiological association rather than outcome data. Studies also suggest association of S.bovis with non- colonic malignancies proposing inherent carcinogenic potential of the organism. Recent studies examining S.bovis and preneoplastic adenomatous colonic polyps report variable association of polyps with bacteremia as compared to colon cancer. However, the consensus remains that S.bovis-based carcinogenesis occurs through the transformation of normal tissue to premalignant lesions and finally malignancy, implicating carcinogenic potential of the bacterium as a propagating factor for malignancy. The simultaneous occurrence of liver disease and colon cancer in 27% patients with S.bovis bacteremia is reason to suspect hepatoportal route entry of the organism into the bloodstream prompting hepatic function testing as a part of evaluation. Few case reports illustrate unusual manifestations of S.bovis infection including osteomyelitis, discitis, liver and splenic abscesses and lateral neck abscess linked to colonic/non-colonic malignancies.

CONCLUSION: S.bovis bacteremia may be an unusual cause for cellulitis of the upper extremity in the presence of predisposing factors such as tubulovillous adenoma and impaired lymph drainage secondary to radical mastectomy.

A NOVEL APPROACH: TRANSGASTRIC AXIOS™ STENT PLACEMENT FOR CYST GASTROSTOMY IN A WALLED-OFF PANCREATIC FLUID COLLECTION

Rajeev V. Seecheran¹; Kevin Kadado¹; William J. Salyers Jr.²

¹Internal Medicine, University of Kansas School of Medicine Wichita, Wichita, KS; ²Internal Medicine, University of Kansas School of Medicine, Kansas City, KS. (Control ID #3877150)

CASE: A 62-year-old man with a history of chronic pancreatitis presented with abdominal pain.Computed tomography (CT) of the abdomen demonstrated mild stranding around the pancreatic body and multiple rim- enhancing fluid collections, which were compatible with pseudocysts. The largest pseudocyst measured 10.7 x 6.4 cm along the medial margin of the inferior right hepatic lobe. esophagogastroduodenoscopy (EGD) with endoscopic ultrasound (EUS) demonstrated an anechoic area measuring 10.0 x 9.1 mm involving the main pancreatic duct which was suspicious for a pancreatic main duct leak. The patient was started on subcutaneous octreotide and planned for endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic duct stent placement.

ERCP demonstrated extravasation of radio-opaque dye in the main pancreatic duct, and the ventral pancreatic duct was deeply cannulated. However, there was limited upstream advancement of the guidewire and no attempt was made at biliary stenting.The patient was started on antibiotic prophylaxis.General Surgery was consulted, and evaluation for endoscopic cyst management was recommended.

EUS demonstrated a 37.9 x 32.9 mm anechoic lesion without septae, and a thick outer wall located off the region of the pancreatic body without apparent communication with the pancreatic duct. A significant amount of peripancreatic fluid surrounded the lesion with extension to the wall of the pseudocyst that was suspicious for contact with the peripancreatic fluid from the pancreatic duct leak. Internal debris was present within the fluid-filled cavity, and the decision to perform a cyst gastrostomy with AXIOS™ stent placement was made. The shared wall between the stomach and the cyst was investigated with color doppler imaging to identify interposed vessels. The electrocautery device was used to create an ostomy. A 15 x10 mm AXIOS™ stent was successfully deployed into the gastric body, through the cyst gastrostomy and with visualization of a draining fluid collection into the gastric lumen.

Follow-up CT of the abdomen demonstrated complete decompression of the fluid collection.

IMPACT/DISCUSSION: Walled-Off Pancreatic Fluid Collections (PFCs) are common complications of acute and chronic pancreatitis due to liquefaction necrosis of inflamed pancreatic tissue or ductal obstruction leading to disruption and leakage of pancreatic fluid. Recent advances in endoscopic interventions, whether transgastric or transduodenal, are the preferred approach for the drainage of PFCs greater than 6 cm in size. We present a case of a pancreatic pseudocyst, less than 6 cm in size, which was managed endoscopically via a transgastric approach with AXIOS™ Stent placement for cyst gastrostomy.

CONCLUSION: This report aims to highlight the paradigm shifts in the management of PFCs towards minimally invasive interventions.Endoscopic interventions are safe, cost-effective techniques with higher success rates, resulting in shorter hospital stays and significantly lower morbidity and mortality.

A NOVEL THERAPY FOR A RARE CONDITION: CONTINUOUS ANAKINRA INFUSION FOR A PATIENT WITH SERONEGATIVE RHEUMATOID ARTHRITIS AND MACROPHAGE ACTIVATION SYNDROME

Laura Nichols^1,2; Meghan Scheibe³; Mitchell Gullickson⁴

¹Internal Medicine, University of North Dakota, Fargo, ND; ²Internal Medicine, Sanford Health, Fargo, ND; ³Rheumatology, Sanford Health, Fargo, ND; ⁴University of North Dakota, Grand Forks, ND. (Control ID #3868859)

CASE: A 41-year-old female presented with synovitis to the bilateral wrists, knees and right ankle. She was noted to have anemia, elevated inflammatory markers and negative rheumatoid factor and anti-CCP antibodies. Additional autoimmune and infectious workup was negative. She was diagnosed with seronegative rheumatoid arthritis (RA) and was started on corticosteroids. Her symptoms ultimately progressed in spite of appropriate treatment with methotrexate and then adalimumab with eventual development of bilateral thigh rash concerning for adult onset still's disease. She subsequently presented with worsening rash, joint pain and odynophagia and during her admission experienced fever to 101^oF, ferritin 4,072 ng/mL, AST 413 U/L, fibrinogen 150 mg/dL and pancytopenia as well as mild hepatosplenomegaly. She underwent upper endoscopy due to odynophagia, which revealed rare viral inclusions on CMV staining. CMV viral load was below 35 IU/mL. There was concern for macrophage activation syndrome given significantly elevated ferritin in the context of RA. The patient was started on high dose steroids and anakinra. She was discharged without treatment for CMV given negligible viral load and pending biopsy results. In spite of initial improvement, she worsened and presented again for care. CMV viral load was 66,500 IU/mL, with ferritin elevated to >33,500 mg/mL. Bone marrow biopsy showed increased hemophagocytic histiocytes and megakaryocytic hyperplasia. The patient was started on gangciclovir for CMV esophagitis and solumedrol with continuous infusion of anakinra, titrated up to a maximum of 1.6 mg/kg/hr with gradual improvement in ferritin, cytopenias, liver enzymes and inflammatory markers. She was discharged with subcutaneous anakinra and oral valganciclovir.

IMPACT/DISCUSSION: Macrophage activation syndrome (MAS), a form of hemophagocytic lymphohistiocytosis associated with autoimmune disease, is diagnosed when patients meet 5 out of 8 of the HLH-2004 eligibility criteria. The current patient met criteria with presence of fever, splenomegaly, pancytopenia, hypofibrinogenemia, ferritin >500 mcg/L and hemophagocytosis in bone marrow. The presentation demonstrates a complex case of macrophage activation syndrome in a patient with seronegative RA, likely worsened by subsequent immunosuppression-related CMV infection. Traditionally, treatment has consisted of corticosteroids with etoposide and/or cyclosporine, therapies with significant cytotoxic effects. Therefore, newer therapies directed at inflammatory cytokines are being utilized including the IL-1 inhibitor, anakinra. Currently, there have been only a few case series demonstrating successful treatment with anakinra infusion in MAS. Our current case adds to the literature and increases internist awareness of a novel therapy with less cytoxicity.

CONCLUSION: Our case demonstrates successful treatment of MAS with continuous IL-1 inhibition with anakinra, which should be considered in place of traditional, cytotoxic therapies.

ANTI-HMGCR IMMUNE-MEDIATED NECROTIZING MYOPATHY WITHOUT CONCURRENT STATIN USE: A CASE REPORT

Jessica H. Grey²; Patton C. McClelland¹; Chandra L. Subedi³; Sean E. Garcia⁴

¹Internal Medicine, Brooke Army Medical Center, Fort Sam Houston, TX; ²Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ³Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ⁴Medicine, University of Texas Health Science Center San Antonio, Helotes, TX. (Control ID #3874569)

CASE: A 62 year-old man with a past medical history of type 2 diabetes mellitus, hypertension, and hyperlipidemia presented to the emergency department after falling while attempting to stand up. 3 months prior, he began experiencing myalgias and proximal muscle weakness that spread from the lower to the upper extremities. The week prior to admission, he noticed mild dysphagia and dyspnea on exertion. His symptoms impaired his ability to perform activities of daily living. His review of systems was negative for chest pain, dizziness, fevers, skin rash, and joint swelling. He reported taking atorvastatin 40 mg daily for 2 years, but discontinued it 5 months prior to admission because his cholesterol was “normal.” Muscle weakness was noted incidentally that admission during a workup for and diagnosis of type 1 non-ST elevation myocardial infarction.

On exam, he had fluent speech, 3/5 strength in the proximal extremities, and 5/5 strength in the distal extremities. There was tenderness of the deltoid and proximal anterior thigh muscles but no skin lesions. Initial labs revealed a creatine kinase (CK) of 9604 U/L, negative ANA, and negative anti-SSA/SSB/Smith /RNP/CCP/Jo-1 antibodies. Magnetic resonance imaging of the right femur demonstrated muscle edema and inflammation extending from the gluteal muscles to the hips. Prior to receiving treatment, he reported worsening muscle pain and dysphagia. Methylprednisolone 75 mg IV daily was initiated due to high suspicion for immune-mediated necrotizing myopathy (IMNM). Open thigh muscle biopsy was obtained and showed a severe necrotizing process featuring multiple myofibers in variable stages of degeneration occurring in a background of mild inflammation. Pathology stated this suggested IMNM. Anti-HMG CoA reductase (HMGCR) antibodies were positive, and the patient started IVIG 0.3mg/kg IV daily for five days. After beginning treatment, CK levels decreased, leveling out between 4000-5000 U/L, dysphagia resolved, pain improved, and proximal muscle strength increased to 4/5 in all extremities.

IMPACT/DISCUSSION: Anti-HMGCR IMNM is a rare but notable cause of myopathy in patients with statin use. The course of IMNM is best described as progressive, proximal muscle weakness and pain, with a substantial rise in CK levels. While dysphagia is noted in a small proportion of patients, generally only skeletal muscle is affected, and other symptoms are rare. A strong association exists between statin use and anti-HMGCR IMNM. We described an unusual presentation of IMNM where symptoms began after statin discontinuation.

CONCLUSION: Symptoms of anti-HMGCR IMNM may begin after statin discontinuation.

Patients with a history of statin use who present with myopathy warrant consideration for anti-HMGCR IMNM.

AN UNEXPECTED CAUSE OF FLANK PAIN

Rachel D. Kroencke¹; Molly Conroy²; Morgan Baudoin¹

¹Internal Medicine, University of Utah, Salt Lake City, UT; ²General Internal Medicine, University of Utah, Salt Lake , UT. (Control ID #3875134)

CASE: A 45-year-old woman presented to primary care with several days of epigastric pain radiating to her left flank and mild nausea. She denied fevers, weight loss, bowel habit changes or urinary symptoms. She noted a new soft tissue mass in her upper right arm. On exam, she had mild left flank tenderness, and a soft, firm mass in her right upper arm. Her flank pain was attributed to a muscle strain from weightlifting; however, pain worsened over the next days despite rest.

Past medical history was notable for papillary thyroid cancer. Her only medication was levothyroxine. Initially, the only laboratory obtained was urinalysis which showed 7 red blood cells. A CT for hematuria ^{showed a soft tissue density in the left retroperitoneum involving the left iliopsoas and moderate right} hydronephrosis/hydroureter.

The patient was referred to our cancer center’s Undiagnosed Clinic but before her appointment was admitted for severe left lower extremity pain. PET CT found diffuse hypermetabolic lymphadenopathy. Flow cytometry of an aspirate from her right upper arm mass and excisional biopsy of an anterior cervical lymph node were positive for large B cell lymphoma, germinal center subtype, double expressor (MYC and BCL2), CD-5 positive.

The patient began treatment with R-CHOP in addition to enrollment in a clinical trial of Tafasitamab and Revlimid. Since starting treatment, she has had significant improvement in her leg pain and reports decreased soft tissue masses.

IMPACT/DISCUSSION: Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non- Hodgkin lymphoma and commonly presents with enlarging, symptomatic nodal mass in the neck or abdomen. Only 30% of patients present with classic B symptoms (unintentional weight loss, fevers, and night sweats). Diagnosis is made on excisional biopsy of an affected lymph node. Presentation is advanced (stage III or IV) in 60% of cases; 60% of cases are curable with R-CHOP treatment, chemo-immunotherapy consisting of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone.

This case shows the importance of a broad differential with common complaints, an algorithmic approach to testing, and the benefit of a strong relationship between patient and primary care provider (PCP). For a healthy young patient, malignancy is not highly likely. When this patient’s course diverged from that of common flank pain, microscopic hematuria triggered the need for imaging leading to a diagnosis. This case also illustrates the benefit of an established relationship between PCP and patients. Multiple visits and close follow-up occurred during this patient’s evaluation before a final diagnosis was made.

CONCLUSION: It is important to maintain a broad differential when evaluating common complaints in the ambulatory setting.

Ordering appropriate lab work up and close follow-up for common patient complaints will often result in the correct diagnosis.

AN UNSAVORY COMBO: A CASE OF CARDIAC AMYLOIDOSIS AND CARDIOGENIC SHOCK

Kevin S. Tang¹; Grace Lee¹; George Tang²

¹Internal Medicine, UC Irvine Douglas Hospital, Orange, CA; ²Cardiology, UC Irvine Douglas Hospital, Orange, CA. (Control ID #3874109)

CASE: Mr. Q is a 66-year-old male who presented with 1 week of increased leg swelling and shortness of breath. Earlier in the year, he was found to have new cardiomyopathy with ejection fraction (EF) of 30%, with subsequent re-admission in October for acute decompensated heart failure exacerbation. At the time, he was diuresed to euvolemia and discharged on optimal medical therapy. Despite adherence to medications and fluid restriction, he slowly accumulated weight. On admission, he was hypotensive with labs notable for a B-Natriuretic Peptide of 2,199. Chest X-Ray showed pleural effusions with pulmonary congestion. Physical exam demonstrated jugular venous distention with hepatojugular reflux, tachycardia, bibasilar crackles, and 2+ bilateral lower extremity pitting edema.

Echocardiogram showed interval worsening of EF to 10-15% and global cardiomyopathy with relative apical sparing of longitudinal strain. With unresolving hypotension and increasing lactate, he was found in cardiogenic shock with mixed venous O2 saturation of 38%. Following consultation with Advanced Heart Failure, Mr. Q was started on dobutamine, norepinephrine, and a furosemide drip with improvement in perfusion markers. Bone marrow biopsy revealed amyloidosis as well as IgG lambda monoclonal plasma cells 5-10%. Serum free light chain assay demonstrated an abnormal K/L ratio of 0.06. Hematology felt this most consistent with AL amyloidosis with cardiac involvement. Mr. Q was ultimately transferred to a major transplant center for cardiac transplant evaluation with concurrent chemotherapy.

IMPACT/DISCUSSION: While cardiac amyloidosis is a rare cause of heart failure, its prevalence and incidence have steadily risen, likely due to increasing awareness and new diagnostic modalities. Amyloid cardiomyopathy should be suspected in patients with left ventricular hypertrophy of unclear etiology, and in those with characteristic extracardiac manifestations such as bilateral carpal tunnel syndrome or concomitant nephrotic syndrome. Although echocardiography is less sensitive than cardiac magnetic resonance imaging, global cardiomyopathy with apical sparing of longitudinal strain is a relatively specific finding for an infiltrative restrictive cardiomyopathy. A positive serum monoclonal light chain with abnormal K/L ratio should be followed by tissue biopsy to confirm light chain (AL) amyloidosis, while a negative light chain screen should prompt evaluation for transthyretin (TTR) amyloid via bone scintigraphy. Although new treatment options have surfaced in recent years for both types, early diagnosis and intervention remain the best predictors of a desirable outcome. Cardiac amyloid that has progressed to cardiogenic shock is associated with fatally poor outcomes.

CONCLUSION: Cardiac amyloidosis is an important and underdiagnosed cause of cardiomyopathy and heart failure.

Diagnostic and therapeutic protocols vary by type of amyloidosis.

Early diagnosis and intervention are key to improving clinical outcomes.

AN UNSUAL CAUSE OF THIGH PAIN IN A DIABETIC

Bala Pushparaji²; Parvathy R. Sankar¹; Amarendhar Gopireddy¹

¹Internal Medicine, Cleveland Clinic, Cleveland, OH; ²Internal Medicine, Maimonides Medical Center, Brooklyn, NY. (Control ID #3867862)

CASE: A 36-year-old female with history of hypertension, type 2 diabetes complicated by retinopathy/neuropathy, end stage renal disease on intermittent hemodialysis presented with acute onset left thigh pain for 1 week. The pain was pulsating and circumferential around the thigh with associated erythema and swelling. She denied history of similar pain, skin injury, or intravenous drug use but was an active smoker. She had a history of a left gluteal abscess that was drained and treated. On exam, the patient was non-ambulatory due to intense pain even with gentle palpation. There was circumferential edema, warmth and redness of the left thigh compared to the right. There were no skin breaks and peripheral pulses were intact. Work-up revealed a C-reactive protein of 10.3 mg/dl, erythrocyte sedimentation rate (ESR) of 58 mm/hr, hemoglobin of 8.5 g/dl (at baseline), creatine kinase (CK) 455 U/L that trended down to 429 U/L, and hemoglobin A1C of 7.1%. Computed tomography (CT) revealed enlargement and hypoattenuation/hypoenhancement of the muscles concerning for myonecrosis and nonspecific myositis including infectious myositis without any drainable fluid collection. Hematoma, thrombosis and compartment syndrome was ruled out. Methicillin resistant staphylococcus aureus coverage with vancomycin and zosyn was started given the recent gluteal abscess and infectious myositis findings on CT. An echo was negative for vegetation. MRI showed severe cellulitis and myositis with myonecrosis of the adductor magnus. There was no improvement with IV antibiotics pointing towards diabetic myonecrosis.

IMPACT/DISCUSSION: It usually presents as acute or subacute pain of thigh or calf with associated swelling and tenderness. There is no associated fever, history of trauma, compartment syndrome or secondary infections. Bilateral presentation is seen in 8% of cases. There are no specific markers but elevated levels of CK, acute phase reactants and leukocytosis are observed. CK levels are above 150 U/L with a mean of 710 U/L and ranging from 10 to 11,000 U/L. Mean value of leukocytosis ranges from 11.5 x 10⁹ /L to 32 x 10⁹/L (3). Mean ESR value observed was 87 mm/hr with the range from 1 mm/hr to 153 mm/hr. Mean HbA1c noted was 9.3%. Muscle necrosis and edema is seen on histology. MRI is ideal. Muscle biopsy is not required for diagnosis unless MRI is equivocal in ruling out infections. Aspirin (75 to 162 mg) is started in patients who are not on antiplatelet therapy with clopidogrel as an alternative. Exercise is avoided during acute phase. NSAIDs and acetaminophen are the mainstay of treatment with opioids used for short term relief.

CONCLUSION: Long-term prognosis of this condition is poor. A prospective cohort study of six patients with diabetic myonecrosis were followed for five years with five patients dying due to major vascular events. All of those five patients had diabetic nephropathy. This is a unique etiology that needs to be on the differential for acute onset extremity pain in a diabetic.

AN UNSUSPECTING CAUSE OF CHEST PAIN IN A PATIENT WITH SICKLE CELL DISEASE Jinal Patel¹; Carol S. Burke²; Sabrina Jones²

¹Rush Medical College, Rush University Graduate College, Chicago, IL; ²Department of Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #3868310)

CASE: The patient is a 32-year-old female with hemoglobin SC disease and asthma who presented with acute onset, severe chest pain. The pain was exacerbated by movement, deep inspiration, eating, and leaning forward. She endorsed right ankle and left foot pain, similar to her prior sickle cell pain crises, but had never previously experienced similar chest pain. On presentation, vital signs were stable and hemoglobin was 10, which was within her baseline. Electrocardiogram showed normal sinus rhythm. Chest radiograph and CT angiogram of the chest were negative for densities, infiltrates and pulmonary embolisms. She had a normal cardiopulmonary exam, but had reproducible chest pain in the midsternal region, without associated rashes or skin changes. The patient was initially treated with acetaminophen, ketorolac and morphine, with the eventual addition of hydromorphone and omeprazole. She experienced only minimal relief of her pain. On day 3 of hospitalization, the patient reported odynophagia to both solids and liquids and worsening chest pain with eating. It was noted that the patient had undergone an esophagogastroduodenoscopy (EGD) 8 years prior, which showed no evidence of esophagitis and no eosinophils on biopsied tissue. On day 5 of hospitalization, the patient underwent an EGD which revealed moderate esophagitis. Biopsies revealed basal zone hyperplasia and increased eosinophils in the proximal and distal esophagus. The patient was diagnosed with eosinophilic esophagitis (EoE) and eventually discharged on omeprazole.

IMPACT/DISCUSSION: This case introduces a unique presentation of EoE in a patient with sickle cell disease. Our differential diagnosis for this patient included acute chest syndrome, vaso-occlusive pain crisis, pulmonary embolism, pericarditis, cardiac ischemia, and herpes zoster. We did not initially consider EoE. Eosinophilic esophagitis exhibits a 3 to1 male majority with Caucasian predominance. Two-thirds of patients with EoE have other atopic conditions, such as asthma, eczema, and allergic rhinitis. Typical clinical manifestations of EoE in adults include dysphagia (most common), food impaction, chest pain, upper abdominal pain and gastroesophageal reflux-like symptoms. This case highlights the need to consider infrequent causes of chest pain. Assessing for exacerbating and palliating factors can be helpful in narrowing the differential diagnosis. Chest pain that is exacerbated by eating or swallowing is suggestive of an esophageal or gastric origin.

CONCLUSION: This case affirms that EoE should be suspected in patients presenting with chest pain exacerbated by eating, even if they do not fit the typical demographics of a patient with EoE. Further, alternative causes of chest pain should be clinically investigated, even when a patient’s risk factors and medical history are suggestive of other more typical causes.

AN UNUSUAL CASE OF CNS INVOLVEMENT IN HUMAN GRANULOCYTIC ANAPLASMOSIS Allison Doyle^1,2

¹General Internal Medicine, UPMC, Pittsburgh, PA; ²Pediatrics, UPMC, Pittsburgh, PA. (Control ID #3875927)

CASE: An 87-year-old woman with history of remote CVA presented with fever and altered mental status in the setting of one week of nausea and generalized weakness. She was previously active with normal cognition. Initial vitals notable for mild tachycardia and fever to 39.3C. Exam notable for somnolence (but able to be aroused) without any focal neurologic deficits. Initial labs showed a new leukopenia with WBC 3.9 (although evolving into pancytopenia within one week). Normal initial CRP, procalcitonin, AST/ALT, LDH (but all progressively increased to peak CRP 26, AST 160s, LDH 550 over one week). Blood and CSF cultures were negative, and CSF analysis (including meningoencephalitis panel, autoimmune encephalitis panel, and cytology) was unremarkable. B12, RPR, HIV, TSH, ammonia were normal. Lyme IgM/IgG negative. CT head, chest, abdomen, pelvis were unremarkable. She was started on empiric antibiotics for sepsis; however, mental status continued to decline over the subsequent two days with fevers persisting, and she required intubation secondary to depressed mental status. EEG demonstrated bifrontal epileptiform activity, but no definitive seizure captured. Blood smear revealed rare neutrophilic inclusions. This finding, in conjunction with developing transaminitis, pancytopenia, and elevated LDH in an endemic area, prompted reconsideration of other tickborne diseases. Serum Anaplasma PCR returned positive, confirming human granulocytic anaplasmosis (HGA). She subsequently improved with a course of doxycycline, and mental status normalized.

IMPACT/DISCUSSION: HGA is caused by the bacterium Anaplasma phagocytophilum and transmitted by the Ixodes tick. The worsening leukopenia, thrombocytopenia, transaminitis (in the context of location in the Mid-Atlantic region) prompted consideration of tickborne illness, including human monocytic ehrlichiosis (HME), Lyme, babesiosis. Both HGA and HME present similarly with nonspecific symptoms, such as fever, nausea, and myalgia. The findings of severely depressed mental status and new epileptiform activity on EEG in HGA are unusual, with less than 5% of HGA cases demonstrating CNS symptoms. In contrast, HME is more commonly associated with CNS manifestations, presenting with meninigitis or meningoencephalitis in 20% of hospitalized cases. Serum PCR or serology require multiple days to result, so doxycycline should be given empirically while results pending. Basophilic intracytoplasmic inclusion bodies are seen in granulocytes in 25-75% of HGA cases and, if present, can differentiate from HME.

CONCLUSION: This is an atypical presentation of HGA presenting with severe CNS manifestations that responded rapidly to appropriate treatment. With rapidly declining mental status in the setting of fever, it is important to consider various tickborne illness if the patient resides in an endemic area. HGA can be rapidly distinguished from other tickborne illnesses via granulocytic morulae on blood smear while awaiting results of serum PCR or antibody testing.

AN UNUSUAL CASE OF TUMOR IN TRANSIT THROUGH PATENT FORAMEN OVALE varshitha kondapaneni, Rhoshini Rajasekaran, Bhanu P. Maturi

Internal Medicine, The University of Alabama at Birmingham Montgomery, Montgomery, AL. (Control ID #3875367)

CASE: A 48-year-old Caucasian woman with extensive smoking history and a family history of renal cell carcinoma (RCC) presented to the emergency room (ER) with acute right flank pain and hematuria. A computed tomography (CT) scan of the abdomen and pelvis showed a right renal mass with extension to the inferior vena cava (IVC) and retroperitoneal lymphadenopathy. All other diagnostic workups were unremarkable. She was then scheduled for elective surgery in three days and was discharged.

However, two days after discharge, she returned to the ER due to shortness of breath and an episode of syncope. On physical exam, she was tachycardic and in moderate respiratory distress. A CT angiogram of the chest showed a sub-massive pulmonary embolus, and a CT scan of the abdomen and pelvis with contrast showed right and left renal artery infarcts; both findings were not present during her last ER visit.

IMPACT/DISCUSSION: Renal cell carcinomas (RCC) are generally associated with tumor extension to the inferior vena cava (IVC). In rare cases, a thrombus with a tumor may extend up to the right atrium. We report a case of tumor thrombus from an RCC causing right atrial mass, sub-massive pulmonary embolus, and paradoxical embolus in the renal arteries through a patent foramen ovale (PFO).

Cardiology was consulted to evaluate the possibility of aspiration thrombectomy, but due to bilateral renal infarcts, there was a high concern for PFO and the need for open thrombectomy and other procedures. TEE revealed the presence of a dense and large mobile mass across the PFO. Cardiothoracic surgery was consulted since the tumor was transiting through the PFO, owing to the evidence of paradoxical embolism. She was admitted to the intensive care unit and underwent nephrectomy, IVC thrombectomy, pulmonary embolectomy, and PFO closure. Histopathology revealed clear cell RCC from the right atrium and pulmonary artery surgical thrombus samples. Her postoperative course was unremarkable, and she recovered without any adverse events. She was discharged on subcutaneous enoxaparin.

CONCLUSION: This case highlights the importance of being vigilant about the presence of PFO, especially in hypercoagulable states like in this patient, and how an early multidisciplinary approach leads to better patient outcomes.

AN UNUSUAL CAUSE FOR BILATERAL NECK SWELLING

Sneha Adidam¹; Naga Sai Shravan Turaga²

¹Internal Medicine, Howard University Hospital, Washington, DC; ²Cardiology, Deaconess Health System Inc, Evansville, IN. (Control ID #3858695)

CASE: A 55-year-old Caucasian man with no medical history presented with gradually increasing bilateral neck masses, progressive dysphagia to solids and liquids, 25 Lb weight loss and voice hoarseness for 6 months. He had 45 pack years of smoking cigarettes, occasional alcohol, cocaine and marijuana use. Vitals were stable. Neck exam revealed bilateral firm, mobile, level II lymphadenopathy. Oral cavity exam revealed bilateral, 4+ tonsillar hypertrophy and poor mandibular dentition. Neck CT revealed an enlarged oropharyngeal mass measuring 3.5 cm x 3.5 cm x 5.5 cm with diffuse adenopathy. Direct laryngoscopy revealed bilaterally enlarged, submucosal tonsillar masses with no extension to the base of the tongue or posterior/lateral pharyngeal walls. Flexible esophagoscopy and bronchoscopy were unremarkable for lesions/masses. Left tonsil frozen sections showed lymphoproliferative neoplasm. Histological exam revealed effaced architecture with diffuse proliferation of medium to large lymphocytes having a minimal amount of cytoplasm and convoluted irregular nuclei. Immunohistochemical stains showed most cells staining positively for CD20 (B-cell marker) and few scattered CD3 (T-cell marker) T-cells. Flow cytometric analysis showed phenotypically normal T -cells ( 38%) and monoclonal medium to large sized B cells (60%). FISH analysis revealed a CCND1/IGH translocation in a total of 74.0% of nuclei. All the findings suggested a pleomorphic variant of mantle cell lymphoma. Bone marrow biopsy of the posterior iliac crest was performed for staging the disease and showed hypocellular bone marrow with minimal lymphoma involvement. Flow cytometry revealed a small population of CD5 positive B-cells with phenotypic features consistent with mantle cell lymphoma. A reasonable management approach was bendamustine/Rituxan given every 4 weeks for 6 cycles. Maintenance Rituxan for 2 years was used to maintain remission.

IMPACT/DISCUSSION: Mantle cell lymphoma is a treatable condition but difficult to cure in patients, regardless of the stage, or degree of aggressiveness of therapy used. Younger healthier patients often undergo aggressive induction, such as Hyper-CVAD alternating with high-dose methotrexate/cytarabine, followed by autologous bone marrow transplant. Recent studies also show benefit from second line treatment such as lenalidomide, ibrutinib, or Velcade-based therapies for subsequent treatment, if progressive. It is difficult to diagnose the clinically aggressive, resistant MCL as it requires detailed immunohistochemistry panel. The prognosis is poor for MCL of the oral cavity.

CONCLUSION: - Mantle cell lymphoma is an extremely rare, aggressive disease with poor survival that must be considered as a differential for bilateral neck swelling in a timely manner.

- MCL is a diagnostic and therapeutic challenge with need for thorough immunohistochemistry work up and it does not have well defined therapeutic modality.

AN UNUSUAL CAUSE OF CHOLECYSTITIS: Q FEVER

Anna K. Shah¹; Andrew Suchan¹; Jane Abernethy^2,1

¹Department of Medicine, Johns Hopkins University, Baltimore, MD; ²Internal Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #3876210)

CASE: A 23-year-old previously healthy woman without medical insurance presented to the hospital with right upper quadrant pain and jaundice. She was found to have elevated alkaline phosphatase (199 mg/dL) and conjugated hyperbilirubinemia (8.9 mg/dL). MRCP showed cholelithiasis without cholecystitis, and ERCP did not reveal signs of choledocholithiasis or obstruction. Biliary and pancreatic stents were placed. Her symptoms improved, but liver enzymes remained elevated. Biopsy revealed canalicular cholestasis with focal bile ductular reaction, consistent with biliary obstruction without features of autoimmune inflammation or fibrosis. Outpatient cholecystectomy was recommended; though given her insurance status, specialty follow up was not arranged at discharge.

Two weeks later, she re-presented to the hospital with worsening pain, fever, and signs of sepsis requiring admission to the intensive care unit. She underwent an emergent laparoscopic cholecystectomy which showed cholecystitis. Further history revealed she was from Honduras, where she lived on a farm with cows, pigs, and chickens, and had consumed unpasteurized dairy products. Additional workup resulted in a positive Q fever IgG phase II. Primary care referred her to Infectious Disease, where Q fever was felt to be a possible underlying cause for her unusual presentation.¹

IMPACT/DISCUSSION: Q fever, caused by Coxiella burnetii, is a rare disease in the United States, with only 178 acute cases and 34 chronic cases reported in 2019.² Though classically Q fever presents with manifestations such as flu-like illness, pneumonia, and endocarditis, cases can present with isolated gallbladder symptoms that require cholecystectomy and/or treatment with doxycycline, an antibiotic infrequently used in the management of typical cholecystitis.³ This case emphasizes the importance of gathering a thorough social and exposure history as it provides clues which can drastically affect management.

One in seven U.S. residents is an immigrant, with over 10 million who are undocumented and ineligible for traditional forms of health insurance.⁴ This diversity impacts the range of diagnoses physicians can expect to see, and it can also lead to roadblocks in post-hospitalization follow up. In this case, the patient’s lack of health insurance meant that specialty follow up could not be coordinated until primary care connected the patient with a financial assistance program, leading to delays in gallbladder removal. While specialists are often called upon to spearhead efforts in unusual presentations, primary care plays a crucial role in coordinating care and highlighting complexities that may require reevaluation.

CONCLUSION: - Coxiella Burnetti is a rare cause of acalculous cholecystitis that should be considered in patients with livestock exposure

- Patients without health insurance may experience delays in care, further emphasizing the role of primary care in complex follow-up

AN UNUSUAL HEADACHE

Danielle Llanos

Internal Medicine, Emory University, Atlanta, GA. (Control ID #3875420)

CASE: A 22-year-old male with history of homozygous sickle cell disease, acute chest syndrome, silent stroke, chronic monthly transfusions for secondary stroke prevention, and iron overload presented to the hospital with new headache and left knee pain. The patient stated that he was awoken by a diffuse headache without associated meningismus, changes in vision, strength, or coordination. He also endorsed sharp non- radiating knee pain. His headache was atypical of his vaso-occlusive episodes, but his knee pain was consistent with previous presentations. He denied any fever, chest pain, or shortness of breath. He had not received his transfusions for the past 3 months. On admission, the patient was afebrile, normotensive, and saturating 98% on room air. On physical examination, the patient was lethargic but neurologic, cardiac, and respiratory exams were normal. Initial laboratory workup revealed a total bilirubin of 8.4 mg/dL, lactate dehydrogenase of 548 U/L, hemoglobin of 7.7 gm/dL, and an elevated reticulocyte count. Given his history, CT imaging of the brain was obtained which showed a parietal epidural fluid collection. MRI brain was then performed which revealed extramedullary hematopoiesis with associated epidural hemorrhage. The patient required brief stay in neurology ICU for serial CT head imaging to monitor hemorrhage for stability.

IMPACT/DISCUSSION: Headaches are a common complaint for patients with the most frequent causes being migraine and tension headaches. Though patients living with sickle cell disease may have headaches due to these causes, their headaches could also be due to severe anemia, infection, frequent opioid medication use, bony infarction, or cerebrovascular accident (CVA). Notably, the prevalence of CVA in all forms of sickle cell disease is about 4%. Extramedullary hematopoiesis is a known complication of chronic hematologic disorders such as sickle cell disease. It is most often seen in the reticuloendothelial system (spleen, lymph nodes, and mediastinum), however, there have been documented cases in all organs that are involved in active hematopoiesis. This case highlights the importance of a broad differential when considering the etiology of headache in patients with a hematologic disorder, especially those with previous severe manifestations of disease. The case is unique due to the location of the extramedullary hematopoiesis and suggests that increased awareness can help guide management and reduce long term complications.

CONCLUSION: Though a rare finding, extramedullary hematopoiesis and its associated complications should be considered during history taking, physical examination, and imaging in a patient with sickle cell disease presenting with acute atypical vaso-occlusive pain symptoms.

AN UNUSUAL PRESENTATION OF ACUTE HEPATITIS C (HCV) CAUSING SEVERE ACUTE LIVER INJURY

Tatyana Nguyen¹; Caroline Ross¹; Margot Rogers¹; Ricardo Cruz²

¹Internal Medicine, Boston Medical Center, Boston, MA; ²General Internal Medicine, Boston Medical Center, Boston , MA. (Control ID #3872242)

CASE: 49 years old male with PMHx of active drug use on methadone presented to the ED with 2 weeks of intermittent fever, jaundice and dark colored urine. He reported a recent needle stick at work, recent travel to Mexico and increased drug use. He had a history of hepatitis C that had spontaneously cleared. HCV viral load was undetectable 3 weeks prior to presentation. Vitals showed fevers with Tmax of 103F and tachycardia to 110. His labs were significant for elevated AST 647 U/L, ALT 839 U/L, PT 17.5 sec and INR 1.49. Liver ultrasound demonstrated hepatic steatosis without portal vein obstruction.

We performed a comprehensive workup including infection, toxin and autoimmune hepatitis antibodies, all of which were unremarkable; except his HCV antibody was positive and HCV viral load resulted at 11.9 million. On day 2, his liver enzymes and synthetic functions continued to worsen to AST 2921 U/L, ALT 3842 U/L, PT 21.2 sec and INR 1.79, raising concern for progression to acute liver failure (ALF). He was started on N-acetylcysteine (NAC) but he developed fever and flushing with NAC infusion so this was subsequently discontinued. He also received 3 days of vitamin K to correct any nutritional deficiencies. He showed no signs of encephalopathy during his hospitalization.

Given the degree of liver injury, the primary team, GI, and ID were in consensus to start inpatient HCV treatment. On day 3, his fever resolved and the liver enzymes began to trend down. Glecaprevir/pibrentasvir was initiated on day 4. Ultimately the patient was discharged on day 6 with significant improvement in his liver enzyme and normalized synthetic function. He also received counseling regarding his opioid use and up- titration of his methadone. He will be followed-up in the hepatology clinic.

IMPACT/DISCUSSION: This case demonstrates an unusual presentation of severe liver injury in the setting of acute HCV infection, as the patient had a negative HCV viral load 3 weeks prior to presentation. It is possible that prior HCV infection that was cleared may have predisposed the patient to severe disease when reinfected. There also may have been unidentified toxins in the substance he was injecting that caused a superimposed drug induced liver injury. Regardless, treatment should be initiated in patients with a high risk of progressing to ALF. A case report has suggested ledipasvir and sofosbuvir can prevent ALF due to rapid clearance of HCV. In our case, as the genotype had not yet come back, we chose glecaprevir/pibrentasvir which is a pan-genotypic direct acting antiviral.

CONCLUSION: HCV can present acutely with systemic signs and significant liver injury which requires starting in-patient treatment of HCV to prevent progression to ALF. Thorough workup should be performed to identify any other cause that can superimpose on HCV.

A multidisciplinary approach including GI, ID, and Addiction Medicine can be helpful to prevent relapse and reinfection in patients with opioid use disorder and acute hepatitis C.

AN UNUSUAL PRESENTATION OF ANTI-MDA5 DERMATOMYOSITIS WITHOUT CUTANEOUS FINDINGS

Frances O. Ho¹; Marlise Pierre-Wright³; Bijal Jain^2,1; Kelley Wachsberg^1,2

¹Department of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ²Medicine, Jesse Brown Va Med Ctr, Chicago, IL; ³Medicine, McGaw Medical Center of Northwestern University, Chicago, IL. (Control ID #3872773)

CASE: A 73-year-old male with a history of non-diabetic polyneuropathy and chronic obstructive lung disease presented to the emergency department with a two-week history of increasing proximal muscle weakness and recurrent falls, most recently when attempting to rise from a sitting position. On exam, he was dyspneic with an oxygen saturation of 89-92% on room air. He had bilateral crackles, though otherwise appeared euvolemic. Strength exam was notable for 4/5 bilateral hip flexion. Skin exam was unremarkable. Labs revealed an elevated ESR (126 mm/hr) and CRP (13.7 U/L), a mildly elevated CK (498 U/L), and an elevated BNP (1722 pg/mL). Work-up for his dyspnea included an unrevealing echocardiogram and a low- probability V/Q scan. Chest CT showed new multifocal ground glass opacities superimposed on upper lobe predominant fibrotic changes. Urine was positive for streptococcus pneumoniae antigen, prompting treatment with antibiotics after which the ground glass opacities resolved on subsequent CT scan. Work-up for his muscle weakness included MRI spine without evidence of spinal cord compression. SPEP, auto-antibody screen, and rheumatoid factors were unremarkable. EMG showed length-dependent axonal neuropathy without evidence of myopathy. MRI of thighs showed evidence of mild anterior compartment thigh muscle myositis bilaterally and generalized muscle atrophy. Aldolase was elevated at 13.7 U/L. Twenty days following admission, anti-melanoma differentiation-associated gene 5 (MDA5) returned positive, confirming a diagnosis of anti-MDA5 dermatomyositis (DM). The patient was started Solumedrol 100mg and IVIG for three days, then transitioned to Prednisone 40mg daily. Eight days after treatment initiation, he was able to walk with physical therapy for the first time since his admission, and he was discharged home after a rehabilitation course. CT scan three months after discharge showed stable ILD.

IMPACT/DISCUSSION: Anti-MDA5 DM is a rare subset of amyopathic DM, characterized by minimal muscle involvement and predominant cutaneous and pulmonary manifestations. Cutaneous findings include those found with classic DM (60-70% of anti-MDA5 patients) as well as more specific findings of painful ivory palmar papules and skin ulcerations (40-80% of anti-MDA5 patients). Anti-MDA5 DM is also characteristically associated with rapidly-progressive ILD, seen in over 40% of patients. In contrast, our patient’s primary presentation was proximal muscle weakness without cutaneous findings and with only mild pulmonary fibrosis. Despite a delay in diagnosis due to this atypical presentation, with treatment, our patient experienced a dramatic improvement in his muscle weakness and had stable ILD on follow up.

CONCLUSION: When a patient presents with worsening proximal weakness and any evidence of ILD, clinicians should have a greater suspicion for anti-MDA5 DM and work up should be considered, even without cutaneous findings or typical respiratory manifestations.

A ONE-SIDED STORY

Rachel Anderson¹; Katherine Harris²

¹Internal Medicine, The University of Iowa Hospitals and Clinics, Iowa City, IA; ²Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA. (Control ID #3875985)

CASE: 80-year-old female with history of rheumatoid arthritis (not on immunosuppression), diastolic heart failure, mild pulmonary hypertension and recurrent right-sided pleural effusions presenting with shortness of breath. Exam notable for tachypnea, hypoxia, diminished right-sided breath sounds, and anasarca. Chest imaging with large right pleural effusion and no evidence of pulmonary embolism.

Per chart review, right-sided pleural effusions dated back two years with repeated thoracentesis for symptomatic relief. Pleural studies consistent with a transudative effusion, fluid cultures without growth, and cytology without evidence of tumor cells. Serum labs notable for positive antinuclear antibody, rheumatoid factor, and anti-cyclic citrullinated peptide antibody. Serum protein electrophoresis, tuberculosis testing, and Lyme antibody negative. Liver ultrasound with evidence of hepatic congestion, although no primary liver abnormalities on imaging.

Transthoracic echocardiogram (TTE) preformed with hyperdynamic left ventricle, abnormal septal wall motion, bilateral atrial enlargement, concern for right ventricular extrinsic compression, and enlarged inferior vena cava. Cardiology had been consulted and was concerned for constrictive pericarditis. Repeat TTE demonstrated annulus reverusus, confirming the diagnosis. Patient’s disease was deemed too advanced for surgery and palliative care with diuresis for symptom management was pursued.

IMPACT/DISCUSSION: Unilateral transudative pleural effusions are most commonly caused by systolic heart failure or liver cirrhosis. As these were not present on imaging, a broader differential was needed. Many pathologies including infection, malignancy, and autoimmune disease were ruled out, although an exudative effusion would have been expected and Light’s criteria is highly sensitive for identifying exudative effusions. Less common etiologies of transudative effusions include hypothyroidism, pulmonary embolism, mitral stenosis, hypoalbuminemia, nephrotic syndrome, urinothorax, Meig’s syndrome, and constrictive pericarditis.

Constrictive pericarditis is a rare cause of diastolic heart failure and often misdiagnosed or undiagnosed due to nonspecific symptoms, usually of volume overload. Imaging can confirm with TTE being first line, however, clinical suspicion needs to be high as more specific evaluation of the mitral annulus is usually needed. Surgery is definitive treatment for constrictive pericarditis but must be completed early in the course.

CONCLUSION: Unilateral transudative pleural effusions are commonly caused by systolic heart failure or cirrhosis but further evaluation is needed in the absence of these as an obvious cause. Constrictive pericarditis is a rare, reversible cause of diastolic heart failure that is often misdiagnosed or undiagnosed. Diagnosis is combination of clinical and specific imaging findings with echocardiography being first line. Early recognition is essential for definitive surgical treatment.

A PATH LESS TRAVELED: A CASE OF AN ANOMALOUS CORONARY ARTERY ORIGIN CAUSING ANGINA

Scott Baumgartner¹; Joshua Levenson¹; Carly E. Sokach²

¹Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ²Internal Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA. (Control ID #3876146)

CASE: A 49 yo woman with a medical history of hypertension and endometriosis presented with a 1.5 week history of acute, progressive chest pain. It was intermittent, squeezing, exertional, and left-sided radiating to the neck and left arm. Symptoms resolved with rest. She denied shortness of breath or diaphoresis. Her SBP on her home cuff was 170, so she presented to the ED and found to be tachycardic to 134 with a BP 144/93. EKG showed sinus tachycardia without acute ischemia. She was admitted to rule out ACS. Serial troponins were negative. Regadenoson stress demonstrated an EF 55-60% and low risk for ischemia. TTE showed grade I diastolic dysfunction, atrial septal aneurysm, and thickened aortic valve. Nitro paste relieved symptoms. ACS was ruled out and follow up with PCP and cardiology was recommened.

At her PCP follow up, chest pain was ongoing and constant. She was referred to the ED where she was hypertensive and tachycardic. EKG was similar to baseline. TSH and troponin were normal. CTA chest ruled out PE but revealed an aberrant origin of the RCA off the left coronary cusp. CTA coronary arteries demonstrated anomalous origin of the right coronary from the sinotubular junction region just above the left sinus of valsalva immediately anterior to the left main coronary artery origin. Its course was intraarterial, between the aorta and main pulmonary artery, and intramural, within the aortic wall, with severe narrowing of the involed segment. An exercise stress test showed markedly reduced functional capacity with a deconditioned heart rate response and no significant EKG abnormalities. CT surgery was consulted. She underwent right coronary artery transposition and unroofing. Anastomotic stenosis and ongoing post-op chest pain complicated her course. She required PCI.

IMPACT/DISCUSSION: Coronary artery anomalies are low prevalence congenital aberrancies that can range from a benign incidental finding to significant clinical disease. Our patient had an anomalous aortic origin of the right coronary from the left coronary cusp. The artery’s intramural course and slit-like ostia created a flow limiting lesion, ischemia, and angina. Anomalous origins are associated with sudden cardiac death making it critical for the clinician to optimize diagnostic modalities to identify these anomalies. While there is a paucity of literature on outcomes, at least one case series suggests minimal risk and favorable outcomes with the unroofing procedure our patient underwent. Yet our patient experienced a less optimal outcome.

CONCLUSION: Recurrent anginal chest pain is a common complaint that presents diagnostic and management challenges particularly when acute coronary syndrome has been ruled out. The clinician must broaden their differential and consider more insidious, less common pathology. Anomalous coronary artery origin often goes undiagnosed. It can be life threatening. Treated surgically, outcomes are typically favorable. Our patient, however, experienced a complicated course.

A PATIENT PRESENTING WITH NON-TRAUMATIC RHABDOMYOLYSIS AND SUBSEQUENT DEVELOPMENT OF STREPTOCOCCUS PNEUMONIAE NECROTIZING FASCIITIS

Peter Westman, Nathan Martin

Internal Medicine, Washington University in St Louis, St Louis, MO (Control ID #3871885)

CASE: A 65-year-old man with unknown medical history was brought to the Emergency Department after being found unresponsive. He was oriented to person, place, and location but remained sleepy. The patient did not remember events prior to arrival but did report regular use of alcohol and marijuana as well as remote opiate use, but not any current injection drug use. Initial labs were remarkable for creatine kinase 2,576 units/L, blood urea nitrogen 19 mg/dL, serum creatinine 2.82 mg/dL (unknown baseline but presumed normal), serum ethanol 104 mg/dL, urine drug screen positive for cocaine and fentanyl. He received 3L of crystalloid and was admitted to the general medicine service for non-traumatic rhabdomyolysis (RM). On hospital days two and three the patient remained clinically stable, had normal vital signs and was not complaining of any pain, fevers, or dyspnea. He was oliguric despite receiving continuous crystalloid infusion. The patient rapidly deteriorated beginning on hospital day four. He became confused, tachypneic, and had new tender swelling of his left forearm. He was transferred to the medical ICU for placement of dialysis catheter and further management. The left arm swelling and pain worsened prompting surgical consultation due to concern for necrotizing fasciitis (NF). He underwent urgent debridement of necrotic muscle and soft tissue. Intra-operative cultures and blood cultures grew Streptococcus pneumoniae. He was transferred to the surgical ICU post-operatively and treated with appropriate antimicrobial therapy. Over several days he was taken back to the operative room five more times for debridement, ultimately culminating in complete glenohumoral disarticulation of his left arm. His clinical status improved afterwards and he was transferred out of the ICU.

IMPACT/DISCUSSION: Both RM and NF are uncommon conditions but serious conditions. They can co- occur in the same patient but usually present simultaneously. The authors performed a PubMed search using (rhabdomyolysis[Title/Abstract]) AND (necrotizing fasciitis[Title/Abstract]) which resulted 20 articles. The only case reports of concurrent RM and NF occurred in patients with recluse spider bites, snake bites, ricin injection, and intra-articular hyaluronic acid injection. Risk factors for development of RM and NF in our patient included alcohol use disorder and suspected injection drug use. It was surprising that he developed NF several days in to his hospital course despite having no signs or symptoms of active infection early on in his hospital course. To our knowledge, this report represents the first case of RM followed sequentially by development of NF in an immunocompetent person whose only risk factors were alcohol use and suspected injection drug use.

CONCLUSION: Necrotizing fasciitis can develop at any time during a patient’s clinical course. A high index of suspicion in needed for diagnosis, and prompt antimicrobial therapy and surgical involvement is necessary to reduce morbidity and mortality.

A PATIENT WITH A PROSTHETIC VALVE PRESENTING WITH SPLENIC INFARCTION: WHAT IS THE LINK?

Akina Fukushima¹; Takaaki Kobayashi²; Sandra Moody³; Miyu Takagi¹; Akihito Yoshida¹

¹Kameda Medical Center, Kamogawa, Chiba, Japan; ²University of Iowa Hospitals and Clinics, Iowa City, IA; ³Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA. (Control ID #3861933)

CASE: An 84-year-old woman with aortic stenosis status post bioprosthetic aortic valve replacement presented with a 5-day history of appetite loss. On physical examination, her temperature was 36.9°C, heart rate 88 bpm and regular, and blood pressure 95/69 mmHg. Abdominal examination revealed pain in the left upper quadrant. Laboratory workup revealed a white blood cell count of 20,700/μL (neutrophils 93%), and a platelet count of 18,000 /μL. Computed tomography of the abdomen with contrast showed a wedge-shaped low-density area in the spleen, indicating splenic infarction. Sepsis was suspected, and she was started on intravenous piperacillin tazobactam. Two sets of blood cultures grew Bacillus cereus. Transthoracic echocardiogram showed increased luminosity with thickening of the mitral and prosthetic aortic valves. Transesophageal echocardiogram (TEE) showed abscess formation surrounding the aortic valve and a 20 mm aortic valve vegetation. Prosthetic valve endocarditis (PVE) due to Bacillus cereus complicated by aortic valve abscess and splenic infarction was diagnosed. Given the size of the vegetation (>10mm) and the presence of an aortic valve abscess, surgery was considered. However, the perioperative mortality was considered high, and the patient chose not to proceed with an operation. She was treated with six weeks of intravenous vancomycin and discharged to home in stable condition. Repeat TEE near the end of therapy showed no vegetation or abscess.

IMPACT/DISCUSSION: Suspecting infectious endocarditis is essential when a patient with prosthetic valves presents with splenic infarction, even without fever. Major etiologies of splenic infarction include atrial fibrillation, hematologic disease, sepsis, and infective endocarditis, which accounts for approximately 10% of all the causes of splenic infarction. In this case, finding the splenic infarction helped us reach the final diagnosis of PVE. Multiple risk factors have been reported for B. cereus bacteremia, including intravenous drug use, central venous catheters, immunosuppressed conditions, and prosthetic valves. A previous study revealed that over 20% of patients with B. cereus infective endocarditis had prosthetic heart valves and most needed surgical intervention. Surgical indications include heart failure due to valve dysfunction, newly developed heart block, annular or aortic abscess, PVE due to fungi, persistent bacteremia, relapsing PVE, recurrent septic emboli, or mobile vegetations > 10mm. We report this case as one of the few B. cereus PVE cases that were successfully treated without surgical intervention.

CONCLUSION: Infectious endocarditis should be suspected in a patient presenting with a splenic infarction. Patients with prosthetic valves have a higher risk of B. cereus bacteremia, which may cause infective endocarditis. Medicine trainees need to be aware of surgical indications for PVE.

A PERNICIOUS CASE OF ANEMIA

Solomon Park¹; Jennifer Schmidt²

¹Department of Internal Medicine, Washington University in St Louis, St Louis, MO; ²Internal Medicine, Washington University in St Louis School of Medicine, St Louis, MO. (Control ID #3874611)

CASE: A 50-year-old male with history of osteoarthritis and anxiety presented to clinic with 2 months of worsening numbness and tingling of both hands. He was not taking any medications. Given the patient’s occupation as a truck driver, the paresthesia was thought to be ulnar and median neuropathy due to vibratory stress. Conservative treatment with wrist splinting was started. At follow-up visit the next month, he reported worsened hand paresthesia and new paresthesia and weakness in bilateral lower extremities resulting in falls and inability to ambulate independently. He was immediately sent to the ED.

In the ED, vital signs were normal. Physical exam was notable for intact sensation to light touch, 5/5 strength in bilateral upper extremities, 4/5 strength in bilateral lower extremities, 1+ bilateral biceps/triceps/Achilles reflexes, and ataxic gait. Initial lab work showed Hgb 12.4, MCV 111.8. Subsequent labs showed folate WNL, B12 undetectable. The patient was given IM injection of B12 for presumed pernicious anemia. The next day, the patient reported significant resolution of paresthesia, weakness, and gait instability. Further lab work showed elevated methylmalonic acid 4,454, homocysteine 22.9, and positive anti-parietal cell

antibodies at 119.3. Patient was referred to gastroenterology for upper endoscopy which showed chronic gastritis and paucity of parietal cells, consistent with autoimmune atrophic gastritis.

IMPACT/DISCUSSION: Pernicious anemia (PA) is the result of B12 malabsorption and deficiency, which can take years to develop given extensive liver stores. It has a wide range of clinical manifestations. Neurologic symptoms such as ataxia, paresthesia, weakness, hypo- or areflexia, and cognitive impairment are common as in this patient. Macrocytic anemia is the most common hematologic finding. As such, diagnosis typically starts with a CBC. However, this patient's previous hemoglobin values were on the lower end of normal for years and even on presentation was not significantly depressed. PA can present in the absence of macrocytosis and anemia in 30% of all cases. It is thus important for clinicians to recognize the neurologic symptoms of pernicious anemia as the degree of illness may not correlate with the common CBC findings and understand how to diagnose if PA is suspected. As neurological sequelae of PA are often permanent, early diagnosis is key. If B12 and folate values are borderline, then methylmalonic acid and homocysteine can aid the diagnosis. Anti-intrinsic factor antibodies and anti-parietal antibodies should also be sent. As autoimmune atrophic gastritis is the most associated cause of PA, upper endoscopy is also recommended for patients diagnosed.

CONCLUSION: A good neurological exam is important in order to be able to prompty identify the neurological changes associated with pernicious anemia.

It is important to avoid anchoring bias even if initial lab findings may not correlate to the severity of disease presentation.

APIXABAN RELATED ADRENAL HEMORRHAGE AND PRIMARY ADRENAL INSUFFICIENCY

Barath Rangaswamy¹; Rahul Atodaria³; SAILAJA D. SARAGADAM^2,1; Duc Le³

¹Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ²INTERNAL MEDICINE, Texas Tech University System, Lubbock, TX; ³School of Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX. (Control ID #3877354)

CASE: 48-year-old male with a history of HTN was started on apixaban for right femoral DVT. Four days later he presented to the ER with complaints of nausea, vomiting, RUQ abdominal pain. CECT Abdomen was reported to have right adrenal prominence/hyperplasia with surrounding strandy opacities, also had right perinephric stranding that could represent pyelonephritis. Cephalexin was prescribed. Ten days later he was admitted to ICU for altered mental status and seizures, generalized weakness, vomiting and watery diarrhea. He was hypotensive and tachycardic. Labs showed severe hyponatremia (103 mmol/L), hyperkalemia (6.3 mmol/L) with non-gap metabolic acidosis. He was treated with hypertonic saline, sodium bicarbonate drip and lokelma. Infectious work up was negative. Mental status improved. He was discharged home and completed three months of anticoagulation therapy.

Over the next few months he developed progressive fatigue, pedal edema, dyspnea and weight loss. Labs showed persistent mild hyperkalemia, hyponatremia and elevated creatinine. Cortisol level was low (1.4 ug/dl) with lack of incremental response to Cosyntropin. ACTH was high (> 2000 pg/ml). Repeat CT showed resolution of the strandy densities surrounding the adrenal gland. The previously seen right adrenal prominence appeared reduced to a more discrete small nodule of 1.8 cm. Primary adrenal insufficiency following adrenal hemorrhage (AH) was suspected. Oral hydrocortisone with fludrocortisone was started after which his fatigue and volume overload improved markedly

IMPACT/DISCUSSION: AH after starting DOACs has been reported previously, but very rare. Only two cases of apixaban related AH have been reported so far. Clinical presentation is ambiguous and AH is often missed by clinicians. A thorough H&P to assess for risk factors including anticoagulant use and having a high degree of suspicion is important for early diagnosis. Symptoms are nonspecific such as abdominal pain, anorexia, nausea, vomiting and fever. Hyponatremia, hyperkalemia, hypoglycemia and acidosis are not invariably present. AH can have variable presentations on CT. Early signs of adrenal congestion such as gland thickening and peri adrenal fat stranding can be missed or misinterpreted like our case. Close follow-up imaging and hormone levels are essential in such cases. MRI is more accurate in diagnosing hemorrhagic neoplasms. Low cortisol and high ACTH levels are highly suggestive of primary adrenal insufficiency. Treatment with stress dose steroids should not be delayed by waiting for lab confirmation if suspicion is high.

CONCLUSION: We report a third case of apixaban related AH which highlights the diagnostic challenges. Given the increasing use of DOACs, clinicians should have a high index of suspicion for this rare ADR.

Early diagnosis and prompt steroids can avoid catastrophic adrenal crisis.

A PRESENTATION OF EUGLYCEMIC DIABETIC KETOACIDOSIS

Juhi Gor¹; Alexander Rittenberg²

¹Internal Medicine, Virginia Commonwealth University, Richmond, VA; ²Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA. (Control ID #3868962)

CASE: A 57-year-old woman with a past medical history significant for type 2 diabetes mellitus presented to the hospital with increased fatigue, dizziness, and shortness of breath that had been ongoing for 4 days. History was further significant for starting a ketogenic diet 2 weeks prior with the goal of weight loss. She had discontinued several of her diabetes medications 2 days after starting the dietary changes due to several episodes of symptomatic hypoglycemia. The medications that were discontinued included glargine, sitagliptin/metformin, and empagliflozin/metformin. Initial labs on presentation were notable for a bicarbonate of 13 mmol/L, sodium of 128 mmol/L, glucose of 171 mg/dL, and an anion gap of 18 mmol/L. Urinalysis was significant for glucosuria >1000 mg/dL and ketones of 100 mg/dL. Hemoglobin A1c was 9.4%. Based on her labs, a diagnosis of euglycemic diabetic ketoacidosis (DKA) was made, and she was started on intravenous insulin and dextrose-containing fluids for treatment until her anion gap normalized. Her symptoms resolved, and she was discharged with instructions to resume a reduced dose of her long- acting insulin and a carbohydrate-controlled, non-ketogenic diet.

IMPACT/DISCUSSION: We report a case of euglycemic DKA triggered by a combination of a ketogenic diet coinciding with the use of a sodium-glucose cotransporter-2 inhibitor (SGLT2 inhibitor). Euglycemic DKA is an uncommon but potentially life-threatening condition that can be present in both type 1 and type 2 diabetes mellitus. The condition has been defined as a triad of high anion gap metabolic acidosis, positive serum and urine ketones, and serum glucose levels less than 250 mg/dL. The use of SGLT2 inhibitors in diabetes and systolic heart failure management has increased the incidence of euglycemic DKA. The pharmacologic effects of SGLT2 inhibitors can notably persist for up to 10 days. Current endocrinology society position statements recommend against simultaneous SGLT2 inhibitor use and a ketogenic diet. CONCLUSION: This case illustrates the importance of considering the diagnosis of euglycemic DKA even after SGLT2 inhibitors have been discontinued. Providers must also caution patients on or with recent use of SGLT2 inhibitors that weight loss measures with ketogenic diets further increase the risk of euglycemic DKA. Other measures of weight loss should be encouraged if SGLT2 inhibitors are to be continued.

References:

Peters AL, Buschur EO, Buse JB, et al., Euglycemic Diabetic Ketoacidosis: A Potential Complication of Treatment With Sodium-Glucose Cotransporter 2 Inhibition. Diabetes Care. 2015 Sep;38(9):1687-93. Handelsman Y, Henry RR, Bloomgarden ZT, et al., American Association of Clinical Endocrinologists and American College of Endocrinology position statement on the association of SGLT-2 inhibitors and diabetic ketoacidosis. Endocr Pract. 2016 Jun;22(6):753-62.

AQUAGENIC URITCARIA

Jeremy Smith¹; Richmond S. Doxey²

¹Internal Medicine, University of Utah Hospital, Salt Lake City, UT; ²Internal Medicine, University of Utah, Salt Lake City, UT. (Control ID #3876679)

CASE: 25 year old female comes to clinic to discuss a rash. She states for many years now she develops both a rash and/or hives whenever her comes into contact with water. These skin changes happen regardless of the type of water including oceans, lakes, showers, baths. She describes the rash as a flat red rash predominately over her chest and upper arms and sometimes develops “raised hives” as well. The temperature of the water does not appear to impact the development of the rash. At times the lesions can be itchy and bothersome. It normally lasts for about thirty minutes and then slowly fades away on its own. She has no past history of atopic dermatitis or asthma. She has trialed over the counter hydrating creams and Benadryl prior to coming into contact with the water and has noticed only minimal relief. She shows photos from her phone, showing light erythematous patches on her chest and shoulders.

Diagnostic workup: Normal CMP and CBC with normal differential

Imaging: none

Interventions: Dermatology consult and trial of Zyrtec 10mg daily

IMPACT/DISCUSSION: Aquagenic urticaria is a rare form of “inducible urticaria”. It is characterized by 1-3 mm folliculocentric wheals with a surrounding 1-3cm erythematous that flares within a half hour of water contacting the skin. These lesions can cause a burning or prickling sensation and in rare cases shortness of breath or wheezing. Young females seem to be the most commonly effected of the handful of cases in the literature. The exact mechanism is unknown however a few theories have been proposed in the literature. One proposal postulates that a reaction of water with sebaceous glands creates a substance that leads to mast cell degranulation and histamine release leading to urticaria. Another, hypothesizes that the water causes sudden changes in osmotic pressure surrounding hair follicles and this pressure change results in indirect provocation of urticarial lesions. Diagnosis is mostly clinical or by applying a damp cloth to the patient’s trunk for twenty minutes; if it leads to urticaria it is a positive test. Biopsy has been reported to show nonspecific findings typical of all urticarial, including higher concentrations of mast cells and other leukocytes, edema, lymphatic and capillary dilation, and endothelial swelling; therefore, biopsy is not indicated. First line therapy is second generation antihistamines like cetirizine. Normally avoidance is a crucial aspect of treatment to urticaria however it is unrealistic in this instance. Other possible therapies include topical barriers, phototherapy, and SSRIs however these seem to be less efficacious.

CONCLUSION: Aquagenic Uritcaria is a rare form of inducible uritcaria that should physicians should be aware of. This can be difficult to treat but trial of second generation antihistamines is generally first line.

A RARE CASE OF ACUTE PANCREATITIS OCCURRING AS A SEQUELA OF COVID-19 INFECTION

Jason E. Lieber¹; Fatima Mahmood²

¹Medical College, Albany Medical College, Albany, NY; ²Internal Medicine, Albany Medical Center, Albany, NY. (Control ID #3860079)

CASE: A 60-year-old male presented with two days of nausea, bilious vomiting, decreased oral intake, fatigue, and sharp left-sided flank pain radiating to the epigastrium. He reported testing positive for Covid-19 five weeks prior to his current visit which was managed supportively. His medical comorbidities included mitral valve replacement for which he was taking warfarin. He endorsed remote history of alcohol abuse but denied recent use.

He was hemodynamically stable, and his labs identified a mild transaminitis and lipase level of 287 U/L (normal range 23-90 U/L). Abdominal CT revealed no pancreatic or biliary abnormalities. He was admitted for symptomatic management, however, his symptoms persisted. Repeat lipase level five days later was 1210 U/L and repeat abdominal CT was significant for mild peripancreatic fat stranding with trace fluid along the inferior duodenal flexure and right anterior para-renal fascia. He was diagnosed with acute pancreatitis and received maintenance IV fluids, analgesics, and his diet was slowly progressed. Workup for etiology of pancreatitis revealed normal serum triglycerides and calcium levels, no gallstones or biliary pathology present on imaging, no recent travel or medication adjustments, and unremarkable family history. Gastroenterology was consulted and patient underwent an EGD with EUS which were also unremarkable. After ruling out the common etiologies of acute pancreatitis, we concluded that our patient likely developed pancreatitis as a sequela of Covid-19.

IMPACT/DISCUSSION: Although upper respiratory infection and constitutional symptoms are the most reported complications from acute infection, there is a growing body of evidence of “long-covid” which is associated with chronic respiratory, neurologic, and hematologic symptoms presenting weeks to months after resolution of acute infection, such as in our patient who developed acute pancreatitis five weeks after resolution of Covid-19. Few studies have described concomitant presentation of Covid-19 and acute pancreatitis. A possible etiology is the presence of angiotensin-converting enzyme 2 receptors on pancreatic cells, making them a potential target for viral entry.

CONCLUSION: We suggest that physicians be aware of the delayed inflammatory response associated with Covid-19 infection and recommend a protocol whereby post-Covid patients presenting with symptoms concerning for acute pancreatitis receive priority imaging to expedite diagnosis, treatment, and improve patient outcomes. Further research is needed to elucidate a mechanism and standardize screening tool for patients at risk for developing acute pancreatitis following Covid-19 infection.

A RARE CASE OF ATYPICAL HEMOLYTIC UREMIC SYNDROME (HUS)

Alina Cheema¹; Nataliia Dyatlova²; Matthew Min¹; Lalarukh Haider²

¹Internal Medicine, UConn Health, Farmington, CT; ²Nephrology, UConn Health, Farmington, CT. (Control ID #3874261)

CASE: A 46-year-old male with history of seizure disorder, provoked DVT, cerebral AVM presented with progressive nausea, vomiting and cola-colored urine. His vital signs were normal. Initial labs revealed serum creatinine 1.6 mg/dL, platelet count 19,000/mcl with a nadir of 5,000/mcl, hemoglobin 13.8 g/dL, undetectable haptoglobin, LDH 1005 IU/L and total bilirubin 3.4 mg/dL. Urinalysis revealed 3+ protein and large hemoglobin. Blood smear showed few schistocytes. He was found to have intravascular hemolysis, hematuria, proteinuria, acute kidney injury and thrombocytopenia in the setting of gastroenteritis. The clinical picture was concerning for thrombotic microangiopathy. A renal biopsy showed acute tubular necrosis with findings reflective of diffuse endothelial cell injury and platelet-rich glomerular microthrombi, confirming glomerular thrombotic microangiopathy. He was started on high-dose steroids and therapeutic plasma exchange (TPE) was initiated with subsequent improvement of thrombocyte count and markers of hemolysis. Further work-up for etiology revealed normal ADAMSTS13 activity of 63%, negative cold agglutinin assay, normal complement C3 and C4 levels and negative direct Coombs test. Thrombotic thrombocytopenic purpura (TTP), paroxysmal nocturnal hemoglobinuria and cold agglutinin disease were ruled out. This established a diagnosis of atypical HUS. Patient declined treatment with eculizumab; however, was responsive to steroid therapy and serum creatinine level improved to 1 mg/dL. He had a similar but more severe presentation 9 months later, provoked by influenza illness. Creatinine had peaked at 8.9 mg/dL at that time. He again responded to high-dose steroid therapy after undergoing TPE, resulting in slow improvement in kidney function close to the patient’s baseline. Despite repetitive insults and miraculous recovery, the patient continued to refuse eculizumab.

IMPACT/DISCUSSION: Atypical HUS is a rare form of complement-mediated thrombotic microangiopathy with an incidence of 0.23 to 1.9 per million. It presents as a triad of thrombocytopenia, microangiopathic hemolytic anemia, and acute renal failure. Normal serum complement levels do not preclude diagnosis. Usual triggers include viral upper respiratory infection, GI illness or pregnancy. Acute treatment options include high-dose steroids and TPE, especially while ruling out TTP. Eculizumab, a monoclonal antibody that inhibits complement activation, is the first-line drug of choice for maintenance therapy and preventing future episodes. Early initiation of Eculizumab within 7 days of hospitalization is associated with lower dialysis rates, less time in ICU and less plasmapheresis. Our case provides an interesting clinical vignette of atypical HUS and further insight into this rare disease.

CONCLUSION: Atypical HUS is rare but should be considered in the differential for a patient with thrombocytopenia, microangiopathic hemolytic anemia, and acute renal failure. Timely and appropriate treatment is lifesaving.

A RARE CASE OF BONE MARROW SARCOIDOSIS AND PROBABLE NEUROSARCOIDOSIS

Michika Maeda¹; Andrew Benck²; Everakes Sarah²

¹Internal Medicine, Rush University Medical Center, Chicago, IL; ²Rheumatology, Rush University Medical Center, Chicago, IL. (Control ID #3871974)

CASE: A 40 year old male with a history of possible schizophrenia, seizures, chronic kidney disease, and right hip arthroplasty presented to the hospital after a fall and unintentional fifty pound weight loss over one year. Family history was notable for sarcoidosis in both parents. Laboratory investigation showed pancytopenia, hypercalcemia, as well as elevated ACE, vitamin D, IgG, IgA. Physical examination was pertinent for flat affect and reduced muscle tone. CT of the chest, abdomen, and pelvis showed widespread lymphadenopathy, splenomegaly, sclerotic lesions of the ribs, and T8 compression deformity. Metastatic malignancy was strongly suspected. Bone marrow biopsy revealed normocellular marrow with non- necrotizing, non-caseating granulomas and associated fibrosis affecting 40% of the bone marrow sample. Further hematological workup including SPEP/UPEP, FISH, and molecular testing were unremarkable. The likelihood of malignancy was deemed very low. Rheumatologic lab testing was negative. Sarcoidosis is a diagnosis of exclusion, so while high on the differential, other causes of non-caseating granulomas were investigated. Infectious workup with fungal cultures and fungal/AFB stains was negative. The patient was started on high dose prednisone which resolved the hypercalcemia and pancytopenia. MRI of the brain during admission was notable for significant atrophy, encephalomalacia in bilateral frontal lobes, confluent white matter changes, and microhemorrhages. The findings raised the question of whether his neuropsychiatric history could be manifestations of sarcoid as well. He had undergone lumbar puncture six months prior to his presentation at another hospital with unremarkable findings and his family declined repeat testing. At follow up appointments, the patient has been more engaged with improved strength. He follows with neurology and is scheduled for a repeat MRI of the brain to evaluate for interval changes since steroid course.

IMPACT/DISCUSSION: Lung involvement is seen in over 90% of patients with sarcoidosis, but bone marrow and neurologic involvement in sarcoidosis are rare, occurring in only 3%-5% and 5%-10% of patients respectively. Our case is an extremely unusual presentation of sarcoidosis with involvement of the bone marrow, bone, spleen, and lymph nodes, as well as strongly suspected involvement of the central nervous system. Only one other case of sarcoidosis presenting in both the bone marrow and CNS has been reported. Our patient presented with textbook signs of a hematological malignancy including lymphadenopathy, pancytopenia, splenomegaly, osseous lesions, and weight loss. These findings can also be all signs of sarcoidosis. We must be careful to avoid anchoring bias and keep a broad differential.

CONCLUSION: We present a rare case of sarcoidosis with involvement of the bone marrow, bone, and CNS. The case highlights the importance of recognizing the myriad presentations of sarcoidosis for appropriate patient care.

A RARE CASE OF CAUDA EQUINA SYNDROME CAUSED BY HSV-2 INFECTION

Rebecca K. Tsevat

Internal Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #3876732)

CASE: A 54-year-old woman with a history of uterine fibroids presented to the hospital with pelvic floor numbness and urinary retention for two weeks. Her symptoms were accompanied by constipation but no fevers or focal neurologic symptoms. On evaluation, she was afebrile with stable vital signs. Her physical exam was notable for mild numbness along the gluteal cleft with an intact anal wink reflex and otherwise normal strength, sensation, and skin findings. Abdominal imaging revealed only a prominent stool burden, and brain imaging was unremarkable. However, MRI of the lumbar spine and pelvis showed enhancement and degenerative endplate changes along L4-L5 as well as enhancement of the lower cauda equina nerve roots. She underwent a lumbar puncture, which revealed a lymphocytic pleocytosis with negative CSF cultures and viral studies. The serum HSV-2 IgG subsequently returned positive, although the HSV-2 IgM serology and CSF HSV PCR were negative. After consultation with infectious diseases and neurology, the patient was started on acyclovir and a short course of prednisone, and her urinary and neurologic symptoms improved. A diagnosis of Elsberg syndrome secondary to HSV-2 was made, and she was discharged on a 14- day course of valacyclovir.

IMPACT/DISCUSSION: Herpes viruses are responsible for significant neurologic morbidity, as they can establish latency in the peripheral sensory ganglia and persist for a lifetime. HSV-2 associated neurologic disease may result from primary infection or reactivation of latent HSV-2; latency has been demonstrated in ganglia throughout the CNS but occurs most frequently in the sacral ganglia.¹ HSV-2 is the most common cause of Elsberg syndrome, an infectious syndrome consisting of acute or subacute bilateral lumbosacral radiculitis often accompanied by myelitis confined to the lower spinal cord.² Elsberg syndrome is a diagnosis that requires both clinical and radiologic evidence of cauda equina involvement. The patient met both of these criteria, although she did not have clear symptoms of HSV or documented HSV infection in the CSF.

However, these features have only been noted in a minority of cases of Elsberg syndrome,² and as such, a high clinical suspicion is needed to secure a diagnosis of this rare condition.

CONCLUSION: Viral etiologies must be considered in patients with acute neurologic concerns, even in the absence of clear signs or symptoms of infection. Among the many neurologic complications of herpes viruses, Elsberg syndrome can present with both clinical and radiographic manifestations of cauda equina syndrome and should be considered in those with consistent features.

References:

1. Berger JR, Houff S. Neurological complications of herpes simplex virus type 2 infection. Arch Neurol.

2008;65(5):596-600.

2. Savoldi F, Kaufmann TJ, Flanagan EP, Toledano M, Weinshenker BG. Elsberg syndrome: A rarely recognized cause of cauda equina syndrome and lower thoracic myelitis. Neurol Neuroimmunol Neuroinflamm. 2017;4(4):e355.

A RARE CASE OF COPPER SULPHATE POISONING VIA INHALATION OF FUMES IN A FACTORY WORKER.

Shreya Garg¹; Harmanjit Kaur²; Vasu Gupta¹; Rohit Jain³

¹Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India; ²Government Medical College Patiala, Patiala, Punjab, India; ³Hershey Co, Hershey, PA. (Control ID #3875472)

CASE: A 28 year old young male working in an alloy manufacturing factory in Jammu, India

presented with acute onset of abdominal pain, vomiting, hematuria and icterus. During the next 3 days, he developed anuria, edema, rising serum creatinine levels, hyperkalemia, deranged LFTs and haemolysis. Hemodialysis was initiated as part of supportive care. Upon further history, it was brought to our notice that the patient's other coworkers also developed similar signs and symptoms in the past few days. The symptoms were caused by inhalation of copper sulfate fumes from a new compound that was recently added as part of the manufacturing process which contained Copper. Serum copper levels were then sent which were found to be raised- 221.1 μg/dL (normal-80-140 μg/dL). Hence the diagnosis of copper sulfate poisoning was made. Patient was managed via multiple sessions of hemodialysis over a month and renal function gradually improved.

IMPACT/DISCUSSION: Copper is an essential trace mineral that acts as a catalyst and aids in the synthesis of hemoglobin, norepinephrine, and plays a role in the electron transport chain. The recommended dose of copper is 1 mg daily1, and a dose of 10 gm is considered lethal2 Copper can cause toxicity via excess ingestion, or dermal or mucosal absorption. Acute Copper poisoning due to homicidal ingestion can present with abdominal pain, vomiting and acute organ failure whereas a chronic exposure as seen in chemical industry workers can lead to intravascular haemolysis, methemoglobinemia, kidney injury, liver failure and rhabdomyolysis over a period of time. To prevent multiorgan failure, early diagnosis is required using blood copper level in suspected patients. Treatment includes supportive care, chelating agents like Penicillamine along with activated charcoal in acute cases, and haemodialysis for severe cases.

In the past, cases of copper sulphate poisoning have been well established in the form of acute ingestion and absorption from skin as seen in farmers but there are a limited number of cases due to chronic exposure from inhalation of Copper sulphate fumes. Although incidence of copper sulphate poisoning is rare, physicians should always keep a keen eye for diagnosis because of high mortality rates associated with it. The probability of morbidity and mortality increases especially in cases of chronic exposure, as the source of exposure is mostly unidentified initially. The non-specific signs and symptoms like vomiting, abdominal pain ,hematuria and jaundice also contribute to a delay in diagnosis and hence increasing the morbidity and mortality.

CONCLUSION: Copper poisoning is rare and presents with a wide range of symptoms, there can be a delay in diagnosis and treatment of copper poisoning. Moreover, the lack of any specific antidote and the fact that copper can cause multi organ failure showcases the importance of detecting signs of copper poisoning early on to avoid fatal consequences.

A RARE CASE OF DISSEMINATED NOCARDIA PAUCIVORANS IN A CD5+ B CELL LYMPHOMA PATIENT PRESENTING WITH STROKE

Natalia Zero, Lauren Sesemann

Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL. (Control ID #3876847)

CASE: A 67-year-old man with COPD, recent diagnosis of not yet treated CD5+ B cell lymphoma, and hypogammaglobulinemia presented with fever and acute right-sided hemiparesis. CT head was without hemorrhage. TPA was administered. MRI of the brain showed bilateral multifocal acute infarcts throughout the supratentorial brain. TEE showed an aneurysmal septum. Subsequent CT head in the setting of headache showed right perimesencephalic subarachnoid hemorrhage. The hospital course was complicated by respiratory distress with leukocytosis and diffuse patchy reticular nodular and ground glass infiltrative changes on CTA chest. He underwent VATS lung biopsy, remaining intubated postoperatively due to unresponsiveness and transferred to the ICU. Lung tissue culture grew Nocardia paucivorans with lung biopsy confirming invasive Nocardia infection showing filamentous branching organisms and caseating granulomas. He exhibited multiple episodes of seizure-like activity. CSF analysis from lumbar puncture showed pleocytosis and MRI brain was indicative of ventriculitis concerning for Nocardia CNS involvement. He was treated with IV Sulfamethoxazole-Trimethoprim and Imipenem. After weaning sedation the patient remained unresponsive except for eye opening. Comfort care measures were pursued in accordance with the patient’s previously expressed wishes following goals of care discussions with family.

IMPACT/DISCUSSION: Nocardiosis is a predominantly opportunistic infection involving aerobic gram- positive actinomycetes of the genus Nocardia which have an ability to disseminate to any organ. Lungs are the most common primary site. The majority of cases occur in hosts with compromised cell-mediated immunity. Malignancy remains a substantial risk factor for infection, most often in the setting of recent glucocorticoid or chemo therapy. The presented case depicts an uncommon species, Nocardia paucivorans, causing likely disseminated infection to the lungs and CNS in the setting of CD5+ B cell lymphoma. Although the patient received no therapy for malignancy, he was found to have hypogammaglobulinemia. Evidence of CNS involvement may be supported by neutrophilic pleocytosis and elevated protein on CSF analysis. Parenchymal abscess is the most common CNS presentation. This patient displayed a rare case of ventriculitis most likely due to Nocardiosis in the setting of supportive CSF analysis and confirmed pulmonary infection on mycobacterial culture of lung biopsy. Treatment is guided by the extent and severity of the infection. Disseminated Nocardiosis with CNS involvement is treated with IV Sulfamethoxazole- Trimethoprim and Imipenem for at least one year.

CONCLUSION: - Nocardiosis is an uncommon infection affecting predominately patients with compromised cell-mediated immunity, infiltrating the lungs and less frequently the central nervous system, among other organs.

- Severe disseminated Nocardiosis require a prolonged course of multiple concomittant IV antibiotics due to the relapsing nature of the disease.

A RARE CASE OF DISSEMINATED SARCOIDOSIS WITH LYTIC CALVARIAL LESIONS

Michika Maeda¹; Meenakshi Jolly²

¹Internal Medicine, Rush University Medical Center, Chicago, IL; ²Rheumatology, Rush University Medical Center, Chicago, IL. (Control ID #3876881)

CASE: A 58 year old female with a history of pulmonary sarcoidosis presented to the hospital with fever, abdominal pain, poor appetite, and headache for a month. She also endorsed 15 pound unintentional weight loss. She was diagnosed with sarcoidosis in 2012 with lung biopsy and had been on chronic steroids at varying doses. She was tachycardic on presentation but otherwise stable with unremarkable labs.

CT brain revealed diffuse moth eaten appearance of the skull with innumerable lytic lesions. CT of chest, abdomen, and pelvis showed innumerable nodules in the lungs, liver, and spleen; large cavitary lesion in the right upper lung (present since 2014); and mediastinal and hilar lymphadenopathy. MRI brain redemonstrated numerous calvarial lesions without evidence of parenchymal involvement.

Metastatic malignancy was suspected. Splenic biopsy showed non-necrotizing noncaseating granulomatous inflammation. Infectious workup including fungal/AFB stains was negative. Given the extent of her lytic lesions, further workup was pursued to rule out malignancy. PET scan only showed mild FDG uptake in the cavitary lesion of the right lung. No abnormal FDG uptake was seen in other organs. She underwent bronchoscopy with transbronchial biopsy which showed noncaseating granulomas consistent with sarcoidosis. Biopsy of RUL cavity showed aspergillus. BAL was positive for Pseudomonas. The patient was treated with Ceftazidime with resolution of fevers and improvement of dyspnea. Afterwards, she was started on methotrexate with some clinical improvement.

The patient had also developed gait abnormalities concerning for neurosarcoidosis. Repeat MRI brain showed improvement in calvarial lesions. MRI thoracic spine demonstrated enhancing lesions at T2 and T9 thought to be due to sarcoid as well. Patient trialed multiple steroid tapers but developed recurrent dyspnea. She is pending initiation of infliximab for refractory sarcoidosis.

IMPACT/DISCUSSION: Rare presentations of sarcoidosis present a diagnostic challenge due to a broad differential diagnosis. Our case is a rare presentation of sarcoidosis with lytic lesions of the skull and vertebrae as well as hepatic and splenic involvement. Her case was complicated by chronic aspergilloma (untreated and stable for 8 years) as well as Pseudomonas pneumonia (contributing to her acute dyspnea and fever). Her concurrent infections presented a challenge in adjusting her immunosuppressive therapy and required a multidisciplinary approach. FDG PET/CT can be helpful to determine the most suitable biopsy site. While non diagnostic for sarcoidosis in our case, PET/CT is sensitive for inflammatory activity of sarcoidosis in any organ.

CONCLUSION: We present a rare case of disseminated sarcoidosis with lytic calvarial lesions as well as involvement of the lungs, liver, spleen, and lymph nodes. Disseminated sarcoidosis can present similarly to metastatic malignancy and infection, which need to be ruled out prior to diagnosis of sarcoidosis.

A RARE CASE OF EXTENSIVE CORONARY ARTERY DISEASE IN A YOUNG PATIENT Sabah Iqbal¹; Akhil Jain²; Krishna Desai¹; Sohiel Deshpande¹; Harsha Sai Sreemantula¹; Bushra Jilani¹; Aisha Abdul Sattar¹; John J. Finley²

¹Internal Medicine, Mercy Fitzgerald Hospital, Philadelphia, PA; ²Medicine, Mercy Fitzgerald Hospital, Darby, PA. (Control ID #3875896)

CASE: 39-year-old obese male with no medical history came with worsening dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea over few weeks. Family history notable for cardiovascular disease in father in early 40s. Patient was initially hypertensive and tachycardic. Laboratory analysis showed elevated creatinine 2.1, high sensitivity troponin 168, BNP 790, total cholesterol 412, LDL 349, triglycerides 120, HDL 39. EKG showed sinus tachycardia, left fascicular block, LVH with intraventricular block. Echocardiogram showed severely reduced left ventricular ejection fraction (LVEF) 20-25%. Right heart catheterization revealed moderate pulmonary hypertension, moderate to severely elevated right and left sided filling pressures, and reduced Fick cardiac index. Left heart catheterization revealed severe multivessel coronary artery disease (CAD) involving distal LAD, diagonal 2, both posterolateral branches, and RCA, consistent with ischemic cardiomyopathy. Heart team discussion determined patient's surgical targets were suboptimal due to extensive diffuse disease. Guideline directed medical therapy was initiated with aspirin, clopidogrel, furosemide, carvedilol, sacubitril/valsartan, atorvastatin and ezetimibe in conjunction with evolocumab, a PSK 9 inhibitor. Percutaneous revascularization was planned with unsuccessful intervention of RCA but later successful intervention of distal LAD, proximal to mid LAD diagonal 2 followed by left posterolateral 2 branch. Repeat lipids two months later showed dramatic improvement with total cholesterol 63, LDL 24, HDL 33, triglycerides 29. Repeat echocardiogram showed improved LVEF of 30-35%.

IMPACT/DISCUSSION: Four different gene mutations have been linked with family hypercholesterolemia (FH) namely, LDLR, ApoB, PSK 9, and LDLRAP. Studies showed association between improper metabolism of LDL and FH due to a mutation in LDL receptor gene on chromosome 19. These mutations are of 2 types, homozygous which is extremely rare and heterozygous which is common with prevalence of 1 in 500 persons worldwide however remains largely underdiagnosed. Key diagnostic factors are elevated LDL-C levels, personal/family history of premture CAD and clinical signs of dyslipidemia. Treatment options include medical management with statins and bile acid sequestrants followed by apheresis and liver transplantation in refractory cases.

CONCLUSION: Although common in occurrence, FH is often underdiagnosed until an initial revelation of extensive underlying CAD. This case is of a patient who had extensive cardiac disease without prior diagnosis of severe genetic dyslipidemia. As seen in this case, concomitant treatment with PSK 9 inhibitor and statins have proven extremely effective in reducing LDL levels. Screening of first-degree relatives, and really all patients, yields to earlier identification before clinical vascular impact. Early management with lipid-lowering agents is key in reducing cardiovascular morbidity and mortality.

A RARE CASE OF FEBRILE LYMPHADENOPATHY PRESENTING AS ASEPTIC MENINGITIS

Ammad J. Chaudhary¹; Mobeen Haider²; Yousra Khalid²; Maria Jamil¹; Momin Samad¹; Indira Brar³

¹Internal Medicine, Henry Ford Health System, Detroit, MI; ²Internal Medicine, Carle Foundation Hospital, Urbana, IL; ³Infectious Disease, Henry Ford Health System, Detroit, MI. (Control ID #3877303)

CASE: 42-year-old female presented with a painful enlarged neck lymph node(LN), fever, night sweats, back pain, vomiting & rash(palm & soles) for three days. Patient was recently hospitalized, three weeks ago, for similar symptoms & treated for aseptic meningitis with clinical improvement. Currently, physical exam revealed tachycardia & palpable tender right cervical LN. Labs revealed anemia (Hb:8.8g/dl), leukopenia (WBC:2700/mm³), & elevated LFTs (AST:117, AST:53, ALP:214). Infectious workup including blood cultures, urinalysis, Quantiferon TB, aspergillus galactomannan, Histoplasma antigen, Blastomyces antigen, pneumocystis jiroveci IgG, Brucella (igG, IgM), Bartonella hensella (IgM, IgG), Q fever (IgG, IgM), syphilis serology, Francisella tularensis (IgG, IgM), Fungitell, VZV IgM, EBV IgM, CMV IgM, Hepatitis B, C & HIV were negative. Autoimmune labs revealed antinuclear antibody (Ab) of 1:320, dsDNA Ab, anti-histone Ab, anti- LKM Ab titer, antimitochondrial M2 Ab, anti-RNP Ab, antiSM Ab, anti-Ro & anti-La Ab were negative. C3 & C4 were within normal limits. CT scan of the chest abdomen pelvis demonstrated cervical lymphadenopathy with 2.5 cm in the largest dimension. The patient underwent a lymph node biopsy revealing benign necrotizing lymphadenitis with no evidence of lymphoma or metastatic process. She received high-dose steroids with clinical improvement.

IMPACT/DISCUSSION: Kikuchi Fujimoto disease (KFD), an uncommon differential in febrile lymphadenopathy, resembles systemic lupus erythematosus(SLE) lymphadenitis, viral infections, bacterial adenitis & malignant lymphomas. Autoimmune & infectious workup was grossly negative. Histopathology differentiates KFD from lymphomas. KFD is a diagnosis of exclusion. Our patient was recently treated for aseptic meningitis, which is also an atypical presentation of KFD. Rash is common in KFD, although rash involving palms & soles is also seen in syphilis, coxsackie A virus & rickettsia but the remainder of the findings were less convincing for any of these infections.

CONCLUSION: Kikuchi Fujimoto disease (KFD), a.k.a histiocytic necrotizing lymphadenitis, is a benign, self-limiting disease with unclear etiology & acute-subacute onset. It is more common in young, females & Asians. Symptoms include fever & lymphadenopathy, mostly posterior cervical group. Lymph nodes (LN) are painful, tender & swollen. Less frequent symptoms include nausea, vomiting & B-symptoms(chills, night sweats, weight loss). Atypical presentations include skin involvement & aseptic meningitis. Lab work may reveal cytopenia, elevated inflammatory markers & elevated liver function tests(LFTs). Diagnosis requires a lymph node biopsy. Management is conservative & steroids are used in severe cases.

A RARE CASE OF FUSOBACTERIUM NUCLEATUM PRESENTING AS PYOGENIC LIVER ABSCESS IN AN IMMUNOCOMPETENT PATIENT WITH SIGMOID DIVERTICULITIS.

Stefani Garcia¹; Marco X. Proano¹; Fatemeh Abbasi²

¹Internal Medicine, University of New Mexico Health System, Albuquerque, NM; ²Pulmonary and Critical Care Division, University of New Mexico Health System, Albuquerque, NM. (Control ID #3876775)

CASE: A 45-year-old previously healthy male presented with two weeks of flu-like symptoms and nonlocalized abdominal pain. He was admitted to the medicine floor for sepsis with fever, leukocytosis, and elevated alkaline phosphatase. Chest radiography was negative for infiltrates, blood cultures had no growth, and transthoracic echography did not reveal vegetations. However, abdomen–pelvis tomography revealed a multiloculated abscess 5.8 cm in diameter and sigmoid diverticulitis. He started Zosyn for six days while the abscess was percutaneously drained, and fluid studies returned. Fluid cultures grew Fusobacterium nucleatum. The patient denied any history of periodontal or oropharyngeal disease, his symptoms resolved, and he was discharged on oral Augmentin to complete four weeks of treatment.

IMPACT/DISCUSSION: Pyogenic liver abscesses (PILs) have high morbidity and mortality globally and present with a wide arrange of clinical features, including nonspecific upper respiratory symptoms and abdominal pain. The most common cause of monobacterial PILs is Klebsiella pneumoniae followed by Streptococcus pneumoniae, and only in rare cases are they caused by Fusobacterium nucleatum. F. nucleatum PILs are more prevalent in patients with periodontal disease. However, at least two cases have been reported in patients with sigmoid diverticulitis. A possible mechanism for the infection in these cases is bowel leakage with hepatic spread via the portal circulation. The preferred diagnostic method is percutaneous drainage when blood cultures are negative or inconclusive. Treatment consists of ultrasound-guided drainage, antibiotic therapy based on susceptibilities, and follow-up abdominal ultrasounds for resolution of the abscess.

CONCLUSION: This case report demonstrates that in immunocompetent patients without histories of hepatobiliary disease or malignancy, there should be a high suspicion for PILs even with negative blood cultures. Ultrasound-guided percutaneous drainage should be performed promptly, both as a diagnostic and therapeutic measure. Transthoracic echocardiography should be performed to rule out endocarditis, and infection resolution is based on ultrasonography findings.

A RARE CASE OF GONOCOCCAL BACTEREMIA IN A YOUNG FEMALE

May Dong¹; Eric Nielsen¹; Fozia Qamar^2,1

¹Medical School, University of Massachusetts Chan Medical School TH Chan School of Medicine, Worcester, MA; ²Infectious Disease, Milford Regional Medical Center, Milford, MA. (Control ID #3876728)

CASE: A 30 year-old female with a history of alcohol use disorder, cirrhosis, chronic hepatitis C infection, and a remote history of intravenous drug use presented to hospital with several days of subjective fever, chills, malaise, abdominal pain, and black stools. She met criteria for severe sepsis with tachycardia, significant leukocytosis to 26.9 x 10*3 cells/μL, and elevated lactate. She also had a profound anemia, which, along with black stools, raised concerns for an upper GI bleed with hemorrhagic shock. EGD showed bleeding esophageal varices which were banded. She was given a blood transfusion and somatostatin analogues for 5 days.

Leukocytosis and hemodynamic instability continued despite stable hemoglobin/hematocrit and the absence of hematochezia or hematemesis. Sepsis was presumed to be secondary to spontaneous bacterial peritonitis due to abdominal pain in the setting of cirrhosis and ascites; empiric ceftriaxone 2g/day was started. A diagnostic paracentesis did not reveal sufficient peritoneal fluid. No vegetative lesions were seen on TTE. Blood cultures drawn prior to initiation of antimicrobial agents were positive for gram negative cocci in pairs. Urine nucleic acid amplification testing was positive for N. gonorrhea. RPR, HIV, trichomonas, and chlamydia testing were negative. As the patient tested negative for chlamydia, doxycycline was not initiated. The patient reported unprotected sexual activity with one new male sexual partner in the past six months. She did not have any symptoms of urethritis and denied vaginal discharge, pruritus, dyspareunia, or dysuria. The gram negative cocci were identified as Neisseria gonorrhea by the state laboratory. Contact tracing was completed. Patient reported pain near the carpal bones of her left hand without swelling or warmth. Imaging did not show any evidence of septic arthritis. Given her systemic gonococcal infection, this was diagnosed as gonococcal tenosynovitis. The patient completed 14 days of ceftriaxone 2g/day with resolution of sepsis and negative repeat blood cultures, though with continued carpal pain. She did not attend follow-up appointments.

IMPACT/DISCUSSION: Neisseria gonorrhea is a gram-negative bacteria transmitted via sexual contact. Carriers may be asymptomatic. Cases of gonorrhea are on rise and have increased 63% since 2014. Disseminated gonorrhea is rare (0.5-3% of all gonococcal infections) and gonococcal bacteremia accounts for about 55% of these disseminated infections. A thorough sexual history may help elucidate sources of bacteremia in persons with or without an obvious source of infection, especially in individuals with chronic liver disease.

CONCLUSION: Gonococcal bacteremia as a cause of sepsis is rare but should be considered in sexually active patients with unknown primary infection.

A RARE CASE OF HEMIPLEGIC MIGRAINE

Shoon L. Oo¹; Myint B. Thu²; Ashish Subedi¹

¹Internal medicine Residency, Cape Fear Valley Health System, Fayetteville, NC; ²Harlem center for nursing and rehabilitation, New York, NY. (Control ID #3876925)

CASE: A 32-year-old male with a history of chronic alcohol abuse presented with fever, and headache to the emergency department. He developed tingling, numbness, and weakness in his left hand after admission to hospital. It is intermittent sharp headache in bitemporal areas, radiating to the neck and associated with photophobia. Five days prior to presenting, he also developed high fever associated with chills, fatigue, and muscle pain. The patient has a history of migraine disorder.

On initial presentation, vital signs were normal except fever of 103.1F. On physical examination, patient is awake, alert, no dysarthria, no facial asymmetry, decreased muscle tone of left upper extremity and left lower extremity, mild sensory deficit present in both left upper and lower extremities, and unable to touch chin to chest. Others examination findings were normal. Blood tests, cerebrospinal fluid analysis, culture, and viral serology were nonrevealing.

NIH stroke scale was 6. Computed Tomography (CT) of head and CT angiogram of head and neck were unremarkable. Patient was started with intravenous vancomycin, ceftriaxone, acyclovir, and dexamethasone for suspected bacterial or viral meningitis and were discontinued after 2 days.

The magnetic resonance (MR) imaging of brain showed restricted diffusion and dural enhancement overlying right frontoparietal convexity. MR venography of brain revealed no evidence of venous thrombosis. Patient’s left sided weakness improved on day 3 of admission but the severe headache persisted which was relieved after intravenous Methylprednisolone, Metoclopramide, and magnesium sulphate.

IMPACT/DISCUSSION: Hemiplegic migraine (HM) is a rare disorder which can either be familial (FHM) or sporadic. Our case does not meet with the diagnostic criteria for hemiplegic migraine by ICH3 as onset of headache precedes the hemiplegia which is more suspicious of infectious etiology. ICH3 criteria states at least two episodes of migraine with aura either fully reversible motor weakness or fully reversible visual, sensory, and/or speech or language symptoms. We can sometimes detect FHM genes, CACNA1A, ATP1A2, and SCN1A, in the sporadic HM.

The hemiplegia may last from 20 to 30 mins usually to months to complete recovery. In severe cases, HM can progress to encephalopathy, coma, and irreversible brain damage.

The treatment of HM is the same as migraine. A single dose parenteral dexamethasone is associated with a 26% relative reduction in headache recurrence within 72 hours.

The prevalence of intracardiac right to left shunt is significantly higher in migraine with aura and stroke in which our case has intracardiac shunt.

CONCLUSION: We present a case sporadic HM with fever and headache as the first symptom. Without a family history of HM, the diagnosis is challenging. Commonly, it is treated as intracranial infections or cerebrovascular accidents until proven otherwise. Including HM in the differential diagnosis list is crucial in treatment of stroke-like symptoms.

A RARE CASE OF ISOLATED CNS LANGERHANS CELL HISTIOCYTOSIS (LCH)

Mahrukh Majeed¹; Muhammad Adeel Samad²; Nida Rizvi¹

¹Internal Medicine, WellSpan Health, York, PA; ²General Surgery, WellSpan Health, York, PA. (Control ID #3847591)

CASE: A 20-year-old female with no significant medical history presented to the ED with complaints of amenorrhea, fatigue, polydipsia, and declining academic performance for about 10-12 months. She also endorsed bifrontal headache, worse early in the morning and associated with nausea and vomiting. She denied any history of trauma or surgery. Vital signs were normal. Physical exam was remarkable for decreased temporal vision in the left eye. No other abnormalities were noted on exam. Initial lab work revealed a hemoglobin of 16.4g/dl, serum sodium 164 mmol/L, chloride 123mmol/L, calcium 10.6mg/dL, and a creatinine of 1.34 mg/dL. Further workup revealed low free T4 (0.5), cortisol (1.5 mcg/dl), luteinizing hormone (0.3 mIU/ml), follicle stimulating hormone (0.8 mIU/ml) and insulin-like growth factor-1 (51 ng/ml) consistent with panhypopituitarism. Prolactin was elevated at 213 ng/ml. Brain MRI was performed which revealed an enhancing mass measuring 2.2 cm x 1.7 cm x 1.9 cm in the suprasellar region at the expected region of pituitary stalk and optic chiasm with extension towards left hypothalamic region. CT chest, abdomen and pelvis did not show any significant findings. Treatment for hypernatremia was initiated with D5 water and desmopressin, hormone replacement therapy was commenced with levothyroxine, and stress dose steroids were started while waiting for craniotomy. Dexamethasone was also administered for reduction of cerebral edema. The patient underwent craniotomy and subtotal resection of the mass. Specimen was analyzed using immunohistochemistry and was strongly positive for CD68 and CD163 (histiocytic markers) as well as S-100. Lymphocytes were positive for B and T cell markers (CD20;and CD3 & CD5). The immunostains for CD1a and Langherin were positive which are specific to Langerhans cell histiocytosis. IMPACT/DISCUSSION: LCH has an incidence of 1 in 100,000 in population aged > 15 years and only 0.04 to 0.6% of these patients have Hypothalamic-pituitary region involvement without extracranial lesions. CNS involvement in LCH can manifest as mass lesion or progress to neurodegenerative LCH (ND-LCH). The latter refers to imaging abnormalities and progressive neurologic dysfunction causing severe ataxia, behavioral and cognitive dysfunction, that commonly occur years later after diagnosis. It can lead to spastic tetraparesis, pseudobulbar palsy, and cognitive deterioration. CNS involvement requires systemic therapy because it is associated with adverse prognosis and increased risk of neurologic damage. PET-CT is required after diagnosis to assess involvement in other areas of the body. Guidelines recommend first line therapy with systemic chemotherapy, or targeted therapy with BRAF/MEK inhibition if a relevant mutation is identified to mitigate progression to ND-LCH.

CONCLUSION: Pituitary involvement by LCH can manifest as panhypopituitarism. Early diagnosis is critical for appropriate treatment initiation. Systemic chemotherapy is indicated to mitigate progression to ND-LCH.

A RARE CASE OF LEAD POISONING FROM AYURVEDIC MEDICATION IN AN ELDERLY PATIENT WITH PARKINSON DISEASE

Nguyen V. Pham¹; Sarah W. Takimoto²; Agnieszka Gryguc-Saxanoff³

¹Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA; ²Internal Medicine, University of California Los Angeles, Los Angeles, CA; ³General Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #3876774)

CASE: A 76 year-old female with a history of Parkinson’s disease (PD) presented with one day of altered mental status (AMS).

The patient was found to be acutely altered by family; on further review, the family described a subacute decline with increasing lethargy, diffuse abdominal pain, and poor oral intake. At baseline, the patient was fully alert and oriented. She had started taking ayurvedic supplements (unknown names) for approximately 10 weeks without changes to her other medications.

Initial evaluation revealed a sodium of 128 with a hemoglobin of 10.4. Venous lead levels were greater than 90 mcg/dL. An abdominal x-ray showed punctate hyperdense foci in her intestine, concerning for lead colic. Toxicology was consulted. She was admitted to the medical intensive care unit and initiated on chelation therapy with dimercaprol. Despite initial improvement, the patient had significant fluctuation in motor function with worsening rigidity and tremor. Her course was complicated by multiple episodes of severe sepsis due to aspiration pneumonia and urinary tract infections. Her mental status continued to decline, and she became comatose. The patient was ultimately transitioned to comfort care.

IMPACT/DISCUSSION: Lead poisoning is rare in adults but should be considered in the evaluation of AMS especially in patients taking ayurvedic medicine. Elevated venous lead level is associated with ayurvedic medicine due to the practice of mixing herbs with metals and minerals. Significant lead content has been found in traditional Chinese herbs, echinacea, St. John’s wort, ginkgo and others.¹

Lead poisoning is associated with a nonspecific clinical presentation. Common features include abdominal pain, constipation, anorexia, joint pain/muscle ache, fatigue, poor concentration, and short term memory deficit.² This raises the importance of a comprehensive medication reconciliation.

While studies are limited, current data suggests that severe lead poisoning can increase the risk of neurological dysfunction in PD patients.³ This case highlights the vulnerability of PD patients to lead poisoning and its neurological consequences.

CONCLUSION: Lead is a common contaminant in traditional Ayurvedic medicine and herbal supplements. Medication reconciliation including non-prescriptive medications is important in AMS patients.

Lead poisoning is associated with worsening neurological dysfunction in PD patients.

1. Chopra A, Doiphode VV. Ayurvedic medicine. Core concept, therapeutic principles, and current relevance. Med Clin North Am. 2002;86(1):75-vii. doi:10.1016/s0025-7125(03)00073-7

2. Cullen MR, Robins JM, Eskenazi B. Adult inorganic lead intoxication: presentation of 31 new cases and a review of recent advances in the literature. Medicine (Baltimore). 1983;62(4):221-247.

3. Weuve J, Press DZ, Grodstein F, Wright RO, Hu H, Weisskopf MG. Cumulative exposure to lead and cognition in persons with Parkinson's disease. Mov Disord. 2013;28(2):176-182. doi:10.1002/mds.25247

A RARE CASE OF LOW-DOSE METHOTREXATE-INDUCED TOXICITY

Hussan Rahim, Shuja Malik, Mehmood Cheema.

Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #3877179)

CASE: We present a case of 73-year-old female with past medical history notable for psoriatic arthritis and gout for which she was on methotrexate (MTX) 2.5 mg weekly and allopurinol. She presented to our institution with chief complaint of new-onset mouth sores and persistent diarrhea. Objective data showed that she was afebrile and hemodynamically stable. Initial labs were significant for pancytopenia (WBC 3.3 x10(9)/L, hemoglobin 8.8 g/dl, and platelet 56 x10(9)/L), macrocytosis (MCV 101fL), folate deficiency (folate levels 2.9) and hypoalbuminemia (serum albumin 2.3 g/dl). Further workup, including serum protein electrophoresis, differential cell count and microbiology was unremarkable. Her serial labs showed worsening pancytopenia during her hospital stay. She underwent bone marrow biopsy which came back unremarkable. Further evaluation of patient revealed that she was taking her methotrexate 2.5 mg daily instead of once weekly and she also endorsed non-compliance of her folic acid supplementation. Considering these findings, along with her hypoalbuminemia and concomitant allopurinol use, diagnosis of MTX toxicity was made. She was started on high-dose folic acid supplementation with leucovorin rescue therapy and MTX was discontinued. She had significant improvement of her pancytopenia, diarrhea and stomatitis over next few days. At outpatient follow-up visit, her cell counts remained stable.

IMPACT/DISCUSSION: MTX inhibits folic acid activation and is commonly used in low doses (ranging from 5 to 25 mg weekly) to treat rheumatoid arthritis, psoriatic arthritis and other immune-mediated chronic inflammatory diseases. Low-dose MTX toxicity is rare and usually seen with contributing factors, including renal dysfunction, hypoalbuminemia, inadequate folate supplementation, and the concomitant use of drugs (Sulfa drugs, PPI, allopurinol) that interfere with methotrexate metabolism and dosing error. Minor side effects commonly associated with MTX toxicity include stomatitis and gastrointestinal upset (nausea, diarrhea etc.). Major side effects include pancytopenia, hepatotoxicity, pulmonary toxicity and renal failure. If low-dose MTX toxicity is suspected, immediate actions should be taken to discontinue MTX and start patient on folic acid supplementation, leucovorin (an activated metabolite of folic acid) rescue therapy and addressing underly factors.

CONCLUSION: This case serves as a reminder to physicians for low-dose MTX toxicity, which is a rare occurrence but can lead to severe life-threatening complications. Some of the modifiable risk factors that contribute to low-dose MTX toxicity can be addressed by adequate folic acid supplementation, avoiding prescription of drugs that will delay MTX clearance and avoiding dosing errors(educating patients thoroughly on weekly dosing of MTX).

A RARE CASE OF NEXPLANON IMPLANT ASSOCIATED GALACTORRHEA

Anika Huq, Usama Ahmad

Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #3867799)

CASE:We present the case of a 22 y/o G1P1 woman who presented with bilateral galactorrhea. The patient had physiologic galactorrhea after pregnancy. She breastfed her child for 3 months, after which the patient still continued to produce breast milk even until she presented to establish care once her child was about 2 years old. Blood work revealed normal prolactin and TSH levels (Prolactin 15 ng/mL, TSH 1.860 uIU/mL). Brain MRI was also normal, and breast ultrasound showed no abnormalities.

Of note, the patient underwent implantation of a Nexplanon two months after her child was born and then requested removal due to side effects about one year later, after which she transitioned to oral contraceptives (OCPs). She eventually discontinued OCPs, and after a brief two month break, had Nexplanon re-implanted. She recalls during the brief break from contraception, her galactorrhea improved. A short three months after Nexplanon implantation, she re-presented to the clinic with worsening galactorrhea to the extent that she would wake up at night having expressed milk onto her shirt. She was recommended by the primary team to consider Nexplanon removal, and ultimately removed the implant two months later. At her return visits, one month and seven months after removal, she endorsed improvement in galactorrhea.

IMPACT/DISCUSSION: This vignette demonstrates a unique case of contraceptive-related galactorrhea. Typically, galactorrhea is caused by elevated prolactin that can be secondary to a prolactinoma, dopamine blocking medications, or hypothyroidism. In this report, the patient had normal prolactin levels. We suspect that progestin from her Nexplanon and OCPs led to her galactorrhea. The Nexplanon implant contains etonogestrel, a progestin analogue that will stimulate the progesterone receptor. Although endogenous progesterone is related to lowering prolactin levels[1], Jordan et al. studied synthetic progestins and found that they stimulated the growth of estrogen receptor (ER) positive cells in culture and concluded that they can “exert estrogenic effects through ER.”[2] Given that elevated estrogen levels can contribute to galactorrhea, as seen in newborns when maternal estrogen crosses into newborn blood, it is possible that the synthetic progestin from this patient’s contraception caused galactorrhea in the setting of normal blood work and imaging. Once her Nexplanon was removed, her symptoms slowly improved. This case presents a unique situation of hormonal influences that might initially be overlooked in contributing to a patient’s symptomatology.

CONCLUSION:

-When assessing a patient’s symptomatology, careful history taking and medical reconciliation can provide clues for further management

-It is possible that exogenous hormones from contraceptives can cause pathologic galactorrhea in patients, as demonstrated in this vignette

A RARE CASE OF SEVERE LOXOSCELISM CAUSING ACUTE HEMOLYTIC ANEMIA WITH SUPERIMPOSED COVID-19 INFECTION

Sumender Sharma¹; Keir MacKay²; Kiran Vedantam¹; Shawn Gill¹; Niranjan Thothala¹; Margaret Beliveau¹

¹Internal Medicine , Indiana University School of Medicine, Evansville , IN; ²Internal Medicine, Indiana University School of Medicine, Indianapolis, IN. (Control ID #3875347)

CASE: A 24-year-old male without any siginificant past medical history presented to the hospital after a Brown Recluse bite three days earlier. He had painful ecchymosis on his back and a fever of 100.6°F. Labs were only notable for an acute kidney injury and leukocytosis (16.0 mcg/L). CT scan did not reveal any evidence of abscess. Patient was not tested for COVID during this visit. Patient discharged by the ER on an antibiotic (clindamycin) and analgesia. Two days later, patient returned to hospital with a new-onset hematuria, a persistent fever (101.1°F), and worsening ecchymosis. Laboratory investigations revealed a WBC 17.4 mcg/L, H&H 13.6 g/dl/41%, platelets 184 mcg/L , CPK 1032 mcg/L, BUN 21 mg/dL, Cr 1.4 mg/dl, T. bili 2.8 mg/dl, LDH 875 units/L, haptoglobin 7 mg/dl. Patient was managed supportively with IV fluids along with low-dose corticosteroids and empiric antibiotics. Several days later, he tested positive for COVID-19 after developing a fever and respiratory distress with radiologic evidence of bilateral airspace opacities. Shortly thereafter, he developed worsening AIHA and multi-organ failure including acute respiratory, kidney, and liver failure. Laboratory evidences of AIHA included a Hb 5.6 g/dl, total bilirubin 8 mg/dl, LDH 1025 units/L, and haptoglobin 2 mg/dl and positive direct antiglobulin test which was negative on presentation. He required multiple blood transfusions, supplemental oxygen (35L 100% O2 via HFNC), high-dose intravenous steroids, and broad spectrum antibiotics. He gradually improved over two weeks and was discharged with a tapering course of corticosteroids.

IMPACT/DISCUSSION: Loxoscelism, or envenomation from brown recluse spiders, can cause AIHA which is rare and frequently self-limited. Most cases of AIHA resolve within 4 to 7 days without any life- threatening multi-organ failure or prolonged course.^1,3 It is likely that COVID-19 infections superimposed on systemic loxoscelism can exacerbate the hemolytic anemia because of shared hemolysis pathway. Studies have revealed that complement-mediated hemolysis is the likely pathway of warm AIHA secondary to both systemic loxoscelism and COVID-19 infections. Red blood cells exposed to Loxosceles reclusa venom failed to undergo hemolysis when incubated with complement-depleted plasma in vitro¹. Similarly, COVID-19 causes an hyper-inflammatory states encompassing various pathways, including the complement cascade which can lead to AIHA² . The management of brown recluse bites is primarily supportive. It rarely requires even low-dose corticosteroids.^1,3 However, our patient required high-dose corticosteroids and 6 units of PRBC’s over a 15-day hospital course.

CONCLUSION: Our case highlights that healthcare providers must carefully consider all the co-morbid factors while treating systemic loxoscelism as this can guide timely treatment. It also reveals that clinical improvement is possible in the context of multi-organ failure.

A RARE CASE OF SUBARACHNOID RACEMOSE NEUROCYSTICERCOSIS WITH SPINAL INVOLVEMENT

Charlotte Ballantine, Stefani Garcia, Leonard Noronha, Lydia M. Crooks

Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM. (Control ID #3874493)

CASE: A 62 year old man, born in Mexico but residing in the US for the past 30 years, with history of hypertension, diabetes and ventriculoperitoneal (VP) shunt placed one month prior in Mexico for suspected normal pressure hydrocephalus presented to our hospital after a fall. He was diagnosed with a small left subdural hemorrhage managed conservatively and was discharged home. Over the next three months he had three re-admissions for unsteady gait and weakness, and underwent several VP shunt revisions with minimal improvement in his symptoms. During the last admission, an MRI brain was performed, which showed multiple cystic lesions in the subarachnoid space, consistent with active subarachnoid racemose neurocysticercosis. He underwent serologic testing, which was positive, and had MRI exams showing extensive spinal subarachnoid cystic lesions, which were likely the cause of his weakness. He was started on Albendazole, Praziquantel, and steroids with improvement in his symptoms. Unfortunately, he experienced an interruption in his therapy and suffered worsening of his spinal disease before resuming appropriate therapy. He is currently continuing treatment and is showing modest clinical improvement.

IMPACT/DISCUSSION: Neurocysticercosis is caused by ingestion of T. Solium cysticerci, which are usually found in undercooked pork. The disease is endemic to Central and South America, Africa, and India. Isolated parenchymal lesions are the most common subtype, and typically present with seizures.

Extraparenchymal disease can be divided into intraventricular lesions (often causing obstructive hydrocephalus), subarachnoid lesions (causing meningitis, communicating hydrocephalus, or local mass effect), and spinal lesions (symptoms based on location and size of lesions). A rare sub-type of subarachnoid neurocysticercosis is racemose neurocysticercosis, in which cysticerci lose their outer membranes, and appear on imaging as multilocular cysts described as a “clump of grapes.” This sub-type is strongly associated with involvement of the spinal subarachnoid space and is considered the most severe subtype. Treatment involves antiparasitic therapy, steroids to decrease brain edema, and VP shunt in select cases, with duration of treatment depending on disease severity and response to therapy. This case of advanced subarachnoid racemose neurocysticercosis with spinal involvement represents not only a rare diagnosis, but also the importance - and the difficulty - of making the diagnosis given its low prevalence in the United States. A willingness to re-think the working diagnosis of hydrocephalus when symptoms persisted despite initial therapy led to the discovery of spinal neurocysticercosis, and initiation of appropriate therapy, in this case.

CONCLUSION: Neurocysticercosis remains rare in the United States, and diagnosis can be delayed due to low index of suspicion and clinicians' lack of familiarity with the wide variety of clinical presentations.

A RARE CASE OF SYNCHRONOUS METASTATIC COLORECTAL CANCER AND ACUTE MYELOID LEUKEMIA (AML)

Chukwudumebi S. Uche, Omar Calderon, Tiana Dodd

Internal Medicine, University of South Florida, Tampa, FL. (Control ID #3876930)

CASE: A 74-year-old male with past medical history significant for hypertension presented to our ED for evaluation of a 1-week history of intermittent bright red blood per rectum. He remained hemodynamically stable on presentation and denied any associated symptoms. Digital rectal exam remarkable for external hemorrhoids. He denied any family history of colorectal cancer and reports he has never had a screening colonoscopy. Laboratory findings notable for a white blood cell count of 70, 000 cells per cubic millimeter, Hgb of 9.3 grams per deciliter (g/dL), and platelet count of 30.0 per cubic millimeter. CT abdomen and pelvis remarkable for multiple hypoattenuating hepatic masses consistent with liver metastases. Colonoscopy performed upon admission was remarkable for a malignant 20 cm cecal mass with biopsy results consistent with invasive adenocarcinoma. Given his marked leukocytosis and thrombocytopenia, a bone marrow biopsy was performed with results remarkable for a markedly hypercellular bone marrow (95%) with 80% blasts, consistent with acute myeloid leukemia (FLT 3+). The patient was not a candidate for surgery of curative intent given the lesion location, size, and comorbid AML. He underwent 5 fractions of therapeutic radiation to the cecal mass as well as Y90 radiation to the hepatic lesions. Subsequently following radiation therapy, he began treatment for his AML with azacitidine and venetoclax. Repeat bone marrow biopsy revealed clinical remission with a hypocellular marrow without blasts.

IMPACT/DISCUSSION: Multiple primary malignancies (MPMs) are divided into 2 categories: metachronous, when tumors are diagnosed more than 6 months after the diagnosis of the first primary cancer, and synchronous, which describe neoplasms that occur simultaneously or within six months of diagnosis. There are few reported cases of synchronous presentations of dual malignancies in the literature. Our case highlights a rare presentation of synchronous Acute Myeloid Leukemia (AML) and colorectal cancer. The pathophysiology of dual primary malignancies remains unknown, but speculations have been made to include ionizing radiation and increasing hormonal and genetic therapies as risk factors. The uncertain origin of synchronous tumors presents a challenge to the clinician, but predisposing factors such as environmental and genetic factors should be considered. Data regarding the incidence and treatment of synchronous dual malignancies remains limited. Treatment strategies suggest treating the more advanced malignancy first, as was done in our patient’s case.

CONCLUSION: - The presence of dual malignancies should be considered in patients with solid tumors combined with unexplained hematological changes.

- Multiple malignant neoplasms can present a real challenge to the clinician, clinical attention should be made to avoid misdiagnosis as early diagnosis and treatment can improve outcomes.

- There is limited data in the literature to determine the incidence of synchronous AML and colorectal cancer.

A RARE CASE OF UROSEPSIS- RAOULTELLA PLANTICOLA

Christian J. Rose, Vishal D. Patel

Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA. (Control ID #3872433)

CASE: We present the case of a 94-year-old female with history of Alzheimer’s dementia and recurrent urinary tract infections who presents as a transfer from an outside hospital for management of urosepsis and obstructive uropathy. She has a history of obstructive uropathy with E. coli bacteremia that was treated with placement of a nephrostomy tube, which was subsequently removed by urology following intervention. A few weeks later she presented to an outside hospital for acute encephalopathy and pain. Vitals notable for HR 91 and labs for WBC 13,000 (K/uL), creatinine of 1.73 (mg/dL). Urinalysis demonstrated numerous white blood cells, positive leukocyte esterase and nitrites. CT demonstrated an 8mm obstructing stone in the distal right ureter with mild hydronephrosis. IV fluids and ceftriaxone were started, and urology was consulted. Urine cultures demonstrated >100,000 CFU’s of pansensitive E. coli and >100,000 CFU’s of Raoultella planticola resistant to ampicillin. Blood cultures remained negative throughout admission. The patient then underwent cystoscopy with right ureteroscopy and laser lithotripsy with the urology team. She had significant improvement, and the antibiotic regimen was transitioned to Keflex upon discharge to home.

IMPACT/DISCUSSION: Raoultella planticola is a gram-negative, non-motile, anaerobic rod commonly found in aquatic environments and soil. Infections in humans with R. planticola are rare and most commonly affect individuals that are immunocompromised. Urinary tract infections with R. planticola are exceedingly rare. Risk factors include an immunocompromised state, invasive urinary tract procedures and contaminated surgical equipment. In the US only a few cases of UTI from this organism have been documented. Our patient did not have risk factors for immunosuppression. She did however have recent invasive urological intervention for obstructive uropathy. Raoultella planticola is typically susceptible to antimicrobials used as first line for UTI’s. Not much is known regarding this rare organism, but it appears to be best classified as an opportunistic organism given the types of infections and commonality of being frequently discovered in immunocompromised patients. Given her history we relate this infection to her history of recent invasive urological intervention.

CONCLUSION: While most reported infections are in the immunocompromised, clinicians should be aware of this uncommon pathogen that can cause UTI’s and systemic infections in immunocompetent patients. Discovery of Raoultella planticola as a cause of infection post-procedure should also be recognized by clinicians to be a sign of needing to re-evaluate surgical equipment sterilization processes in their clinical settings.

A RARE CASE OF WERNICKE ENCEPHALOPATHY IN THE SETTING OF ALCOHOL USE DISORDER AND DIABETIC KETOACIDOSIS

Nicole Xu¹; Wendy Jin¹; Ayman Salem³; Jasdeep Bathla²; Dana Kabbani³; Manmeet Singh²

¹Medical Education, Wayne State University School of Medicine, Detroit, MI; ²Internal Medicine, Detroit Medical Center, Detroit, MI; ³Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #3874562)

CASE: A 68-year-old man with a medical history significant for hypertension presented to the emergency department from his nursing home due to altered mentation. He was alert but not oriented and nonverbal. On physical exam, the patient was volume depleted. Labs showed hyperglycemia of 809 mg/dL, corrected sodium of 164 mmol/L, high anion gap metabolic acidosis, and positive serum ketones.

The patient was admitted for management of acute metabolic encephalopathy secondary to severe hypernatremia and diabetic ketoacidosis (DKA). He was given low-dose empiric thiamine on admission. His sodium and glucose returned to normal ranges. However, he remained oriented only to self, which was his baseline mentation per his nursing home. The authors were eventually able to reach his sister who provided a detailed history to establish the timeline. The patient had a history of alcohol use disorder and started drinking heavily prior to admission. Given the updated history, his thiamine dose was increased and the next day he was forming coherent sentences. In the following days, he became oriented to person, place, and time. IMPACT/DISCUSSION: Wernicke Encephalopathy (WE) results from thiamine deficiency, leading to a classic triad of encephalopathy, oculomotor deficits, and gait ataxia. Of note, only one-third of WE patients present with all three symptoms. Encephalopathy is commonly seen in isolation, with 82% of patients having mental status changes and less than 30% having ocular abnormalities and ataxia. Around 80% of patients with the condition do not receive a diagnosis, and many cases are only diagnosed postmortem. Left untreated, WE has a 17% mortality rate. Thus, clinical suspicion for WE is warranted even when only deficits in mentation are present in at-risk patients.

An inverse relationship between blood lactate and thiamine levels in diabetic ketoacidosis (DKA) has been reported, suggesting that thiamine deficiency could contribute to some DKA cases. It is important to recognize that new-onset DKA in a patient with chronic alcohol use can be associated with thiamine deficiency and WE. There are few reported cases of WE in the setting of alcohol use disorder and DKA.

WE is readily reversible if treated with adequate doses of parenteral thiamine. However, multiple regimens exist and there are no universally accepted guidelines with regard to optimal dose, mode of administration, and duration of treatment. More aggressive treatment with higher doses is recommended. The treatment outcome of our case supports a more aggressive thiamine approach.

CONCLUSION: WE is a challenging diagnosis due to the lack of specific diagnostic tests and varying clinical presentations. Obtaining a thorough social history is imperative to making a correct diagnosis of WE.

Thiamine deficiency was essential in our patient’s metabolic decompensation and DKA. Recognizing and diagnosing WE early on and following a more aggressive thiamine regimen proved to be effective in our case.

A RARE ETIOLOGY OF ISOLATED LEFT-SIDED ABDOMINAL PAIN IN A YOUNG FEMALE: THINKING OUTSIDE THE PELVIS

Ramsha Riaz

Internal Medicine, Jersey City Medical Center, Jersey City, NJ. (Control ID #3875350)

CASE: A 27-year-old female with a history of childhood asthma and preeclampsia presented with complaint of left-sided abdominal pain for 2 days, associated with nausea and vomiting. The pain was 10/10 in intensity, non-radiating and sharp in nature, with no associated aggravating or relieving factors. On further questioning, patient also endorsed upper respiratory tract symptoms for 1 week, including fever and chills, dry cough, and mild sore throat. Her last menstrual period was approximately 3 weeks prior to presentation. She denied any history of blunt trauma, contact sports, accidental injuries or falls. Also denied sick contacts, burning micturition, abnormal vaginal discharge or inter-menstrual bleeding, and painful sexual intercourse. Patient reported being monogamous with a male partner, with inconsistent use of protection. On physical examination, abdomen was found to be soft, non-distended, with tenderness on deep palpation of left upper quadrant, no hepatosplenomegaly, and normal bowel sounds. Kehr’s sign was negative and no costovertebral angle tenderness elicited. Vital signs were significant for sinus tachycardia. Lab investigations were evident for lymphocytosis (62.7%) with a normal white cell count. A urine pregnancy test was negative. Ovarian torsion was ruled out on pelvic ultrasound, however, a 3.4 cm left ovarian cyst was found incidentally. CT Abdomen with IV contrast revealed a splenic laceration of indeterminate age. In the setting of patient reporting flu-like symptoms days prior to initiation of abdominal pain, a Monospot test was sent which came back positive. Surgical consultation was sought but no acute surgical intervention was warranted. Her pain improved subsequently, she remained hemodynamically stable throughout the hospital course and was discharged home.

IMPACT/DISCUSSION: Splenic rupture is a rare but well-known complication occurring in association with infectious mononucleosis. However, it mostly occurs in the setting of varying degrees of trauma or underlying pathologies and most commonly in males. Unprovoked splenic injury is rarely ever encountered but has the potential to be life-threatening. This case emphasizes the importance of obtaining a thorough history and considering rare diagnoses in the setting of seemingly common presentations. Also emphasizes on being vigilant about the possibility of potentially life-threatening splenic injury occurring in the setting of infectious mononucleosis, even in the absence of a provoking incident, as well as counselling patients to be wary of the same.

CONCLUSION: Isolated left-sided abdominal pain in the setting of preceding flu-like illness and absence of specific trauma can be due to spontaneous splenic rupture. Clinicians should counsel patients testing positive for EBV in an outpatient or in-patient setting to not just avoid contact sports for few weeks, but also seek medical attention for left-sided abdominal pain in the absence of a traumatic event.

A RARE HIGH-GRADE SMALL CELL NEUROENDOCRINE AMPULLARY CARCINOMA IN A PATIENT WITHOUT AN OBVIOUS RISK FACTOR

Hyun Jung¹; Russell C. Langan²; Neil Kothari¹; Aditya Kuwadekar³

¹Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ; ²Department of Surgery, RWJBarnabas Health, Livingston, NJ; ³Pathology, Cooperman Barnabas Medical Center, Livingston, NJ. (Control ID #3873533)

CASE: A 52-year-old Dominican immigrant man with no known past medical history presented due to intermittent fever for three weeks and jaundice for a week. He denied appetite changes, abdominal pain, or unintentional weight loss. He denied recent alcohol, tobacco, or illicit drug use or family history of gastrointestinal malignancy. Initial vitals were fever of 103°F, blood pressure 129/75 mmHg, and heart rate 119 beats per minute. Physical exam was notable for jaundiced skin and soft and nontender abdomen. Initial labs included WBC 11,900 μL, AST 242 U/L, ALT 454 U/L, alkaline phosphatase 931 U/L, total bilirubin 3.4 mg/dL, direct bilirubin 2.0 mg/dL, and GGT 2,284 U/L. CT of the abdomen showed a dilatation of intrahepatic biliary ducts and common bile duct to 1.3 cm without a discrete obstructing lesion. ERCP revealed a polypoid lesion at the major papilla and no significant gallstones or biliary sludge. Three plastic stents were deployed, and the lesion was biopsied. The biopsy yielded a high-grade small cell neuroendocrine carcinoma, with positive staining for insulinoma-associated protein 1, synaptophysin, chromogranin, cytokeratin AE1 and AE3, and Ki67 >90%. PET-CT demonstrated a single focus of hypermetabolic activity at the ampulla of Vater (SUV 4.0). The patient subsequently underwent pancreaticoduodenectomy,

cholecystectomy, and celiac and portal lymphadenectomy. The surgical specimen showed lymphovascular invasion of the neuroendocrine carcinoma into peripancreatic and periduodenal tissues as well as 6 out of 34 positive lymph nodes. The patient had an uncomplicated postoperative course and was initiated on chemotherapy with atezolizumab, cisplatin, etoposide, and dexamethasone.

IMPACT/DISCUSSION: Ampullary carcinomas are rare, accounting for 0.2% of gastrointestinal cancers. They commonly present with obstructive symptoms, such as jaundice or abdominal pain, but are rarely preceded by nonspecific symptoms such as fever. Neuroendocrine carcinomas (NEC) are a rare subtype of ampullary carcinoma, and there is a paucity of related studies. They present earlier in life during the 5th to 6th decade and are associated with neurofibromatosis 1. Although most are typically noticed on imaging for their size, they may not be obvious on initial imaging, as was the case with our patient. They are often associated with early metastasis and poor prognosis despite aggressive surgical intervention involving pancreaticoduodenectomy and adjuvant chemotherapy and warrant a close surveillance.

CONCLUSION: -Ampullary carcinomas commonly present with obstructive symptoms, such as jaundice or abdominal pain, but are rarely preceded by nonspecific symptoms such as fever

-Even in the absence of discrete lesion on the initial imaging, ampullary carcinomas should be considered in patients presenting with obstructive symptoms without obvious causes or risk factors

-Ampullary NEC is rare and is often associated with a poor prognosis despite aggressive surgical intervention and adjuvant chemotherapy

A RARE IMPLICATION OF POOR NUTRITION: SUPERIOR MESENTERIC ARTERY SYNDROME IN A PATIENT WITH PANCREATIC CANCER

Trisha S. Gupte¹; Astha Saini^2,1; Preetha Ghosh¹; Anupama Devara^2,1

¹Internal Medicine, Wayne State University School of Medicine, Detroit, MI; ²Internal Medicine, Detroit Medical Center, Detroit, MI. (Control ID #3875328)

CASE: A 66-year-old woman with past medical history of pancreatic cancer with peritoneal carcinomatosis and liver metastasis, type 2 diabetes mellitus, hypertension and chronic systolic heart failure presented for concerns of postprandial abdominal pain and nausea. She was diagnosed with pancreatic cancer 1 year prior to presentation and was receiving chemotherapy.

Due to persistent abdominal pain and vomiting, there was concern for malignant obstruction and CT abdomen and pelvis revealed findings consistent with SMAS. Conservative management was initiated with nasogastric tube. Due to known history of pancreatic cancer, there was concern for tumor invasion resulting in compression of duodenum, therefore she underwent EGD, which revealed no evidence of tumor invasion into duodenum or proximal jejunum. The patient had clinical improvement with conservative management and was discharged with a plan for outpatient surgical duodenal jejunostomy or endoscopic gastrojejunostomy. Eventually, she returned to the hospital 13 days later for worsening abdominal pain.

Surgical intervention for SMAS was recommended but deferred by the patient. Two days later, she underwent EGD with EUS celiac axis neurolysis to provide relief from her cancer-related epigastric pain. Unfortunately, she did not achieve relief from the neurolysis, and she opted to pursue hospice care. She passed away two months later.

IMPACT/DISCUSSION: While SMAS is rare, its delayed diagnosis and treatment can lead to complications that are associated with high morbidity and mortality. Our patient had delayed diagnosis and delayed initiation of chemotherapy due to social determinants of health, such as lack of health insurance and poor financial and emotional support. Weight loss from delayed diagnosis of pancreatic cancer and poor nutritional status due to financial insecurity exacerbated our patient's cachexia, resulting in SMAS. Primary care physicians treating patients with malignancy should be aware of the consequences of weight loss and methods of maintaining nutritional intake to avoid complications such as superior mesenteric artery syndrome. Thus, this case adds to current literature by emphasizing the need for physicians to consider social determinants of health when treating patients in order to optimally treat their medical conditions.

CONCLUSION: This case showed us that it is essential for us to inquire about our patients' food security and home life so we can anticipate how these factors may compound with patients' medical conditions. This will help us create a more well-informed treatment plan.

Additionally, though it is rare, we must anticipate the possibility of superior mesenteric artery syndrome whenever a patient is going through rapid weight loss as its morbidity and mortality increase greatly when it goes unrecognized.

A RARE PHENOMENON: ACUTE SYSTOLIC HEART FAILURE SECONDARY TO MACROPHAGE ACTIVATION SYNDROME

Syed H. Ali^2,1; Umer N. Khan²; Shanti Nulu^1,3

¹Dell School of Medicine, The University of Texas at Austin, Austin, TX; ²Internal Medicine, The University of Texas at Austin Dell Medical School, The University of Texas at Austin Dell Medical School, Austin, TX, US, academic/medsch, Pflugerville, TX; ³Ascension Texas Cardiovascular Austin, Austin, TX. (Control ID #3877066)

CASE: Patient is a 45 year old hispanic female who was admitted for altered mental status and weakness. During her stay, she was treated for Epstein Barr Virus (EBV) mononucleosis. After treatment, she remained symptomatic despite negative infectious workup. However, labs were significant for new onset systemic lupus erythematosus (SLE). Given elevated ferritin (4150), elevated AST (86), triglycerides (185), and thrombocytopenia (69), our patient met criteria for macrophage associated syndrome (MAS) according to the 2016 American College of Rheumatology criterion. Bone marrow biopsy showed hemophagocytosis.

On physical exam, she remained altered and developed acute hypoxic respiratory failure requiring non- invasive positive pressure ventilation. Transthoracic echocardiogram (TTE) showed ejection fraction (EF) 35-40% confiirming new onset systolic heart failure. Goal directed medical therapy and diuresis were initiated with improvement in respiratory status. She was administered high dose steroids without improvement. She was then transitioned to intravenous immunoglobulins and cyclophosphamide. There was notable improvement in weakness and mentation. Cardiac MRI showed improvement in EF to 64% without residual myocardial scarring. Patient was safely discharged to an inpatient rehabilitation facility.

IMPACT/DISCUSSION: Macrophage activation syndrome (MAS) is a subset of hemophagocytic lymphohistiocytosis (HLH) that occurs in the presence of a rheumatologic condition such as SLE. MAS is a life threatening syndrome characterized by excessive immune activation that can result in multiorgan failure with high rates of mortality. MAS can be due to a genetic abnormality in perforin coding gene. It portends a prolonged state of inflammation in patients with rheumatologic conditions or a viral infection such as EBV.

We present a rare case of MAS complicated by new-onset systolic heart failure. Heart failure is an extremely rare manifestation of MAS that can be fatal without timely treatment. Our patient was treated with goal directed medical therapy for heart failure and high dose steroids, IVIG, and cyclophosphamide for SLE flare. Subsequently, cardiac MRI showed improvement in ejection fraction without residual cardiac scarring.

CONCLUSION: - MAS is a form of HLH that occurs in the setting of rheumatologic conditions such as SLE; it can be triggered by viral infections such as Epstein Barr Virus.

- Acute systolic heart failure is a rare complication of MAS that requires a collaborative effort from hospitalists, cardiology, hematology, and rheumatology to treat acute end-organ disease.

- Prompt treatment of MAS and GDMT initiation lead to favorable outcomes for patients in the acute phase. Other treatments that have shown efficacy include etoposide and biological agents such as anakinra, tocilizumab, and rituximab.

A RARE POST-INFECTIOUS RASH: PITYRIASIS RUBRA PILARIS AFTER COVID-19

INFECTION

Philicia Duncan. Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #3875124)

CASE: A 55yo woman with no history of rheumatologic disease presented to the hospital with erythroderma. Two months prior to presentation, she had sudden eruption of patchy, erythematous plaques and diffuse scaling of the scalp, face, upper chest, and back. This progressed to involve her entire torso and extremities. She was seen in the outpatient dermatology clinic and laboratory exam revealed positive ANA of 1:320, negative DsDNA, ENA, and hepatitis viral panel. Two skin biopsies were performed, she was diagnosed with cutaneous lupus and started on oral prednisone, hydroxychloroquine, and mycophenolate. Notably, 3 weeks before onset of the rash, she was diagnosed with COVID-19 infection. On physical exam, she had diffuse erythema encompassing 90% BSA, erythematous plaques with islands of sparing, and waxy keratoderma of the palms and soles. Dermatology was consulted and performed a skin biopsy of an abdominal lesion. This revealed psoriasiform dermatitis with alternating orthokeratosis and parakertasosis and follicular plugging, consistent with a diagnosis of pityriasis rubra pilaris (PRP). She was discharged from the hospital on acitretin, topical triamcinolone, and a prednisone taper. She was seen in clinic one month after discharge without improvement in symptoms and started on ixekizumab.

IMPACT/DISCUSSION: PRP is a rare inflammatory dermatosis of unknown etiology, but has been associated with malignancy, autoimmune disorders, and infections and may be the primary manifestation of HIV. Because PRP is unresponsive to systemic steroids and has debilitating sequela that results in poor quality of life and depression, early recognition and diagnosis is important. PRP is classified into 6 subtypes, based on Griffith’s classification, with variable presentations and natural history. Though it may be confused with other erythrodermic disorders, especially psoriasis, PRP has characteristic physical and histologic findings. In adults, PRP usually starts on the face and scalp with a cephalocaudal progression and skin lesions have interspersed areas of uninvolved skin known as “islands of sparing.” Nail changes occur, but unlike psoriasis, onycholysis, nail pitting, and the oil drop sign are absent. Histopathologic findings include alternating horizontal and vertical parakeratosis and hyperorthokeratosis, keratotic plugging, and a predominantly lymphocytic dermal infiltration. Though response to treatment varies depending on the subtype, response is better achieved with combining topical (emollients, steroids, retinoids) and systemic (retinoids, methotrexate, TNFa inhibitors) therapies.

CONCLUSION: While internists may be familiar with various post-infectious, drug-induced, and auto- immune cutaneous lesions, PRP is a rare culprit that is usually not considered in patients presenting with rash after COVID-19 infection. Given that it is frequently misdiagnosed as systemic cutaneous lupus or psoriasis, knowledge of its characteristic physical exam and histopathologic features is important.

A RARE PRESENTATION OF HEART FAILURE, BUNDLE BRANCH BLOCK AND CARDIAC THROMBI

Ying Yin Zhou, Kwame Quaye, Morris Jrada

Department of Internal Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #3874552)

CASE: A 39-year-old otherwise healthy male presented with fatigue, abdominal tightness, dyspnea on exertion, and lower extremity swelling for 1 month. He denied chest pain, recent illness, alcohol use, or family history of heart disease.

Vital signs were normal. Exam was notable for jugular venous distention, a tense abdomen, and 4+ lower extremity pitting edema. Laboratory findings showed moderate transaminitis, elevated B-type natriuretic peptide levels, and an elevated creatinine. Electrocardiogram (EKG) showed normal sinus rhythm with a right bundle branch block. Echocardiogram (TTE) revealed four-chamber dilatation, global left ventricular wall motion hypokinesis, an ejection fraction of 5%, a left ventricular filling defect, and 2 right ventricular masses. No valvular abnormalities were noted. Diuretics, beta blockers and anticoagulation were started. Given the presence of thrombi, cardiac angiography was deferred. Nonischemic cardiomyopathy workup including infiltrative, inflammatory, and metabolic etiologies were unremarkable. Given that the patient was from El Salvador, trypanosoma cruzi (T. cruzi) antibody test was sent, which resulted positive.

Patient was diagnosed with Chagas cardiomyopathy. A cardiac MRI confirmed thrombi in both right and left ventricular apices, and the right atrial appendage. Myocardial thinning and transmural enhancement were noted in the left ventricular apex. Confirmation T. cruzi antibody testing was again positive. Patient was evaluated for heart transplantation.

IMPACT/DISCUSSION: The literature notes an average duration of 6.3 years of heart failure at the time of heart transplantation with a mean left ventricular ejection fraction of 19%. We present a rare case of rapidly progressive Chagas cardiomyopathy with a severely depressed ejection fraction one month after symptom onset. Right bundle branch block is a hallmark finding on EKG. Global ventricular hypokinesis and mural thrombus with aneurysm are common on TTE, but multiple thrombi in the absence of an aneurysm is very atypical. Management is similar to heart failure from other etiologies, including diuretics, beta blockers, and angiotensin-converting enzyme inhibitors as tolerated. Anticoagulation is needed in patients with thromboembolic events or intracardiac thrombi. In refractory cases, heart transplantation may be the only option; however, it is associated with T. cruzi reactivation from the use of immunosuppressive therapy post transplantation. More widespread screening of T. cruzi infection is needed in patients from endemic regions who present with heart failure or conduction abnormalities of unclear cause. Further studies on therapies to decrease parasitic burden and damage on cardiac tissue are warranted.

CONCLUSION: Screen for T. cruzi infection among at-risk populations with heart failure or conduction abnormalities of unclear etiology; Manage Chagas cardiomyopathy similar to heart failure of other causes, with heart transplantation being the only option in refractory cases.

A RECENTLY DEFINED CAUSE OF RAPIDLY PROGRESSIVE DEMENTIA

Danielle Kubicki¹; Stephen Fuest²

¹Internal Medicine, Washington University in St Louis, St Louis, MO; ²Internal Medicine, Washington University School of Medicine in St. Louis, Saint Louis, MO. (Control ID #3860028)

CASE: A 71 year old man presented to a VA Medical Center in the Mid-West Region with 2 months of worsening cognition. History was provided by his wife. At baseline, he lived with his wife and performed activities of daily living independently except driving, due to blindness from diabetic retinopathy. Two months ago, he began to have lapses in concentration while speaking. Three weeks ago, he forgot how to use utensils, shave, and navigate around his home. One week ago, he developed bowel and bladder incontinence. Positives: visual hallucinations, hypersomnia, tremor, anorexia, weight loss. Negatives: abnormal movements and disinhibition.

Social history: former smoking (10 pack years), rare alcohol use, no drug use.

Medical history: diabetes with retinopathy, transient ischemic attack, hypertension, coronary artery disease. Family history: no history of dementia.

Medications: amlodipine, aspirin, insulin, metformin, pravastatin, spironolactone.

Physical exam: awakens to voice, oriented to self only, nonsensical speech, resting tremor of bilateral hands, no focal strength deficit, heart with normal rate and regular rhythm, lungs clear, abdomen soft and nontender. Diagnostic studies: CMP, CBC, B12, TSH, RPR, HIV, urinalysis, urine drug screen normal. CT head normal. Brain MRI with chronic small vessel ischemic disease. Lumbar puncture with glucose 71; nucleated cells 37 (no reliable cell differential or protein due to a delay while testing for CJD); RBC 1; viral PCR including enterovirus, HSV, CMV, and VZV negative; bacterial PCR and cultures negative; RT-QuIC negative; autoimmune encephalitis panel positive for anti-glial fibrillary acidic protein (GFAP) antibody with titer 1:16. CT Chest, Abdomen, Pelvis with a left renal mass.

Interventions and course: He underwent left nephrectomy with exam and pathology showing stage III (pT3aNxM0) clear cell renal cell carcinoma. He was treated with IV methylprednisolone 1 g daily for 5 days.

Subsequently, he was alert and oriented to person, place, and year. He was transitioned to a steroid taper and mycophenolate mofetil. Cognition improved over one week and he was discharged home. At one week after discharge, his cognition had returned to baseline.

Final diagnosis: Paraneoplastic autoimmune GFAP astrocytopathy secondary to renal cell carcinoma IMPACT/DISCUSSION: This case raises awareness of autoimmune GFAP astrocytopathy, a cause of rapidly progressive dementia that was first defined in 2016 (Fang et al.). It highlights the association of GFAP astrocytopathy with neoplasms, which may be present in up to one-third of cases (Gravier-Dumonceau et al. 2022). The clinical course underscores the steroid-responsive nature of the disease, although some patients relapse after initial treatment response (Shan et al. 2018).

CONCLUSION: -Autoimmune GFAP astrocytopathy is a steroid-responsive cause of subacute meningoencephalitis.

-Coexisting neoplasms are common in patients with GFAP astrocytopathy.

A ROCKING DIAGNOSIS

Ryan Geffin¹; Priyen M. Patel¹; Ashley Patel^1,2; Vanessa Medrano²; Purnima Hirudayaraj²

¹Internal Medicine, Baylor College of Medicine, Houston, TX; ²Cardiology, Baylor College of Medicine, Houston, TX. (Control ID #3872461)

CASE: A 52-year-old man with HIV (on Biktarvy) and bicuspid aortic valve status post mechanical aortic valve replacement (AVR) one year prior presented with dyspnea on exertion for one week. Two months ago, he was treated with two weeks of ceftriaxone for Streptococcus equinus (S. equinus) bacteremia without a clear source. During that admission, a transthoracic echocardiogram (TTE) did not show any obvious valvular vegetations and showed a well-seated AVR. He reported overall improvement of his symptoms after being discharged, however, he gradually developed dyspnea on exertion, as well as dizziness which worsened during the past week. On exam, the patient was hemodynamically stable with a wide pulse pressure and a new diastolic murmur. Given recent bacteremia, blood cultures were drawn and were without growth. Repeat TTE identified severe aortic regurgitation (AR) and rocking motion of the prosthetic valve suggesting valve dehiscence. He was admitted to the coronary care unit for closer monitoring and empiric antibiotics were initiated. Transesophageal echocardiogram (TEE) showed prosthetic leaflet vegetations, perivalvular abscess, pseudoaneurysm, valve dehiscence, and severe AR. Ultimately, the patient underwent an uncomplicated bioprosthetic AVR and aortic root reconstruction. Echocardiographic findings were confirmed during surgery.

IMPACT/DISCUSSION: Approximately 3-6% of patients with a prosthetic valve develop infective endocarditis. Culture-negative endocarditis makes up 16-18% of all prosthetic valve endocarditis cases. By some estimates, morbidity and mortality ranges from 20-40% in patients with PVE occurring more than 60 days after valve intervention. Therefore, this is a disease process that requires prompt diagnosis and treatment.

It is unclear why additional workup was not performed during the previous hospitalization for S. equinus bacteremia. Although TTE did not identify endocarditis, the sensitivity of this imaging modality is quite low and an argument can be made that further investigation was warranted. It is possible that if TEE was perfomed at that time, endocarditis might have been diagnosed and he would have been treated for PVE. Interestingly, this patient had negative blood and surgical cultures. We surmise that the negative surgical cultures were a result of one week of antibiotic administration prior to the swab of the mechanical valve. Unfortunately, no biologic tissue was collected and thus no PCR testing was performed. He was treated with six weeks of antibiotics for culture-negative PVE.

CONCLUSION: Culture-negative PVE with extensive complications is exceedingly rare. Recent antibiotic administration likely contributed to the challenge in this case. Although the sensitivity of TTE for diagnosis of endocarditis is low, clinical suspicion for PVE must remain high, with a low threshold for serial TTE and TEE for expedited diagnosis and management of serious complications.

ARTERIES & AIRWAYS - A CASE OF A PSEUDOANEURYSM

Ayesha Khader

Internal Medicine, University of Washington Department of Medicine, Seattle, WA. (Control ID #3877020)

CASE: A 32-year-old otherwise healthy woman presented with one week of left posterior mandibular pain, sore throat, fevers, and chills. Hours prior to admission, she developed rapid swelling of the neck, odynophagia, and dyspnea.

She was afebrile, normotensive, tachycardic, with a respiratory rate of 20 and oxygen saturation of 94% on ambient air. Her exam demonstrated a muffled voice, inability to manage secretions, pain with neck extension and flexion, swelling at the base of the tongue, last molar along the left mandible, and posterior oropharynx. She had submandibular and left neck edema, tenderness, erythema, with symmetric bilateral carotid pulses. Her white blood cell count was 38.8. She received dexamethasone and broad spectrum IV antibiotics. Due to impending airway compromise she was intubated.

CT angiography demonstrated a 2.8cm x2.2cm x1.4cm pseudoaneurysm of the left high cervical internal carotid artery (ICA) with severe narrowing of the native lumen. There was concern for epiglottitis, retropharyngeal phlegmon, and mediastinal cellulitis. Neuro-interventional radiology performed a parent vessel sacrifice with coil embolization of the artery. Blood cultures grew streptococcus pyogenes. Notably there was no evidence of endocarditis on transthoracic echocardiogram.

She was treated with IV vancomycin, cefepime, and metronidazole, narrowed to ceftriaxone and metronidazole, and then narrowed to levofloxacin to complete a four week course. After a month long hospitalization she was discharged home.

IMPACT/DISCUSSION: Osler first used the term "mycotic aneurysm" in 1885 to describe a fungal- appearing infected aneurysm in a patient with bacterial endocarditis. It now refers to dilation of an arterial wall caused by an infection. A mycotic aneurysm can develop due to bacteremia or local spread (if there is pre-existing vessel injury), local injury (e.g. trauma, injection substance use, percutaneous intervention), or septic emboli.

A mycotic aneurysm of an extracranial carotid artery is rare; exact incidence is unknown however between 1980 and 2010 there were approximately 60 cases reported. Medical therapy is associated with in-hospital mortality of 50% and event-free 1-year survival of 32%, therefore definitive surgical intervention is necessary. Symptoms and exam are often non-specific resulting in delayed diagnosis and complications such as rupture, hemorrhage, stroke, or septic shock. This case highlights the importance of early recognition and management of a rare clinical conditon associated with high morbidity and mortality.

CONCLUSION: The differential for oropharyngeal and neck swelling is broad. After appropriate airway management and consideration of deep neck space infections, it is important to consider vascular involvement. Notably, mycotic aneurysms are typically found in the presence of endocarditis, which was not the case for our patient. Clinicians should utilize angiography to evaluate for vascular infections and plan for possible intervention.

A SALTY FINDING: PSEUDOHYPONATREMIA IN A PATIENT WITH MULTIPLE MYELOMA Shreya Bhandari, Kemar Barrett, Aparna Iyer, Fausto G. Lisung, Sofia Terner. Internal Medicine, Englewood Health, Englewood, NJ. (Control ID #3841041)

CASE: A 65-year-old female with a recent diagnosis of Multiple Myeloma (MM) presented after a syncopal episode. She reported an associated 3-day history of diarrhea and productive cough. She denied loss of consciousness, chest pain, dyspnea, hemoptysis, fever, abdominal pain, nausea or vomiting. Vital signs revealed a fever of 101.6 F. Physical exam was unremarkable. Labs showed a Hemoglobin of 7.5 g/dL, Sodium (Na) 122 (136-145 mmol/l), Anion Gap 7 (9-18 mmol/l), Total Protein >13.0 (6.3-8.3 g/dL), Creatinine 1.28 (0.57-1.11 mg/dL), and calculated osmolar gap of 40.0 (7-19 mOsm/kg). Urine Na and osmolality were normal. CT head showed calvarial radiolucencies. CT chest showed no emboli but right lung plasmacytoma and lobar pneumonia. She was started on intravenous 0.9% normal saline infusion for presumed hypovolemic hyponatremia. Serum Na improved to 125 but subsequently fell to 124. Blood cultures and GI pathogen panel were negative. Intravenous fluids were discontinued on day 2 of admission and a trial of fluid restriction was done for possible Syndrome of inappropriate antidiuretic hormone secretion (SIADH). Na levels plateaued at 124 indicating no response to fluid restriction. Further labs revealed Serum IgG of >4,181 (552-1631 mg/dl). She was given regular diet and unrestricted fluid intake. She was discharged on day 5 of admission with a serum Na of 125 to follow-up with Oncology to commence chemotherapy.

IMPACT/DISCUSSION: Hyponatremia is the most common electrolyte imbalance affecting 15-38% of hospitalized patients. It is defined by plasma Na <135 mmol/L. MM is characterized by neoplastic proliferation of plasma cells producing a monoclonal immunoglobulin. Pseudohyponatremia refers to spuriously low serum Na levels, commonly due to high non-aqueous components such as serum proteins. It can occur in patients with MM who have hyperproteinemia (usually >10g/dl), which leads to a reduction in plasma water content and subsequently, a spuriously low serum Na. A low anion gap occurs due to hypergammaglobulinemia, which also decreases the Na level.

We present an elderly female with MM with hyperproteinemia, IgG hypergammaglobulinemia, high osmolar gap and low anion gap - the perfect set-up for pseudohyponatremia. While infective complications such pneumonia are common in MM and can cause SIADH, a well-documented cause of hyponatremia, the lack of response to fluid restriction and normal urine studies were non-diagnostic. The suboptimal response to saline infusion further rules out hypovolemic causes of hyponatremia. A diagnosis of pseudohyponatremia in the setting of MM was therefore made and no further treatments pursued.

CONCLUSION: Hyponatremia is a common electrolyte imbalance with a broad differential diagnosis.

Recognition of pseudohyponatremia is crucial, as the treatment and follow-up differs from “true” hyponatremia. While it does not require treatment, if misdiagnosed, unnecessary treatments with fluid restriction, hypertonic saline or continuous saline infusion may occur.

A SPINDLY REASON FOR A PULMONARY EMBOLISM

Alec Goldberg¹; Jason Chen²; Helen Pope¹

¹Internal Medicine, Tulane University School of Medicine, New Orleans, LA; ²Internal Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #3872315)

CASE: A 36-year-old man with no significant past medical history presented with worsening back pain, shortness of breath, and hemoptysis for several days. The back pain worsened with inspiration and positional changes. He denied smoking, recent travel, sick contacts, or fever. He was afebrile, mildly tachycardic to 114 beats/minute, and hypoxic to 83% on room air. On auscultation there were decreased breath sounds over the right lower lobe. Laboratory tests demonstrated an elevated white blood cell count of 15.6 K/uL and an elevated D-dimer of 0.96 mg/L. Computed tomography angiogram (CTA) of the chest demonstrated a large central pulmonary embolus with smaller emboli within the segmental and subsegmental arterial branches of both lungs. Interventional cardiology was consulted for intrapulmonary tissue plasminogen activator (tPA) administration. Following tPA administration, pulmonary angiography revealed a pulmonary embolism remained in the right main pulmonary artery. He was discharged on rivaroxaban with a planned follow-up CT in one week. Follow-up chest CT revealed worsening of the right main pulmonary embolism. Cardiothoracic surgery was consulted and planned a Trendelenburg operation to remove the presumed pulmonary emboli. During the procedure, multiple firm tumor masses arising from the walls of the pulmonary artery trunk and right pulmonary artery were discovered and resected. Pathology was consistent with spindle cell angiosarcoma of the pulmonary artery and the patient underwent further treatment with adjuvant radiotherapy followed by chemotherapy.

IMPACT/DISCUSSION: Patients presenting with shortness of breath are commonly encountered by general internists. In this case, the clinical picture and diagnostic studies pointed to a diagnosis of pulmonary emboli. Pulmonary artery intimal sarcomas are often mistaken for pulmonary thromboembolism leading to late diagnosis, disease progression, and delayed treatment. Although there is no gold standard for diagnosis, CT scan is usually the standard imaging modality. Comparing the CT images taken eleven days apart, the size of the tumor in the pulmonary artery grew and expanded the lumen despite treatment. Lack of clot resolution was suspicious for another etiology than pulmonary emboli. Additionally, we would expect a distal clot to expand the lumen proximally due to increased pressure rather than diffuse expansion of the vessel lumen. Diagnosis and treatment of this condition is difficult due to the lack of formal guidelines, however early diagnosis is pivotal to maximizing survival.

CONCLUSION: Pulmonary artery intimal sarcomas are extremely rare malignant tumors that are easily misdiagnosed as pulmonary thromboembolic disease.

A STORMING CONSTELLATION OF SYMPTOMS: PULMONARY EMBOLUS AND THYROID STORM

Audrey Y. Lim, Casey N. McQuade

Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #3869473)

CASE: 66-year-old male with history of Grave’s disease, atrial fibrillation (AF), prior COVID-19 infection, active cocaine use, and no current medications presented with shortness of breath, hypoxia, and hemoptysis. He was at his usual state of health until he awoke from sleep with acute left pleuritic chest pain, abdominal pain, and dyspnea. In the ED, HR 150 BPM (EKG showed AF with rapid ventricular response), BP 159/91, RR 26, SpO2 96% on room air. Chest XR showed bilateral perihilar haziness, and a probable density in the left lung base. He was admitted on a diltiazem drip for rate control and ampicillin/sulbactam for presumed bacterial pneumonia. A subsequent CT angiogram showed extensive pulmonary embolism (PE) in the left lower lobe trunk and segmental branches, some nonocclusive thrombus noted in the left upper lobe anterior branch, and no right ventricular strain. Labs showed a troponin peak to 0.09. The patient maintained hemodynamic stability and was diagnosed with an intermediate-high risk PE. Heparin drip was started for anticoagulation. He however demonstrated persistent fevers, tachycardia, and hypoxia over the next day. Thyroid function tests showed TSH suppressed at 0.01, tT4 elevated at 15.8, fT4 elevated at 3.6. He was diagnosed with thyroid storm, with possible inciting events including IV contrast, infection/PE, and recent cocaine use. He was treated with methimazole and hydrocortisone, and demonstrated brisk clinical improvement.

IMPACT/DISCUSSION: Dyspnea, chest pain, and tachycardia are common presenting symptoms, and can result in a wide differential. In this case, the patient had both intermediate-high risk PE and thyroid storm, which can have overlapping presentations. Though heuristic-based, non-analytical Type 1 thinking and slow, analytical Type 2 thinking can both be susceptible to errors, this case specifically demonstrates Type 1 thinking resulting in cognitive biases, and how Type 2 thinking was imperative in challenging them.

CONCLUSION: Cognitive errors are some of the most common causes of diagnostic error. When reasoning through a case, clinicians process information through two modes – Type 1 and Type 2 processes. Type 1 is subconscious, fast, and built through experience (e.g. using illness scripts), though it is prone to error. Type 2 is slower, deliberate, and analytical. Bias-prone Type 1 reasoning was demonstrated at multiple points through this case. The patient was initially diagnosed with bacterial pneumonia given the consolidation on chest XR (premature closure). The subsequent diagnosis of PE resulted in an anchoring bias (reliance on early case information) so that the persistent hypoxia, fevers, and arrhythmia were attributed to the PE. These findings were however out of proportion to his clot burden in the setting of appropriate anticoagulation and did not fit the illness script. Type 2 reasoning was hence important in recognizing discordant data, broadening the differential, and ultimately reaching the final diagnosis.

A TICKY CASE OF THROMBOCYTOPENIA: BABESIOSIS AND BORRELIOSIS CO- INFECTION

Swetha Vontela, Andrea Carter

Medicine, UPMC, Pittsburgh, PA. (Control ID #3876840)

CASE: A 64 year old previously healthy man presented to an outside hospital with 1 week of headache, abdominal pain, and jaundice. The patient reported working outside trimming trees for the past 3 weeks. He had normal vital signs, physical exam was notable for jaundice and splenomegaly, and labs were notable for white blood cell count of 4.2 thousand/uL, hemoglobin 13.4 g/dL, platelet count 19 thousand/uL, total bililirubin 9.0 mg/dL, lactate dehydrogenase 756 IU/L. Peripheral blood smear showed pancytopenia without schistocytes. Lyme IgG and IgM were positive, and the patient was started on doxycycline. Patient was transferred to our hospital due to concern for thrombotic thrombocytopenic purpura.

On arrival to our hospital, re-review of the peripheral blood smear showed intranuclear parasites. Thin and thin blood smear revealed inclusion bodies in 7.6% of red blood cells, indicating a moderately severe babesiosis infection. The patient was started on treatment with atovaquone and azithromycin. On hospital day 3, his jaundice, headache, abdominal pain were significantly improved. Labs showed improving platelet count of 31 thousand and decreasing parasitemia of 3.4%. He was discharged to complete a 14 day course of atovaquone and azithromycin for babesiosis and doxycycline for borreliosis (Lyme disease).

IMPACT/DISCUSSION: The differential for thrombocytopenia includes a wide variety of illnesses, such as infections, medication reactions, idiopathic thrombocytopenia, and hypersplenism. Although not often thought of, clinicians in endemic areas should be aware that thrombocytopenia is a common laboratory finding seen several tick-borne illnesses.

Babesiosis infections are typically due to Babesia microti in North America, and are transmitted by the Ixodes scapularis tick. Endemic geographic areas and incidence have grown over the past decades to include the Midwest, Florida, and the west coast. Borrelia burgdorferi and Babesia microti are both transmitted by the Ixodes tick and share deer and mice as animal reservoirs, and so are likely to be transmitted concomitantly. Current IDSA guidelines do not comment on testing for co-infection of other tick-borne illnesses in the setting of positive Lyme testing; they do encourage testing for other tick-borne illnesses if a diagnosis of Babesiosis or Anaplasmosis is made.

CONCLUSION: All tick-borne illnesses can present with thrombocytopenia and should be included in the work-up of thrombocytopenia, particularly in areas of endemic infection. Clinicians should be aware of the relative incidence of tick-borne illnesses in their area of practice and consider co-testing if patients do not improve clinically with treatment of Lyme disease.

A TIGHT CASE OF CONSTRICTION

Karl Wallenkampf^1,3; David Lambert^1,3; Sudhir K. Jain^2,3

¹Internal Medicine, Washington University in St Louis School of Medicine, St Louis, MO; ²Washington University in St Louis Cardiovascular Division, Saint Louis, MO; ³Barnes-Jewish Hospital, St Louis, MO. (Control ID #3877289)

CASE: A 51 year-old man with OSA, NASH and T2DM presented with one year of anasarca and dyspnea at exertion and later at rest, progressive bilateral leg swelling, fatigue, orthopnea and weight gain of 100 pounds. His symptoms relapsed with courses of diuretics then recurred when stopped. Medications at admission included lisinopril and torsemide. Exam showed pitting edema of his lower extremities and abdomen, decreased breath sounds in the lung bases, distant heart sounds with no friction rub and elevated JVP. His total bilirubin was 1.6 mg/dL, alkaline phosphatase was 148 IU/L, NT-proBNP was 751 pg/mL and CBC was normal. X-ray showed bilateral pleural effusions and no cardiomegaly. ECG notable for normal axis, markedly reduced voltage, and no ST segment changes. TTE revealed septal bounce, a dilated IVC, annulus paradoxus and a decreased LVOT VTI with normal EF. CT showed marked thickening of the pericardium sparing the ventricular apices with no pericardial calcification or effusion. LHC showed elevated LV pressures with no gradient across the aortic valve and non-obstructive CAD. Right heart hemodynamics showed elevated right-sided pressures which did not change on deep inspiration, pulmonary hypertension, and elevated pulmonary artery wedge pressure. A wave and V waves were elevated. Constrictive pericarditis was diagnosed, diuresis was optimized and he underwent radical pericardiectomy. On 2-month follow-up symptoms are resolving and he has returned to work.

IMPACT/DISCUSSION: The case illustrates the diagnostic approach to constrictive pericarditis, a less

common cause of heart failure in a patient with risk factors for ischemic disease. However, it must be considered in patients with recurrent heart failure symptoms, especially in those with a history of pericarditis, radiation therapy, or cardiac surgery. The case highlights common exam and laboratory findings, including low-voltage on the ECG and mild elevation of NT-proBNP. His TTE showed several features, including annulus paradoxus (E/E’ inversely correlated with LV filling pressures) and exaggerated ventricular respiratory interdependence. The case also required imaging to determine pericardial thickness. His catheterization highlights the abnormal pericardial compliance in constrictive pericarditis, meeting five of six criteria proposed by Talreja et al (2008): nearly matched LVEDP and RVEDP, elevated RVEDP compared to RVSP, only small inspiratory decrease in RAP, high systolic area index; and high LV height of rapid filling wave. Also, while surgery was performed as definitive therapy, in this case sodium restriction and diuretics remained a mainstay of his treatment.

CONCLUSION: The case highlights an uncommon diagnosis in a patient with ischemic risk factors Exam, labs, imaging, and catheterization iteratively revealed classic findings.

While constrictive pericarditis and restrictive cardiomyopathy present similarly, this case highlights constrictive physiology

A TROJAN HORSE: RECOGNIZING A RETROPERITONEAL LYMPHOMA DISGUISED AS BENIGN LEG SWELLING

Cedric Mutebi, Dana Kabbani

Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #3875386)

CASE: A 60-year-old woman with a past medical history of mitral valve prolapse presented to her primary care physician for persistent bilateral lower extremity edema that started one month prior to presentation. Review of symptoms was pertinent for mild decreased urine output and abdominal discomfort, but otherwise negative and physical exam was significant for bilateral lower extremity edema up to knees. Work-up including a CBC, CMP, chest x-ray, heart ultrasound were normal and bilateral lower extremity ultrasound for DVT was negative. CT abdomen/pelvis with contrast was obtained and revealed a large homogenous enhancing conglomerate mass measuring 8.3x13x11.6cm in the retroperitoneum with enlarged proximal lymph nodes suggestive of a lymphoma. There was a significant mass effect on the inferior vena cava and renal collecting system causing lower abdominal edema and right kidney atrophy. Ultrasound guided biopsy was significant for low-grade follicular lymphoma; the patient followed up with hematology and started treatment with Rituxan and Bendamustine. On follow up, the patient is doing well and has reported improvement of bilateral lower extremity edema and abdominal discomfort.

IMPACT/DISCUSSION: Unilateral lower extremity edema as the initial symptom of lymphoma is a rare presentation and has rarely been reported in literature. This initial presentation has been reported in women without B-symptoms, and is associated with inguinal lymphadenopathies or abdominal masses. To date, no cases have been reported of bilateral lower extremity edema as an initial presentation of lymphoma.

This case highlights the significance of recognizing that lymphedema may be the first presentation of lymphoma. This patient’s lymphedema presentation secondary to mass effect is not typical in that most mass- effect is a late presentation. The proximity of the mass to the lymphatic system resulted in this patient’s bilateral lower extremity edema, which led to an early diagnosis. Although a rare presentation of bilateral lower extremity edema, clinicians must keep lymphoma on the list of differentials when working up a patient while correlating other symptoms clinically.

CONCLUSION: - Bilateral lymphedema can be the initial presentation of retroperitoneal follicular lymphoma.

- Clinicians should have suspicion for retroperitoneal sources of leg swelling when more common etiologies of leg swelling are ruled out.

- Follicular lymphoma can commonly present without B symptoms.

A TROUBLESOME CASE OF M-POX VIRUS (MPXV) IN A FEMALE WITHOUT TYPICAL RISK FACTORS

Sergio A. Vallejo Avila^1,2; Justin T. Dunn²; Ribesh Shrestha²

¹Internal Medicine, The University of Texas Health Science Center at San Antonio Joe R and Teresa Lozano Long School of Medicine, San Antonio, TX; ²Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX. (Control ID #3875086)

CASE: A 28-year-old female with no medical history presented with five days of progressively worsening pain, erythema, and swelling behind her right ear and on her left arm. She received a new tattoo on her left upper arm in the weeks prior to symptom onset. She was initially treated with an oral antibiotic, but the rash continued to progress over the ensuing days. Following initiation of intravenous antibiotics, the lesions became vesicular and the right cervicofacial soft tissue became progressively indurated. Imaging did not demonstrate any evidence of abscesses or necrotizing infection; however,extensive localized lymphadenopathy was identified. Antimicrobial therapy was broadened to include broad-spectrum antibiotic, antiviral, and antifungal coverage, however the lesions continued to progress. The initial vesicular lesions became pustular and umbilicated, and similar lesions developed on the patient’s trunk and extremities. Testing for HIV was negative. Histologic samples from the lesions were consistent with MPXV, which was confirmed by polymerase chain reaction. Patient has since been initiated on Tecovirimat, and she has had slow recovery to date. The source of infection has yet to be identified, however the timeline of symptom development and lack of additional risk factors suggest that the patient’s inoculation may have occurred via tattoo placement.

IMPACT/DISCUSSION: MPXV is a disease resembling smallpox. In the prodromal phase, fever, headache, fatigue, and lymphadenopathy will develop, lasting several days. The skin lesions will then erupt and progress from macules to papules to vesicles and then to pustules. The lesions are often firm, umbilicated, pruritic, and are characteristically in the same stage of development. Finally, the lesions will crust over and desquamate, and may leave behind areas of scarring and hypopigmentation. The rise in MPXV incidence is thought to be largely related to the waning herd immunity to poxvirus following the cessation of smallpox vaccination after 1980. HIV coinfection could also contribute to the rise in MPXV, as MPXV has been shown to have more severe outcomes in immunocompromised patients. Recent epidemiologic studies have shown that the majority of affected patients are male, with disproportionally high rates in men who have sex with men and in HIV-positive individuals. Transmission usually occurs through direct contact of biologic fluids or with infected skin lesions, though other sources of transmission have been identified in the literature, including via tattoo placement.

CONCLUSION: Given the variability of presentations and increasing incidence globally, clinicians should have a low threshold for suspicion of MPXV, even in low-risk populations, particularly when clinical improvement doesn’t occur with treatment for alternative pathologies

ATYPICAL BACK AND HIP PAIN: A CASE REPORT OF RETROPERITONEAL LEIOMYOSARCOMA

Nehal Galal

Internal Medicine, Columbia University, New York, NY. (Control ID #3867483)

CASE: 48 year old female with past medical history of uterine fibroids presented with chief complaint of chronic right hip and lower back pain for more than 1 year. Patient described pain as “severe”. Patient previously completed remedies including physical therapy and injections without relief of pain. Patient has a family history of CLL in mother. She denied toxic habits and uses OTC pain relievers. Prior imaging completed to evaluate symptoms included X-ray of hips and pelvis which showed degenerative changes of the sacroiliac joints, MRI abdomen w/wo contrast showing right hepatic hemangioma, US pelvis showing myomatous uterus. On examination, there was no spinal or CVA tenderness. A 3-5 cm non-tender mass was palpated in right upper quadrant of abdomen. Patient was referred for abdomen US which showed a “solid right lower quadrant mass accounts for patient's palpable finding, possibly pedunculated leiomyoma”. MRI abdomen and pelvis w/wo contrast was ordered and showed a “5.5 cm tri-lobed solid mass of the right hemiabdomen, inferior to the right kidney, exerting slight mass effect upon the IVC, and abutting small- bowel.” Patient was referred for surgical consultation and completed IR guided biopsy of retroperitoneal mass which revealed leiomyosarcoma. Patient underwent surgical resection of mass and follow-up imaging has shown no signs of local tumor recurrence or metastatic disease to date.

IMPACT/DISCUSSION: Retroperitoneal soft tissue sarcomas are rare, accounting for 0.1-0.2% of all malignancies (1). Retroperitoneal leiomyosarcoma (RLS) is the second most common type of retroperitoneal sarcoma (2). Diagnosis of RLS can be delayed because symptoms often present late when the tumor grows and infiltrates or compresses on surrounding structures. Review of literature suggests that RLS can be asymptomatic and may present with vague symptoms such as neurologic symptoms in lower extremity and pain. An abdominal mass can be palpated in most cases (2-3). I present a case of RLS presenting with back and hip pain and a palpable abdominal mass. The case highlights the importance of physical examination and maintaining a high index of suspicion for secondary disease processes when examining common musculoskeletal symptoms.

CONCLUSION: Retroperitoneal tumors are rare. Sarcomas represent a third of retroperitoneal tumors and retroperitoneal leiomyosarcoma (RLS) is the second most common type (2-3). Diagnosis of RLS can be challenging and delayed until tumors grow to a significant size. This case describes the subtle symptoms of retroperitoneal masses and emphasizes the importance of a physical exam.

ATYPICAL FINDINGS OF REACTIVE ARTHRITIS IN THE SETTING OF RECENT COVID 19

INFECTION

Saman Razzaq¹; Jambunathan Ramanathan²; Ahmed Raza³

¹Internal Medicine, Wayne State University School of Medicine, Detroit, MI; ²John D Dingell VA Medical Center, Detroit, MI; ³Internal Medicine, University of Vermont Medical Center, Burlington, VT. (Control ID #3877356)

CASE: A 31-year-old man with past medical history of COVID-19 infection two months ago presented with fever, fatigue, and pain of finger joints for one week along with a pruritic rash over the lips, penis, and inner thighs for two weeks. He initially noted discomfort and numbness of both hands and subsequently developed painful, stiff and swollen joints of both hands. Family history is significant for systemic lupus erythematosus (SLE) in his mother. On exam, he had fever, tachycardia, scleral icterus, a systolic ejection murmur at the left sternal border and apex, and swelling of finger joints of both hands. Erythematous, circumferential plaques and a desquamating rash was noted on the penile shaft and scrotum consistent with circinate balanitis. Desquamation was also noted along the inguinal folds. Labs demonstrated leukocytosis with neutrophilic predominance, elevated transaminases, hyperbilirubinemia, and elevated inflammatory markers (ESR and CRP). We started empiric antibiotics to treat suspected infective endocarditis, however, this led to no improvement in symptoms, therefore antibiotics were discontinued. Blood cultures, hepatitis panel, HIV, syphilis, rheumatoid factor, anti-cyclic citrullinated peptide antibody, antinuclear antibody (ANA), anti smooth muscle antibody (ASMA) were negative. Clinical picture was supportive of possible post-infectious reactive arthritis therefore we started prednisone, which resulted in marked improvement of his symptoms within 24 hours. Trigger for reactive arthritis was thought to be COVID-19 infection given that chlamydia and gonorrhea PCR testing was negative and patient did not have a history of recent gastroenteritis.

IMPACT/DISCUSSION: We present a case of a 31-year-old male with fever, fatigue, and joint pain two months after having COVID-19 infection. Through diagnostic testing, physical findings, and a thorough review of his medical records, it was determined that he was experiencing COVID-related reactive arthritis.

CONCLUSION: The unique diagnostic challenge of this case involved identifying the underlying etiology in the setting of clinical findings such as systolic ejection murmur, neutrophilia, sclera icterus, LFT elevation which was nonspecific for the reactive arthritis. This case highlighted the importance of history and thorough physical examination in the diagnostic process.

ATYPICAL HEMOLYTIC UREMIC SYNDROME ASSOCIATED WITH LUPUS NEPHRITIS Pauline H. Lin¹; Neha Syed¹; Suliman Alradawi²; Bassem Chaar³

¹Internal Medicine Residency, Advocate Christ Medical Center, Oak Lawn, IL; ²Rheumatology, Advocate Christ Medical Center, Oak Lawn, IL; ³Hematology-Oncology, Advocate Christ Medical Center, Oak Lawn, IL. (Control ID #3877207)

CASE: A 19-year-old male with no significant medical history presented with worsening shortness of breath over the past 2 months. This was accompanied by bilateral lower extremity swelling and orthopnea. He does not have any significant surgical, social, or family history. On admission, he was markedly hypertensive. Physical examination was notable for bilateral lower extremity pitting edema and skin rash. Laboratory results showed microcytic anemia, thrombocytopenia, increased BNP, increased serum creatinine, and significant proteinuria. Reticulocyte count and LDH were increased, and haptoglobin was low. DAT was negative. Schistocytes were noted on the peripheral blood smear. Transthoracic echocardiography showed reduced left ventricular systolic function and large pericardial effusion, requiring pericardiocentesis. He was started on diuretics, antihypertensive, and dialysis. Given the multiorgan involvement and evidence of microangiopathic hemolysis, thrombocytopenic thrombotic purpura (TTP) was considered. Kidney biopsy, autoimmune workup, and ADAMTS 13 testing were done. Plasmapheresis was initiated with an initial improvement in hemolysis. Further results revealed a positive dsDNA and ANA with significant titer. Kidney biopsy noted Class IV lupus nephritis and the pathologist could not exclude thrombotic microangiopathic changes. ADAMTS13 resulted at 58%, ruling out TTP. Hence, he was diagnosed with atypical hemolytic uremic syndrome (aHUS). Plasmapheresis was discontinued and Eculizumab was started. He was also started on pulse-dose steroids, mycophenolate mofetil, and hydroxychloroquine for SLE. Haptoglobin levels markedly improved after two doses of eculizumab. Patient’s renal function continued to improve, and dialysis was discontinued. He was eventually discharged home.

IMPACT/DISCUSSION: Lupus nephritis has been increasingly implicated as a trigger for thrombotic microangiopathies (TMA). aHUS is a rare complement-mediated TMA causing dysregulation of the alternative complement pathway characterized by hemolysis, thrombocytopenia, renal impairment, and preserved ADAMTS13 function. We described a case of aHUS in lupus nephritis that showed partial response to plasmapheresis and a notable response after starting Eculizumab. Eculizumab is a monoclonal antibody inhibitor of C5 activation and has shown significant improvement in patients with TMA. Early recognition of lupus nephritis and TMA is vital for prompt management given that early initiation of eculizumab therapy with immunosuppressive treatment has shown notable response in this patient. He continues this therapy on an outpatient basis with continued improvement in his condition and laboratory parameters.

CONCLUSION: Lupus nephritis complicated by aHUS is a life-threatening illness, and a high level of suspicion with rapid initiation of treatment is vital for a better patient outcome. Eculizumab therapy in addition to immunosuppressive treatment signifies a paradigm shift for patients with lupus nephritis- associated TMA.

ATYPICAL PRESENTATION OF MYCOBACTERIUM KANSASII - MISDIAGNOSED AS TREATMENT RESISTANT PSORIATRIC ARTHRITIS

Charu D. Bajracharya, Pooja Jaisawal, Suchetha Jagan, Sravan K. Ponnekanti

Internal Medicine, Guthrie Healthcare System, Sayre, PA. (Control ID #3874069)

CASE: 62-year-old male with a past medical history of Mycobacterium chelonia of his left middle finger, presented to rheumatology clinic with concern for progressively worsening right index finger swelling, extending to his wrist and forearm. No prior history of trauma or injuries. Patient worked at a sewage plant; owned a fish tank that he cleans without proper protection. Initial encounter with orthopedics, resulted in incision and drainage for possible abscess; results were negative for organisms on gram stain and culture. A short course of antibiotics and steroids were ineffective. Patient continued to have pain and swelling of right index finger with progression to the middle finger. MRI of hand noted synovial thickening of the second MCP joint compatible with synovitis without erosions; synovial thickening of the flexor tension sheaths of the second and third digits resulting in tenosynovitis. Rheumatology workup for arthritis unresponsive to steroids resulted in negative results for autoimmune arthritis or vasculitis. The patient was diagnosed with suspected psoriatic arthritis with tenosynovitis and started on Hydroxychloroquine, later switched to methotrexate and then to Adalimumab and Aprelimast due to side effects and ineffectiveness. The patient continued to have pain and swelling of his fingers with progression to his wrist. He underwent flexor Teno synovectomy with incision and drainage of numerous rice bodies. The pathology report noted fragments of synovium-lined tissue with necrosis and chronic inflammation consistent with chronic synovitis. Culture grew Mycobacterium kansasii; negative for Mycobacterium tuberculosis and Mycobacterium avium complex. The patient was referred to infectious disease clinic and was started on Ethambutol, Rifampin and azithromycin for 9 months with the resolution of his ling and symptoms.

IMPACT/DISCUSSION: NTM tenosynovitis is a rare clinical condition most often misdiagnosed as inflammatory arthritis leading to delayed diagnosis and structural impairment. We report a case of an immunocompetent individual with chronic swelling of his right index finger with progression to his right middle finger and wrist. Teno synovectomy noted several rice bodies, and biopsy grew Mycobacterium kansasii. Patient was treated with ethambutol, azithromycin and Rifampin for 9 months. Delayed diagnosis unfortunately resulted in limited range of motion of his right middle finger and wrist, compromising his quality of life.

CONCLUSION: Chronic tenosynovitis secondary to Mycobacterium Kansasii is uncommon with symptoms often overlapping with inflammatory arthritis and septic arthritis. NTM infections seldom occur in immunocompetent individuals, with lung involvement as the primary site. M. kansasii cutaneous lesions usually present as nodules, plaques, ulcers, abscesses and pustules. This case demonstrates considering broad diagnosis and consulting specific specialties earlier for better clinical outcomes, patient satisfaction and improved quality of life.

A UNIQUE CASE OF AUTOIMMUNE HEPATITIS PRESENTING AFTER A 5-DAY COURSE OF NITROFURANTOIN FOR UNCOMPLICATED URINARY TRACT INFECTION.

Ammad J. Chaudhary¹; Ali Rahim¹; Muhammad Zarrar Khan²; Eric Denha¹; Adrian Michel³

¹Internal Medicine, Henry Ford Health System, Detroit, MI; ²Gastroenterology, Henry Ford Health System, Detroit, MI; ³Internal Medicine, BHSH Beaumont Health, Royal Oak, MI. (Control ID #3877044)

CASE: An 84-year-old African American woman with a history of type 2 diabetes mellitus presented with postprandial right upper quadrant sharp shooting abdominal pain with associated nausea and vomiting. She reported taking nitrofurantoin 100 mg tablets twice daily for five days for a recent UTI. Denied taking herbal remedies or unprescribed supplements. Never smoked or drank excessive alcohol. Initial blood tests revealed elevated liver biochemistry with bilirubin 7.6 mg/dL, alanine transaminase 343 IU/L, aspartate aminotransferase 261 IU/L, and alkaline phosphatase 135 U/L. Her coagulation screen, full blood count, electrolytes, and renal function were normal. Viral hepatitis profile was negative. Toxicology labs were negative for acetylsalicylic acid (ASA), acetaminophen, and alcohol. Abdominal imaging was unremarkable. Immunological tests revealed positive smooth muscle antibodies with a titer of 95 units: normal IgA and IgG levels and low IgM. Double-stranded DNA antibodies, anti-mitochondrial antibodies, and anti-microsomal antibodies were not detected. A liver biopsy was performed which showed acute hepatitis with moderate necroinflammatory activity consistent with AIH and drug-induced liver injury (DILI).

IMPACT/DISCUSSION: Several viruses and drugs have been reported to have caused autoimmune liver disease. One of the drugs is nitrofurantoin which is commonly prescribed due to its low cost, high efficacy, and minimal antimicrobial resistance.

Acute liver injury from nitrofurantoin has a prevalence of ~0.3/100,000 prescriptions, while chronic nitrofurantoin liver injury is estimated to be one in 1500. AIH is more common in females than males, with a ratio of 3.6:1.

Acute hepatotoxicity is drug-induced liver injury immediately after exposure; chronic nitrofurantoin use is associated with chronic AIH. Our case is unique as the patient developed AIH three weeks after a 5-day course of nitrofurantoin for an uncomplicated UTI. The patient never had elevated liver function tests, a negative viral hepatitis profile, and any history of autoimmune disease or alcohol abuse. Our case was not a DILI, as these usually occur immediately after exposure or when the patient is actively taking the medication.

We hypothesize that nitrofurantoin is associated with the development of AIH and the formation of antibodies (in our case, anti-smooth muscle antibodies). It may not only be a dose-related immune response that needs months of constant exposure to be evident; it might be related to nitrofurantoin acting as an antigen, possibly an idiosyncratic reaction.

Treatment with steroids improved the LFT and symptoms within days which is also evidence in favor of AIH.

CONCLUSION: In patients with recently treated UTI with nitrofurantoin who presents with acute elevation of LFTs within a few weeks, always take into consideration nitrofurantoin-induced AIH. Moreover, treatment with steroids should begin if the antibodies come out positive.

A UNIQUE PRESENTATION OF ACUTE DYSPHAGIA DUE TO ESOPHAGEAL CANDIDIASIS IN A NON-HIV PATIENT

Sadia A. Tanami²; Nandini Ray¹; Anjali Rani Roy²; Waqas Rasheed²; Tarek Naguib²

¹Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; ²Internal Medicine, Texas Tech University Health Sciences Center - Amarillo, Amarillo, TX. (Control ID #3874947)

CASE: An 87-year-old male with a medical history of type 2 diabetes mellitus, hypertension, and adrenal insufficiency developed difficulty swallowing abruptly on day 30 of his hospital stay. He initially presented for sepsis with septic shock due to a sacral decubitus ulcer and acute hypoxic respiratory failure secondary to pleural effusion. At that time, the patient received parenteral antibiotics, and a proton pump inhibitor (PPI) and underwent surgical debridement and thoracentesis. The patient was stabilized, and before discharge to the skilled nursing unit (SNU) he started coughing, choking, and developed dysphagia without chest or abdominal pain. A chest CT scan with contrast was done due to multiple failures to insert a feeding tube which showed a dilated esophagus with retention of food material. Esophagogastroduodenoscopy showed severe esophageal candidiasis (EC) extending from the proximal esophagus all the way to the gastroesophageal junction without strictures or other lesions. The lack of corticosteroid exposure and negative HIV screening laboratory results made antibiotic therapy and PPI the likely culprit. Despite the initial improvement on oral fluconazole, the patient again developed dysphagia four days following this diagnosis. Due to cultures or sensitivities of the lesion was not taken, fluconazole was changed to intravenous micafungin to expand the anti-candida spectrum leading him to tolerate a regular diet without any further episodes of dysphagia. The patient was discharged to the SNU with a 14-day course of micafungin.

IMPACT/DISCUSSION: EC is a common cause of infectious esophagitis. EC is increasingly seen in patients without HIV, due to increased use of PPI, broad-spectrum antibiotics, inhaled steroids, or immunosuppressant use, increase incidence of diabetes mellitus, and an aging population. Several studies have shown that antibiotic use may lead to the development of EC potentially due to the broad elimination of certain bacteria that inhibit fungal growth, thereby allowing for Candida overgrowth. The relationship between PPI and the development of EC is obscured, but PPI-induced elimination of the gastric barrier is a major mechanism to lead to Candida colonization in the esophagus. Our patient is unique in the fact that EC caused mechanical obstruction against feeding tube placement. Physicians need to be aware of the side effects of these drugs and prompt discontinuation of medicine is necessary when no longer indicated.

CONCLUSION: EC is a common and challenging infection of the esophagus, especially in patients with decreased immune function and those using broad-spectrum antibiotics and acid-lowering agents. In addition to stricture and mass obstruction, failure to place a feeding tube in these patients can be merely due to severe EC that should be investigated by endoscopy.

A UNIQUE PRESENTATION OF SEVERE B12 DEFICIENCY

Jasmin Hundal, Victoria Forbes, Enrique Ballesteros

UConn Health, Farmington, CT. (Control ID #3873678)

CASE: A 55-year-old Asian male with no significant medical history presented to the emergency department with three months of worsening generalized weakness, fatigue, and dyspnea on exertion.He ate one meal a day consisting of rice, vegetables and fish.On admission,he was afebrile and normotensive. Laboratory workup was significant for hemoglobin of 5.7 g/dL,hematocrit 16.7%,mean corpuscular volume 125.6 fL,white blood cell count 4 x 10*3/uL and platelet count of 149 x 10*3/uL.His basic metabolic panel was within the normal range.His liver function tests demonstrated AST of 120,ALT 80,alkaline phosphatase 47,total bilirubin 1.8, and direct bilirubin 0.6.Prothrombin time was 14 seconds and partial thromboplastin time was 23.6. seconds with an INR of 1.2. Peripheral smear demonstrated marked anisocytosis, hypersegmented neutrophils and macro-ovalocytes.Vitamin B 12 was <148 pg/mL and folate was 14.2 ng/mL. Iron panel demonstrated iron of 159 mg/ml,iron-binding capacity of 217 ug/dL, and ferritin of 494 ng/ml.Haptoglobin was <8 mg/dL and LDH was 5027 U/L.Reticulocyte count was 2.5 %, and fibrinogen was 187.The patient was provided one unit of packed red blood cells.His PLASMIC score was intermediate with no renal failure making this case unlikely to represent TTP.His reticulocyte index was 0.5, consistent with hypoproliferation and an inadequate response to his anemia.Methylmalonic acid was 24.71 umol/mL and homocysteine was 158 μmol/L.Intrinsic factor was positive and gastric parietal cell antibody was 61.9.Treatment was started on daily B12 1000 mcg injections for one week, followed by weekly injections. He was advised to follow up with Hematology/Oncology as an outpatient. His macrocytic anemia improved with hemoglobin of 13 and hematocrit of 39.7.He was advised to follow up with Gastroenterology given that pernicious anemia increases the risk of developing gastric malignancies.

IMPACT/DISCUSSION: Vitamin B12 is an essential co-factor in metabolic pathways of hematological and neurological function.Acute presentation of severe vitamin B12 deficiencies can mimic features of acute myeloid leukemia and thrombotic thrombocytopenic purpura (TTP).Thrombocytopenia, anemia,high lactate dehydrogenase,indirect bilirubin,and low haptoglobin raised concerns for hemolytic anemia. His PLASMIC score was intermediate with no renal failure making this case unlikely to represent TTP.His reticulocyte index was 0.5, consistent with hypoproliferation and an inadequate response to his anemia.However, vitamin B12 levels were obtained on admission and demonstrated deficiency leading to a diagnosis of pseudo-thrombotic microangiopathy early in his course.

CONCLUSION: This case illustrates the need to rule out hematologic emergencies and pursue a full workup for cytopenias, including vitamin B12 levels. Obtaining B12 levels can confirm a more benign diagnosis, avoid further unnecessary workup such as a bone marrow biopsy, and allow clinicians to initiate treatment in a timely fashion.

AUTOIMMUNE DISEASE UNMASKED: HYPERVISCOSITY SYNDROME WITH CONCURRENT ACQUIRED VONWILLEBRAND DISEASE AS THE INITIAL PRESENTATION OF SYSTEMIC LUPUS ERYTHEMATOSUS

Wei Tang¹; Makeda Dawkins²; Vincent Prawoko¹

¹Medicine, Westchester Medical Center, Valhalla, NY; ²Internal Medicine, Westchester Medical Center, Valhalla, NY. (Control ID #3875764)

CASE: A 43-year-old Hispanic man with no past medical history presented with recurrent gingival bleeding and epistaxis, with six prior emergency room visits. He also reported left-sided headaches and blurry vision. Review of systems was negative for musculoskeletal or mucocutaneous symptoms. He denied any family history of hematologic or autoimmune disorders. Vital signs were normal, and physical exam was notable for dried blood in the bilateral nares and gingiva. Fundoscopic examination showed bilateral retinal vein occlusions with intraretinal hemorrhages and vascular engorgement. Labs showed mild anemia and leukocytopenia; a peripheral smear was consequently obtained after multiple errors to process serum samples and revealed Rouleaux formation. Serum viscosity was elevated to 9.62, establishing a diagnosis of HVS. Aggressive fluid resuscitation was initiated. Further evaluation revealed vWF Ag of 19, vWF RCP of 40%, and normal Factor VIII level consistent with acquired von Willebrand Disease (vWD). Bone marrow biopsy was unrevealing. Continued evaluation revealed IgG hypergammaglobulinemia, elevated anti- dsDNA antibody, hypocomplementemia, and positive ANA, meeting SLICC, not ACR criteria for SLE. His concurrently elevated RF and anti-CCP antibodies were insufficient for a diagnosis of RA in the absence of musculoskeletal manifestations. Pulse dose dexamethasone and rituximab were initiated, with the latter discontinued due to delayed serum sickness and replaced with cyclophosphamide. His HVS was attributed to high levels of circulating autoantibodies as a rare presentation of SLE and likely the etiology of his acquired vWD.

IMPACT/DISCUSSION: This case explicitly highlights HVS and aVWD as the initial presentation of underlying SLE, with only three prior cases reported in the literature. Although IgG elevations are commonly seen in connective tissue disorders, it remains unclear if this patient’s hypergammaglobulinemia is attributed to SLE alone, although both can be treated with rituximab, cyclophosphamide, and aphaeresis. This case emphasizes the importance of including autoimmune disorders in initial differential diagnoses for HVS, with serologies ideally collected prior to aphaeresis, as hemotherapy may cofound the autoantibody profile. This presentation also highlights differences in sensitivity and specificity between SLICC and ACR diagnostic criteria for SLE, as our patient only met SLICC criteria, consistent with prior reports of limited ACR criteria utility in Hispanic and African American patients.

CONCLUSION: 1. Hyperviscosity Syndrome and acquired von WilleBrand Disease can be the initial presentation of SLE, albeit rare.

2. It is advisable to include autoimmune disorders in initial differential diagnoses for hyperviscosity syndrome.

3. SLICC criteria is more sensitive and specific than ACR criteria for diagnosing SLE among Hispanic patients.

AUTOIMMUNE HEMOLYTIC ANEMIA IN AN ADULT WITH COMMON VARIABLE IMMUNODEFICIENCY

Pinguang Yang, Toluwalashe Davies

Internal Medicine, University of Rochester Medical Center, Rochester, NY. (Control ID #3852181)

CASE: A 23-year-old male with recent history of leukopenia and thrombocytopenia presented with 2 weeks of jaundice, fatigue and exertional dyspnea, and he was found to have autoimmune hemolytic anemia (AIHA) as DAT IgG were positive. For initial cytopenias workup seven months ago, he was referred to hematology and oncology with concern for intrinsic bone marrow disorder. Bone marrow biopsy was unrevealing. An autoimmune disorder was suspected however the workup was unremarkable. Patient had splenomegaly detected by ultrasound, raising concern for lymphoma. PET/CT showed FDG avid retroperitoneal lymphadenopathy along with splenomegaly, and it supported the hypothesis of Non-Hodgkin Lymphoma, especially in the setting of newly diagnosed AIHA. Lymph node biopsy was undertaken but negative for malignancy. Further infectious and immunological workup revealed hypogammaglobulinemia (low IgG/IgA and normal IgM/IgE). CD3 and CD19 lymphocyte counts were normal. He had only 2 out of 23 protective pneumococcal IgG titers. He was challenged with pneumococcal polysaccharide 23-valent vaccine and only responded to 4 out of 11 serotypes unique to unconjugated ones, demonstrating poor response to immunization. Furthermore, genetic testing identified variants of uncertain significance in the immune- regulatory gene, IRBA (lipopolysaccharide response beige like anchor protein), a finding associated with common variable immunodeficiency (CVID).

IMPACT/DISCUSSION: Immunodeficiency disorders were not on the initial differentials for cytopenias in this patient. Newly diagnosis of AIHA in the setting of FDG-avid lymphadenopathy and splenomegaly made the differential diagnosis of underlying B cell lymphoma most likely. After malignancy was ruled out, further investigations were pursued and the clinical picture of CVID became clear. CVID is a primary immunodeficiency disorder caused by impaired B cell differentiation into plasma cells resulting in impaired antibody production. Patients with CVID often have recurrent infections, however CVID can present with autoimmune disorders. 24-30% of CVID patients have autoimmune conditions, and autoimmune hematologic disorders are the most common and might explain his previous cytopenias. Autoimmune cytopenias are likely to be associated with other non-infectious CVID related conditions. It is puzzling that patients with CVID have profound hypogammaglobulinemia and yet are still capable of producing anti-red blood cell or platelets antibodies. Our case shows IRBA deficiency could partially explain this mystery in CVID as LRBA plays an important role in immune regulation. We further demonstrate the importance of considering CVID in the differential diagnosis for cytopenias even in the absence of recurrent infections history.

CONCLUSION: 1. CVID should be included in the differential diagnosis for AIHA in young patients with history of cytopenias.

2. CVID is associated with immune dysregulation leading to autoimmune disorders, which can be the presenting manifestations.

BACK TO THE BASICS - THE IMPORTANCE OF HISTORY TAKING OUTLINED IN A SEVERE CASE OF BABESIOSIS

Erik X. Tan, Lindsay G. Goldblatt, Nicholas D. Martin

Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA. (Control ID #3855901)

CASE: A 63-year-old male with a past medical history notable for recent COVID infection (two months prior) presented with fevers, chills, and body aches. Initially, he was treated with antibiotics for a presumed dental infection. He re-presented three days later with persistent symptoms and new onset diarrhea. Vital signs were notable for a fever, hypotension, and hypoxemia. Labs showed elevated creatinine and transaminases, hyponatremia, and thrombocytopenia. He was started on broad-spectrum antibiotics, and an infectious workup was sent. He continued to decompensate, but further history elicited from family noted a deer tick removed from the patient two weeks prior. Peripheral blood smear then showed Babesia with 1.1% parasitemia. Although the patient was started on azithromycin and atovaquone, he clinically worsened, and subsequent blood smears showed parasitemia levels with a peak at 5.4%. He was transitioned to clindamycin and quinidine, however, he had persistently worsening thrombocytopenia, acute kidney injury, and altered mental status requiring transfer to a tertiary care center, where he was quickly intubated and found to be in four-pressor shock. Urgent exchange transfusion was performed with clinical improvement within a 24-hour period. Though his course consisted of further complications, including renal failure, he was discharged after a month with renal recovery.

IMPACT/DISCUSSION: This is a unique case of severe Babesiosis leading to refractory septic shock in the setting of relatively low parasitemia in an otherwise immunocompetent patient. Prior literature for immunocompetent patients often note septic shock in patients with much higher parasitemia levels. It is possible that our patient had underlying immunosuppression as his COVID test remained positive over two months after initial diagnosis. Given that not all hospitals have the ability to perform red blood cell exchange transfusions, it is essential to consider early transfer to a facility with these capabilities in severe cases or for those who continue to deteriorate despite appropriate antimicrobial therapy.

Another notable learning point from this case is a reminder to take thorough histories even when time-limited and checking for biases throughout a case. Here, anchoring bias, availability bias, and premature closure may all have contributed to the initial treatment of our patient, and ultimately played a role in delay of care. The unprompted mention of a tick provided the clue that quickly altered the course of his care and prompted urgent transfer for an exchange transfusion and reversal of his rapidly deteriorating condition.

CONCLUSION: - Babesiosis can cause refractory septic shock even at low parasitemia levels in immunocompetent patients. Exchange transfusion can quickly reverse clinical course, so early consideration may prevent further complications.

- Biases can easily drive clinical reasoning and management, so they should be considered during unexpected clinical courses.

BARTONELLA ENDOCARDITIS MISDIAGNOSED AS ANTI-PHOSPHOLIPID SYNDROME PRESENTING AS RECURRENT CEREBROVASCULAR ACCIDENTS

Shawn Wen, Abraham Z. Cheloff, Caitlin Driscoll

NYU Langone Health, New York, NY. (Control ID #3875025)

CASE: A 28-year-old Nicaraguan male with a history of bioprosthetic mitral valve (pathology showing myxomatous changes) presented with acute left arm weakness. 6 months prior, he presented to another hospital with syncope and fever and was found to have an acute right temporal infarct. Beta 2 glycoprotein was positive (IgM >150, IgG 137, normal < 20). He was discharged on warfarin for presumed APLS.

On arrival, the patient was febrile to 102.5 degrees F. He had a new diastolic murmur and 4/5 left grip strength. WBC was normal. CRP was elevated to 27. MRI brain revealed acute right parietal lobe infarct. Empiric antibiotics for prosthetic valve endocarditis were initiated. TTE and TEE revealed a severely elevated prosthetic mitral valve gradient of 25mmHg (normal < 5mmHg) and thickened leaflets consistent with prosthetic valve endocarditis. On hospital day 7, he developed acute hypoxia in the setting of volume overload due to worsening mitral valve dysfunction.

Three sets of blood, fungal, and acid-fast cultures were negative. On hospital day 13, Bartonella henselae IgG resulted positive >1:2560. Warfarin was discontinued. Antibiotics were switched to rifampin and doxycycline. On hospital day 20, the patient underwent mitral valve replacement. The valve was “stenotic with large vegetation.” The patient’s hypoxia resolved after surgery and he was discharged with 3 months of doxycycline and 6 weeks of rifampin. The 16S ribosomal RNA sequencing from the valve was positive for Bartonella.

IMPACT/DISCUSSION: Diagnosing culture-negative infective endocarditis, defined as 3 negative blood cultures after one week, is elusive because it presents more indolently compared to Staphylococcus or Streptococcus endocarditis which often presents as sepsis. Several features of this patient’s case pointed away from APLS. His recurrent fevers and bioprosthetic valve prompted immediate concern for infection. Additionally, the patient was adherent to warfarin and was therapeutic during all but one of his clinic INR checks. If he had APLS, it would be unusual to have a recurrent stroke with his INR at goal. Only one biomarker was positive for APLS, which is not diagnostic. These factors raised suspicion for endocarditis due to zoonotic organisms like Bartonella, Coxiella, and Brucella. Interestingly, the patient had no identifiable Bartonella exposures like cat contact. Having now diagnosed Bartonella endocarditis, the two ischemic events were more consistent with septic emboli, not APLS. In this patient, earlier diagnosis would have prevented the morbidity of unnecessary anticoagulation, delays in appropriate antibiotic treatment, and potential avoidance of surgery.

CONCLUSION: A young patient with recurrent strokes is a common illness script for APLS. However, individual risk factors (i.e. prosthetic valve, animal/water exposures) and clinical features (i.e. intermittent fevers) should prompt consideration of culture-negative endocarditis due to indolent organisms to facilitate early diagnosis and treatment.

BILATERAL CRANIAL NERVE VI PALSY IN MPO-ANCA POSITIVE EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS

Hadley Greenwood, Isaac Smith, Jeremy Lin, Mary L. Guan

Internal Medicine, NYU Langone Health, New York, NY. (Control ID #3873686)

CASE: A 65-year-old man with a history of adult-onset asthma presented to the emergency department with 3 months of progressive paresthesia. His paresthesia started in the first and second digits of his left hand, which spread to the remainder of that hand. Subsequently, he developed intermittent periods of burning pain originating at the soles of his feet and shooting up his calves. He presented to an outside hospital, where a skin biopsy was taken and he was discharged on a prednisone taper. He presented to our hospital 3 months later for worsening symptoms after being lost to follow-up. On admission, vital signs were stable. His exam was remarkable for hyperalgesia of bilateral lower extremities and wasting of the left hand. Neurology was consulted and noted bilateral cranial nerve VI palsy without diplopia on end-gaze, peri-orbital edema of the right eye with mild proptosis, generalized areflexia, and mononeuritis multiplex. Labs were notable for WBC 12,900/uL with absolute eosinophils 4,300/uL and MPO antibody 3.8 AI. MRI brain and spine showed no abnormal enhancement and visualized intra-orbital contents were normal. Subsequently, outside biopsy records were obtained revealing eosinophil-enriched leukocytoclastic vasculitis. The patient was started on a three-day course of pulse dose IV solumedrol for Eosinophilic Granulomatosis with Polyangiitis (EGPA), with immediate improvement in neuropathic pain and left-hand grip strength. Unfortunately, the patient declined further MRI and MRA studies to evaluate the orbits and vasculature to better characterize his bilateral CN VI palsy and elected to leave on oral steroids before receiving his third dose of solumedrol. IMPACT/DISCUSSION: Cranial nerve (CN) involvement and, more specifically, ocular movement anomalies are relatively rare disease manifestations of EGPA at present. Few isolated reports of unilateral abducens nerve palsy in EGPA exist, with a recent case report identifying successful treatment of unilateral CN VI palsy with a Fresnel prism rather than more invasive standard treatments such as botulinum toxin (1). Our case is unique in the finding of bilateral abducens nerve palsy highly suspected to be secondary to EGPA vasculitis.

CONCLUSION: Although EGPA is often thought of in association with the lungs, heart and sinuses, we present here a patient whose presentation was predominated by mononeuritis multiplex causing significant pain and disability with the unique finding of a bilateral abducens nerve palsy. A primary take away is the importance of a careful neurological exam in all EGPA patients, as CN findings may guide clinical decision- making.

References:

1) Toma C, Sindaco D, Musolino M, Traverso CE, Iester M, Vagge A. Eosinophilic granulomatosis with polyangiitis associated with abducens nerve palsy [published online ahead of print, 2022 Sep 28]. J AAPOS. 2022;S1091-8531(22)00450-5.

BOER-“HAVE” OR BOER-“NOT”? A CASE OF SPONTANEOUS IDIOPATHIC PNEUMOMEDIASTINUM WITHOUT ESOPHAGEAL PERFORATION OR COMPLICATIONS Cameron Fateri, Jagmeet Arora, Kevin S. Tang, Joseph Younis, Kevin Hua

Internal Medicine, University of California Irvine, Irvine, CA. (Control ID #3875231)

CASE: Ms. P was a 24-year-old female who presented to the emergency department with 2 days of intractable vomiting in the setting of cannabis use and 1 day of swelling, pain, and a “crunchy” sensation under the skin of her face and neck. Medical history was significant for cannabinoid hyperemesis syndrome and a chronic history of pre-menstrual vomiting.

On admission, the patient was afebrile, hemodynamically stable, and labs were overall unremarkable without leukocytosis. Physical exam was significant for crepitus extending from the anterior chest to the bilateral cervical levels and left side of the face with clear swelling along the left mandible. Chest and neck x-rays demonstrated subcutaneous emphysema over the bilateral lower neck extending to the right chest wall and subtle linear lucencies over the upper mediastinum. The concern for pneumomediastinum secondary to Boerhaave syndrome in the setting of intractable vomiting prompted cardiothoracic surgery and gastroenterology consults. Follow-up CT esophagram and barium swallow did not find any esophageal perforation.

Given the lack of imaging findings suggestive of clinically significant esophageal perforation, a diagnosis of spontaneous idiopathic pneumomediastinum was made. Throughout admission, the patient remained hemodynamically stable and afebrile. As no further intervention was required, she was safely discharged with antibiotic therapy for infectious prophylaxis.

IMPACT/DISCUSSION: Pneumomediastinum is a rare condition that can be secondary to a wide variety of etiologies including trauma, asthma exacerbation, COPD, pneumothorax, pulmonary embolism, and emesis.

The classic clinical triad of pneumomediastinum consists of retrosternal or pleuritic chest pain, subcutaneous emphysema, and dyspnea. Subcutaneous emphysema is the most common finding and is characterized by crepitus over the skin. Cough, fever, and dysphagia are less commonly reported symptoms that may also be seen.

Pneumomediastinum occurs as a result of increased thoracic pressure causing air to dissect alveoli and leak into the mediastinum. Most reported cases, roughly 50%, are spontaneous and not associated with a specific trigger. Etiologies for the remainder of cases include exercise, cough, infection, and vomiting.

Our patient’s clinical presentation was consistent with classical Boerhaave syndrome; however, no perforation was seen on barium swallow. Boerhaave is extremely rare, with an incidence of less than 0.01% each year. Pneumomediastinum can be secondary to a multitude of etiologies given its pathophysiology and thus, physicians should maintain a wide differential in concordance with the patient’s presentation. In the absence of a specific trigger, spontaneous pneumomediastinum can be managed symptomatically in addition to antibiotic prophylaxis for mediastinitis.

CONCLUSION: 1. Pneumomediastinum is a rare condition with a wide differential diagnosis.

2. Most cases of Pneumomediastinum are idiopathic and may be a result of esophageal or alveolar microtears.

BRAIN SET AFLAME: CASE REPORT ON SERONEGATIVE AUTOIMMUNE ENCEPHALITIS

Jessica Atieh¹; Thanmayi Palegar²; Jabra Zarka³; Pooja Bhatt¹

¹Internal Medicine, UPMC, Pittsburgh, PA; ²Neurology, UPMC, Pittsburgh, PA; ³Internal Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #3875704)

CASE: 50-year-old woman with depression presented with acute onset confusion, agitation, and behavioral changes. Symptoms began 4 days prior and were characterized by restlessness, lack of engagement, inappropriate answers, and combative behaviors. There was no recent illness or medication changes. On physical exam, the patient appeared agitated. Vital signs and neurologic exam were normal. Labs showed normal WBC, ESR 65 and CRP 2.3. Basic labs and thyroid function tests were normal. Serum and urine drug screens, blood cultures, and serum autoimmune panel were negative. Cerebrospinal fluid (CSF) cell count and differential were normal. CSF paraneoplastic and autoimmune encephalitis panels were negative. EEG was without seizure tendency. Computed tomography (CT) of head showed no acute intracranial process. Magnetic resonance imaging of brain was unable to be performed due to weight limitations. CT of abdomen/pelvis revealed 11.5 cm right ovarian teratoma. The patient remained agitated and confused and engaged in skin picking. The negative neurologic and infectious workup, lack of response to antipsychotics or benzodiazepines, and new finding of ovarian teratoma and negative antibody raised high suspicion for seronegative autoimmune encephalitis. High dose steroids were started followed by removal of the teratoma. Patient had significant improvement in symptoms on post-op day 4 and mental status continued to return to baseline on steroids. She was discharged with a 4-week course of prednisone taper.

IMPACT/DISCUSSION: This case illustrates the rapid onset of primarily psychiatric symptoms as early clinical features of autoimmune encephalitis. The development of acute onset psychiatric or neurologic manifestations in a young to middle aged woman with no history or evidence of psychiatric disorder and minimal response to antipsychotics or benzodiazepine should raise suspicion of autoimmune encephalitis. In our case, the presence of newly found ovarian teratoma strengthened our suspicion. Data on presentation and progression of seronegative autoimmune encephalitis are scant; case reports describe patients with psychiatric symptoms or neurologic symptoms, similar to the presentation of NMDA encephalitis. Patients with ovarian teratoma may develop other forms of encephalitis without NMDA-R antibodies. Prompt treatment with immunosuppressives is crucial; the disease progresses quickly and delaying immunotherapy is associated with poor long-term outcomes. First-line therapies include corticosteroids or intravenous immunoglobulin. In patients with NMDA encephalitis,tumor resection has shown to improve symptoms in ~50% of patients within the first 4 weeks.

CONCLUSION: -Acute onset of psychiatric or neurologic symptoms in young to middle aged women with a new tumor and negative infectious and neurological workup should raise suspicion of autoimmune encephalitis.

-Prompt treatment with immunosuppression and surgery is necessary for improvement in morbidity and mortality of autoimmune encephalitis.

BRASH SYNDROME: A CASE OF OCCULT BRADYCARDIAC SHOCK LEADING TO SYMPATHETIC OVERDRIVE

Michael M. Kattula¹; Lark Steafo²; Nicholas J. Corsi³; Radhika N. Gutta⁵; Eric Scher⁴

¹Internal Medicine, Henry Ford Hospital, Detroit, MI; ²Osteopathic Medicine, Michigan State University, East Lansing, MI; ³Internal Medicine, Wayne State University, Rochester Hills, MI; ⁴Medicine, Henry Ford Hospital, Detroit, MI; ⁵Internal Medicine , Henry Ford Hospital, Detroit , MI. (Control ID #3873969)

CASE: A 58-year-old African American male with a past medical history of chronic diastolic heart failure, chronic kidney disease stage IV, and poorly controlled hypertension who presented following persistent bradycardia, and hypotensive readings at home. His anti-hypertensive regimen prior to arrival included Lisinopril, Nifedipine, Hydralazine, Isosorbid Mononitrate, and Carvedilol daily. On arrival, he was hemodynamically labile with a systolic blood pressure in the 90’s, heart rate in the low 50’s, and hypothermic to 33.8 degree Celsius. Initial lab work showed a creatinine of 3.56 (baseline of 2.80) and potassium of 6.4. A rapid EKG demonstrated sinus bradycardia, and CXR consistent with pulmonary edema. He was transferred to the MICU after initial management with calcium gluconate, Insulin, D50, Lokelma, and warming measures with a bear hugger. On arrival to the MICU, he required 4L via nasal cannula due to pulmonary edema and was aggressively diuresed with resolution of potassium disturbance. However, he was found to rebound and became increasingly hypertensive to 200s systolic without evidence of end organ damage. His blood pressure was medically managed on the floors and within 24 hours his kidney function neared baseline. He was discharged on a new regimen of antihypertensives, specifically with discontinuation of his beta blocker.

IMPACT/DISCUSSION: The combination of bradycardia, renal failure, av nodal blockade, shock, and hyperkalemia creates a condition known as BRASH syndrome. Unfortunately, this is a cycle where one complication begets another in patients who take av nodal blocking agents and anti-hypertensives that cause hyperkalemia. There are different thoughts on whether it is renal failure or the combination of beta blockers and hyperkalemia that stimulates the cascade. Nonetheless, these components are interrelated and the cycle will continue if it’s not identified and treated immediately, ultimately leading to multi-organ failure. What is unique to this case is the rare complication of hypertensive urgency as a result of sympathetic overdrive in response bradycardia causing reduced cardiac output. Furthermore, what is controversial is whether or not to restart medications that demonstrate improved mortality in patients with heart failure, yet may be the cause of this disease process.

CONCLUSION: BRASH syndrome is unique because it’s a continuum of a single disease, and therapy includes correction of hyperkalemia, fluid management, and vasopressor support when required. There is not enough data that shows if re-introducing these medications following resolution of BRASH syndrome is necessary and whether recurrence rates are significant in those who are restarted on these medications. Additionally, a rare complication that physicians should be aware of is the sympathetic drive that can lead to hypertensive urgency as a result of bradycardia causing reduced cardiac cardiac output.

BROKEN BY THE HEART: A CASE OF SEVERE THROMBOCYTOPENIA CAUSED BY INFECTIVE ENDOCARDITIS

Biplov Adhikari¹; Mayuri Patel¹; Mahsa Mohebtash²

¹Internal Medicine, MedStar Union Memorial Hospital, Baltimore, MD; ²Hematology and Oncology, MedStar Health, Baltimore, MD. (Control ID #3871843)

CASE:

A 40-year-old male with the history of injection drug use, bipolar affective disorder, and untreated hepatitis C was brought to the emergency department when he was found to be lying on the street, somnolent. He had injected heroin into his groins two days prior to the presentation.

He was afebrile with a normal heart rate but hypotensive to 85/52 mmHg. Laboratory results were significant for serum sodium of 119 mmoL, blood urea nitrogen and creatinine of 70 and 1.60 mg/dL. Serum lactic acid was 5.1 mmol/L. He had neutrophilic leukocytosis of 41.8 k/uL and a severely low platelet count of 5 k/uL. His hemoglobin was 11.5 gm/dL. He was started on broad-spectrum antibiotics and admitted to the intensive care unit.

Given increased risk for spontaneous hemorrhage, the patient was emergently transfused 2 units of platelets. However, his platelets only increased to 8 k/uL. Repeat testing of the platelets in citrated tubes confirmed the severe thrombocytopenia, which further dropped to 3 k/uL the next day despite transfusing one more unit of platelets. The patient's PT/INR was 19/1.6. PTT was 34.2 seconds. Fibrinogen was 177 mg/dL. His reticulocyte count was 0.8; reticulocyte index was 0.22. This peripheral smear showed reduced red blood cells with mild anisopoikilocytosis and 1-2+ schistocytes. His haptoglobin level was less than 8 mg/dL. ADAMTS 13 activity was 29%. Rheumatological workup was significant for a low C3 level of 59 mg/dL (reference range 90–170 mg/dL).

Blood cultures showed gram-positive bacteremia. A complete echocardiography revealed a large pedunculated and mobile vegetation on the tricuspid valve. His blood cultures speciated to Streptococcus mitis. The patient’s antibiotics were then transitioned to ceftriaxone. Eventually, the patient's platelets improved with antibiotics with no need for plasmapheresis or further platelet transfusions.

IMPACT/DISCUSSION: Thrombocytopenia is seen in about 20-25% of patients with bacterial infective endocarditis. Most cases of thrombocytopenia are only mild to moderate. Severe thrombocytopenia, in the setting of infective endocarditis, has been seen in the setting of platelet-reactive autoantibodies or syndrome that resembles thrombotic thrombocytopenic purpura (TTP).

In our patient, the thrombocytopenia could have multiple explanations, including ongoing sepsis, infection- associated autoimmune thrombocytopenia, consumptive thrombocytopenia, or destruction related to TTP. The ADAMTS 13 activity in our patient was not severely low to suggest TTP. However, given the low complement C3 levels, an immune-mediated destruction leading to consumptive thrombocytopenia was the most likely cause.

Thrombocytopenia on presentation in patients with infective endocarditis identifies higher risk groups and carries higher mortality risk.

CONCLUSION: Infective endocarditis can present with severe thrombocytopenia and signs of sepsis. The presence of thrombocytopenia is an independent prognosticator of poor outcomes in infective endocarditis.

BROKEN HEART AND BROKEN FEET: TAKOTSUBO CARDIOMYOPATHY IN THE SETTING OF ACCIDENTAL HYPOTHERMIA AND FROSTBITE

Mohamed Ramzi Almajed, Parul Kochhar, Ahmed M. Ibrahim, Dana Nachawati, Mustafa Mohammed

Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #3848261)

CASE: A 58-year-old man presented on a snowy winter night with severe bilateral foot pain for one week in addition to shortness of breath and bilateral lower limb swelling for several days. He was experiencing unstable housing and often slept without adequate shelter or heating.

On examination, he was normothermic, tachycardic, hypertensive, and tachypneic. He had bilateral pitting pedal edema and his feet were erythematous and blistered, consistent with frostbite from environmental injury.

Workup was notable for an elevated creatine phosphokinase consistent with rhabdomyolysis. High-sensitivity troponin was high at 75 ng/L, it rapidly increased to 2355 and peaked at 7649 within ten hours of presentation. Brain natriuretic peptide was high at 135 pg/mL. Electrocardiogram showed anterolateral t-wave inversions. Throughout this course, the patient denied chest pain.

Given the laboratory and electrocardiogram abnormalities, acute coronary syndrome was suspected and the patient was treated with antiplatelets, statin, and intravenous heparin. Transthoracic echocardiogram demonstrated a left ventricular (LV) ejection fraction of 21% with aneurysmal LV wall deformity. Invasive coronary angiography had no evidence of coronary artery disease. Repeat echocardiogram showed severe hypokinesis of the middle and distal LV wall segments with preserved basal wall motion.

In the context of the clinical presentation, these echocardiographic findings supported the diagnosis of stress cardiomyopathy, termed Takotsubo Cardiomyopathy (TCM). The patient was treated with guideline-directed medical therapy (GDMT) for heart failure with beta-blockers, angiotensin II receptor blockers, and diuretics after which he clinically recovered.

IMPACT/DISCUSSION: TCM is an entity in which left ventricle (LV) dilation and ballooning, notably in the apex, results in a decline in systolic function that manifests as heart failure. It is classically described in the setting of emotional stress, although, recent literature suggests that this condition is underdiagnosed and frequently occurs after physical and physiological stress. Pathophysiology is uncertain but the surge in stress- associated hormones has been implicated in myocardial toxicity.

This case offers an atypical presentation for TCM. The diagnosis warrants extensive workup including ischemic evaluation to rule out common causes of heart failure. Diagnostic criteria includes LV regional wall motion abnormalities that exceed a single vascular distribution, evidence of myocardial injury, and the absence of significant coronary artery disease. Management consists of medical optimization with GDMT. Most patients recover well with low mortality rates.

CONCLUSION: Internists should be aware of TCM and consider it in patients experiencing significant stress who present with features of heart failure and laboratory testing suggestive of myocardial injury. This case highlights the different triggers for stress response, whether emotional, physical, or physiological.

BRUCELLA OSTEOMYELITIS IN A TRAVELER TO THE UNITED STATES

Ahmed M. Ibrahim, Mohamed Ramzi Almajed, Indira Brar

Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #3875556)

CASE: An 84-year-old male presented with a two-month history of intermittent fevers, malaise, weight loss, difficulty ambulating, and bowel and bladder incontinence. Before the onset of these symptoms, he had been independent in mobility with normal bowel and bladder function. On initial assessment, the patient had unremarkable vital signs and was afebrile. Examination was notable for tenderness over the lower lumbar spine with decreased strength, but normal sensation in the bilateral lower extremities. Workup was notable for a leukocytosis to 13.2 K/uL with elevated CRP 9.9 mg/dL and ESR 86 mm/hr. Given the neurological findings, spinal MRI was performed and showed osteomyelitis at the C5-6 and L4-5 levels. CT-guided bone biopsy was obtained, and antibiotics were initiated with Vancomycin and Piperacillin-Tazobactam.

Despite coverage with broad-spectrum antibiotics, the patient developed persistent fevers with a maximum temperature of 102.5 F. Blood and bone biopsy cultures later returned with concern for Brucella. Subsequent testing was remarkable for Brucella IgM of 1.56 and Brucella Antibody titer of 1:80, suggestive of active Brucella infection. Further elicitation of history noted that the patient was a shepherd in Yemen, where he had traveled from about 4 months ago; he had daily contact with sheep and cattle and would often consume unpasteurized milk. Given the diagnosis of Brucellosis, antibiotics were adjusted to Doxycycline and Rifampin, which he was treated with for six months. He had significant clinical improvement and followed up with Infectious Disease clinic.

IMPACT/DISCUSSION: Brucellosis is a zoonotic infection with reservoirs typically including cattle, dogs, sheep, and goats. It is usually transmitted via ingestion of unpasteurized dairy products or undercooked meat from infected animals, inhalation of aerosols, and contact of broken skin or mucous membranes with animal tissues, bodily fluids, and placentas. At-risk populations include slaughterhouse workers, shepherds, and veterinarians. Brucellosis is rarely seen in the US, with 100-200 annual cases.

Our case demonstrates the varying and often nonspecific presentation of Brucellosis, which can mimic other diseases, including osteomyelitis, tuberculosis, malignancy, and meningitis. Although Brucellosis is very rare in the US, it should be considered on the differential in patients presenting with fevers, back pain, and night sweats, especially in travelers. It also underlines the importance of thorough history taking, including travel and occupational history, as it can give clues to aid in diagnosis and management.

CONCLUSION: -Recognize the importance of thorough history taking, including travel and occupational history, especially in patients presenting with infectious symptoms

-Being aware of the signs and symptoms of Brucellosis, as well as general management

-Although Brucellosis is rarely seen in the US, keeping it on the differential, especially in patients who have lived or recently traveled abroad

BURIED BUMPER SYNDROME: A RARE COMPLICATION OF PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)

Melvin Joy¹; Rucha jiyani¹; Jenoj Gnana¹; Tulika Saggar¹; Atul Sinha¹; James Pellegrini¹; Prachi Anand¹; Nausheer A. Khan²

¹Internal Medicine, Nassau University Medical Center, East Meadow, NY; ²Gastroenterology, Nassau University Medical Center, East Meadow, NY. (Control ID #3877182)

CASE: A 56-year-old Caucasian male with a history of benign esophageal stricture underwent percutaneous gastrostomy tube (PEG) placement in 2016 and had a psychiatric history of bipolar disorder brought in by EMS with complaints of abdominal pain and drainage from the gastric stoma. On examination, the PEG tube was visible with minimal sera-mucinous discharge. CT abdomen/pelvis with contrast was obtained, revealing a possible PEG tube dislodgement. For further evaluation, the Interventional Radiology team attempted a fluoroscopic-guided PEG replacement procedure. However, the procedure was aborted because an opacified contrast was noted in the gastrostomy lumen, which was suspicious for retained gastrostomy bumper. Repeat CT abdomen/pelvis with contrast revealed a metallic density projecting from the anterior abdominal wall to the body of the stomach. Upper Endoscopy was subsequently performed but was limited due to a pinpoint stricture of the esophagus. Laparoscopic removal of the buried bumper was performed, followed by a new laparoscopic gastrostomy tube placement. The pathology report was consistent with the gastric tube bumper.

IMPACT/DISCUSSION: Percutaneous endoscopic gastrostomy (PEG) is a widely used method of nutrition delivery for patients with long-term insufficiency of oral intake. The PEG complication rate varies from 0.4% to 22.5% of cases. Buried bumper syndrome (BBS) is a severe complication of this method. It develops as a consequence of the tight positioning of the external bumper of the PEG tube against the abdominal wall. Slowly, the internal bumper of the G-tube erodes and is enveloped by the gastrostomy tract because of tension created on the tract. This can also occur when the PEG tube is strongly pulled away from the person, moving the internal bumper into the gastrostomy tract. This causes swelling and erythema of the surrounding cutaneous tissues and lodging of the internal bumper into the gastric wall of the gastrostomy tract. CT scan may show a migrated internal bumper. Fluoroscopy through the PEG tube will still show contrast material entering the stomach because the gastrostomy tract is still open, and the diagnosis may be missed. So, the ideal way to diagnose buried bumper syndrome is with endoscopy, in which the internal bumper is seen buried within the gastric wall.

CONCLUSION: Buried bumper syndrome is a rare complication of PEG tube that can be easily avoided by taking good care and patient instructions as follows:

1. Place the external bolster of the gastrostomy tube approximately 0.5 to 1 cm from the abdominal wall to prevent excessive traction.

2. Gauze pads should not be placed under the external bolster.

3. The gastrostomy tube should be pushed in and out 1 to 2 cm and rotated 360° during daily care.

4. The length of the protruding external portion of the PEG should be measured periodically to recognize early migration, which may signify a progression to buried bumper syndrome.

CAN CHECKPOINT INHIBITOR PNEUMONITIS(CIP) TRIGGER RHEUMATOID ARTHRITIS(RA)?: ATYPICAL COINCIDENCE OF CIP AND RA WITH PEMBROLIZUMAB Murali Ranjani Behara¹; Diana I. Zamora²; Betsie Ruiz²; Jue Wang³

¹Internal Medicine, Creighton School District 14, Phoenix, AZ; ²Internal Medicine, Creighton University School of Medicine Phoenix Regional Campus, Phoenix, AZ; ³Genitourinary Oncology , Dignity Health Cancer Institute St. Joseph’s Hospital and Medical Center, Phoenix, AZ. (Control ID #3876861)

CASE: This is a case of a 43-year-old man with a history of smoking, metastatic right upper lobe adenocarcinoma diagnosed 5 months prior to presentation, completed 4 cycles of carboplatin, pemetrexed, and pembrolizumab(Immune Checkpoint Inhibitor(ICI)) and underwent palliative thoracic radiation. He presented with recurrent fevers, shortness of breath, and a worsening cough. He was tachycardic, tachypneic, and hypoxic. CT scan showed extensive consolidation of the right lung. His symptoms did not improve on antibiotics. Bronchioalveolar lavage(BAL) was done which showed no infection. He was diagnosed with radiation pneumonitis and was sent home on prednisone. One month later, he receive 1 more dose of ICI after which he presented with worsening shortness of breath, imaging showed worsening ground glass opacities of the right lung. An extensive workup was done which was positive for ANA 1:640, rheumatoid factor(RF), and anti Cyclic Citrullinated Peptide (CCP) suggestive of rheumatoid disease. High-dose steroids and cyclophosphamide were given after which his symptoms improved, and he was discharged home on a steroid taper.

IMPACT/DISCUSSION: ICI is a class of agents that block the interactions between the tumor and immune cells and are currently the standard therapy for metastatic melanoma, non-small cell lung cancer(NSCLC), Renal cell Carcinoma (RCC), etc. Their use is being extended to breast, head, neck, and hematological malignancies. With the recent increase in the use of ICI, the incidence of side effects has also increased. Fatigue, rash, diarrhea, and skin disorders are commonly reported, and rarely colitis, endocrinopathies, and pneumonitis. Checkpoint inhibitor Pneumonitis (CIP) is a rare life-threatening complication of ICI with an incidence of about 3% and occurs a few days after ICI therapy. It is more common in NSCLC and RCC than melanoma. Patients present with worsening dyspnea, cough, fever, and hypoxia. Inflammatory markers like C Reactive Protein, Sedimentation rate are high. Imaging shows ground glass opacity, consolidation, septal thickening, and nodularity. BAL is recommended to rule out other differential diagnoses like infectious pneumonia, tumor progression, COPD exacerbation, radiation pneumonitis etc. Depending on the severity, CIP is classified into 4 grades with 4 being life-threatening pneumonitis. Glucocorticoids (GCS) are the mainstay treatment for CIP. In cases that are resistant to GCS, IVIg, immunosuppressors like mycophenolate, cyclophosphamide, and TNF inhibitors can be used.

CONCLUSION: Rarely ICI can trigger an autoimmune process in the body resulting in an increase in Immune markers like RF, anti CCP can be detected before any signs and symptoms of arthritis as in our patient. Studies showed that autoimmunity for RA is initiated outside of the joints, commonly in the lungs and oral mucosa. With this case, we suggest that the inflammatory process in CIP can be related to triggering RA in some patients.

CANNABIS-INDUCED SUPERIOR MESENTRIC VEIN THROMBOSIS; AN UNUSUAL ETIOLOGY

Mohammed Abdelsalam, Sadia A. Tanami, Tarek Naguib

Internal Medicine, Texas Tech University Health Sciences Center - Amarillo, Amarillo, TX. (Control ID #3875036)

CASE: 40-year-old male with a history of cannabis abuse, alcohol abuse, hyperlipidemia, hypertension and GERD presented with complaints of nausea, vomiting, intermittent epigastric dull aching abdominal pain for a week. The patient reported using of cannabis edibles at least 500 mg/day, accompanied by 5-8 marijuana cigarettes per day and vaping for two weeks. He denied any history of liver disease, thromboembolic episodes, endoscopic interventions, flu like symptoms or recent travel. On physical examination, mild tenderness in the epigastric region was found. Vital signs were unremarkable. Family history noncontributory. Initial lab results were non-significant and urine toxicology was only positive for cannabis. CT abdomen pelvis with contrast showed thrombosis in the superior mesenteric vein (SMV) extending to portal vein confluence and main portal vein. Hypercoagulability panel was negative. Patient also tested negative for HBV, HCV, HAV, AFP, CEA, CA19-9 and COVID-19. The patient was first started on UFH and later discharged on oral rivaroxaban. His abdominal pain improved and he was counseled on cessation of cannabis.

IMPACT/DISCUSSION: Portal venous system thrombosis is caused by slowing of blood flow, endothelial injury, and hypercoagulability. Factors including systemic hypercoagulable states (eg, protein C deficiency), pancreatitis and cirrhosis are among the most common etiologies.

There is evidence that heavy regular cannabis use is associated with acute myocardial infarction, stroke and acute limb ischemia. The pathophysiology underlying cannabis induced thrombosis is not well understood but research showed that cannabinoid receptors CB1 and CB2 exist on the cell membrane of platelets. Tetrahydrocannabiol (THC) was shown to augment the expression of glycoprotein IIb-IIIa and P selectin receptors on platelets in a concentration-dependent manner and was demonstrated to cause platelet aggregation in vitro. Furthermore, THC caused dysfunction of the vascular endothelium by decreasing synthesis of nitric oxide which causes activation, adhesion and aggregation of platelets. It is very likely that extensive cannabis use especially edible form might have triggered endothelial dysfunction and thrombosis in mesenteric vasculature.

SMV thrombosis can present with dull abdominal pain, nausea and vomiting. High suspicion index is necessary to reach an early diagnosis. CT abdomen is the best initial imaging as it is reliable and can rule out other causes of acute abdominal pain. Management is mainly conservative with anticoagulation UFH or LMWH initially and oral anticoagulants for 6 months if risk factor is transient and for longer if risk factor is irreversible. After anticoagulation, most thrombosed veins partially or completely recanalize.

CONCLUSION: Heavy cannabis use likely contributed to the development of SMV thrombosis in this patient as there were no other precipitating risk factors. More observational studies are needed to explore the magnitude of cannabis on SMV thrombosis.

CARCINOID SYNDROME: A UNIQUE PRESENTATION

Eric Lai¹; Abby Terlouw²; Heidi Park²; Ilana Schlam^1,3

¹Tufts University School of Medicine, Boston, MA; ²Internal Medicine, Tufts Medical Center, Boston, MA; ³Hematology and Oncology, Tufts Medical Center, Boston, MA. (Control ID #3875910)

CASE: A 53-year-old male with a history of hypertension presented after a reported episode of hypotension at home. He described a 12-month history of progressive indurated skin thickening of the nose, forehead, and glabella with deep longitudinal furrowing. Other symptoms included diffuse erythema, especially in the facial distribution, weight loss, progressive hearing loss, and watery diarrhea. Initial laboratory testing demonstrated elevated calcium of 13.6 mg/dL and PTH of 147 pg/mL with normal PTHrP and FGF23. CT imaging was significant for a 2 cm hilar mass and multiple hepatic lesions, with the largest measuring 10 cm. MRI head and echocardiogram were unremarkable. Hepatic biopsy was consistent with neuroendocrine origin, staining positive for AE1/AE3, chromogranin A, and synaptophysin with a Ki-67 proliferation index of 5.8%. Other laboratory results later demonstrated an elevated 24-hour urine 5-HIAA of 238.6 mg/24 hours, plasma 5-HIAA of 670 ng/ml, and plasma chromogranin A of 5972 ng/mL. A DOTATATE scan demonstrated a left perihilar mass and multiple hepatic lesions which were DOTATATE avid with no focal gastrointestinal uptake. The diagnosis of carcinoid syndrome (CS) was established. Initial treatment with intramuscular long acting release octreotide did not improve symptoms requiring dose increase and transarterial chemoembolization with interval reduction of flushing and swelling. Genetic testing is planned.

IMPACT/DISCUSSION: Common presenting symptoms of CS can include cutaneous flushing, bronchospasm, and diarrhea. However, the presentation can vary and potentially delay diagnosis. The heterogeneity of symptoms can be explained in part by the embryologic origin of the neuroendocrine tumor causing the CS. While neuroendocrine tumors associated with the classic presentation of CS are usually midgut in origin, these tumors can also arise from other regions and lead to a more unique presentation, as demonstrated in this case where a foregut carcinoid tumor caused the development of leonine facies in addition to other more common symptoms of CS. Other reports indicate that chronic flushing can lead to the appearance of rosacea and phymatous changes as seen in this case, however this case demonstrates a very severe presentation associated with CS. Additionally, carcinoid tumors of different embryologic origin can have associations with other conditions requiring additional workup. Reports have found a higher association between multiple endocrine neoplasia (MEN) and foregut carcinoids compared to carcinoids of midgut or hindgut origin. In this case, MEN1 remains important to rule out given the association with foregut carcinoids and the patient’s hyperparathyroidism.

CONCLUSION: The clinical presentation of CS can include atypical symptoms in part due to the variable locations where carcinoid tumors can arise. Recognition of the clinical behavior of CS allows for earlier detection and treatment, thereby improving patient prognosis and quality of life.

CARDIAC TAMPONADE IN THE SETTING OF SEVERE PRE-ECLAMPSIA IN THE IMMEDIATE POSTPARTUM PERIOD

Haya Kaliounji³; Rissa Zudekoff¹; Justin A. Edward²; Alexis Tumolo²

¹Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ²Cardiology, University of Colorado Denver School of Medicine, Aurora, CO; ³University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #3877181)

CASE: A 33-year-old woman presented for a scheduled cesarean delivery with dyspnea and edema. She was diagnosed with pre-eclampsia with severe features as she was hypertensive (153/99) with elevated liver enzymes and creatinine. In the immediate postpartum period, the patient became hypotensive and was found to have a pericardial effusion with early cardiac tamponade physiology. The pericardial effusion was drained, and the patient recovered without immediate complications. Days later, the patient developed dyspnea again and was found to have a recurrent pericardial effusion on echocardiogram. She underwent a pericardial window procedure to prevent cardiac tamponade. The inpatient workup which included pericardial fluid cultures, IgG4 staining, scleroderma workup, rheumatologic markers, and a viral panel was unremarkable. Her cardiac MRI was consistent with inflammatory pericarditis. After recovery, she was discharged with ibuprofen and colchicine for six months. On follow-up, ibuprofen was switched to prednisone as her repeat cardiac MRI showed evidence of constriction and inflammation.

IMPACT/DISCUSSION: Although clinically insignificant, pericardial effusion in the third trimester of pregnancy is seen in 44.4% of patients; cardiac tamponade, however, is a rare complication. Previous cases of cardiac tamponade in the peri- and postpartum periods have been noted to be the initial presentation of certain diseases such as systemic lupus erythematosus and scleroderma. Therefore, it is crucial to conduct a full workup to rule out underlying disease processes to prevent recurrence and further complications. In this case, the etiology of tamponade is not clear, but likely related to a previous viral infection that precipitated pericarditis and was exacerbated by severe pre-eclampsia as other sources were ruled out. Normal physiologic changes during pregnancy include increased blood volume, which leads to increased stress on the heart. Pre-eclampsia worsens cardiac strain with elevated blood pressure. As cardiovascular disease is a major cause of mortality in pregnancy, the prompt diagnosis of cardiac tamponade can be life-saving. Providers should evaluate for JVD and pulsus paradoxus. Additional diagnostic testing can identify signs of tamponade with evidence of low voltage on EKG and pericardial effusion with tamponade physiology on echocardiogram. Following an accurate diagnosis, tamponade should be treated promptly with pericardiocentesis. If there are clinical signs of pericarditis, treatment with both NSAIDs and colchicine should be considered. Initially, the patient in this case was discharged on NSAIDS without colchicine as she was breastfeeding. Monotherapy may have contributed to her recurrent pericarditis and pericardial effusion.

CONCLUSION: Consider pericardial effusion on the differential for patients with pre-eclampsia who present with dyspnea and hypotension.

Discuss empiric treatment of pericarditis with both NSAIDs and colchicine to help prevent recurrence of pericarditis.

CASE OF GRANULICATELLA ADIACENS ENDOCARDITIS

Joseph Maenza

Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY. (Control ID #3873435)

CASE: Our patient is a 63-year-old male with a history of hypertension and HIV well-controlled on Biktarvy (viral load of 37 and CD4 count of 379 one month before presentation). The patient began to experience shortness of breath with only minimal exertion. He was diaphoretic and had one episode of non-bloody diarrhea. He denied any chest pain, palpitations, or dizziness. The patient also had a dental cleaning a month before onset of symptoms without antibiotics.

On arrival to the ED the patient was found to meet 3 out of 4 SIRS criteria with BP 80/54, HR 126, RR 22, Temp 97.8F, WBC 20.4, SpO2 60% on room air and was intubation after arrival with need for pressor support. A CT chest showed diffuse bilateral consolidations concerning for either pneumonia or pulmonary edema. He was then started on antibiotics for possible pneumonia coverage and given diuretics for new onset heart failure. Blood cultures returned positive for granulicatella adiacens and patient was switched to penicillin and gentamicin for sensitivities. While initial TTE showed a borderline ejection fraction and no evidence of valvular abnormalities, follow up TEE showed evidence of a 1.3 x 1 cm vegetation on the aortic valve with perforation of the left coronary cusp and severe aortic insufficiency. While continuing his treatment with antibiotics, the patient developed a rapidly rising creatinine level presumed secondary to gentamicin. The patient’s treatment course was continued with ceftriaxone and follow up echoes showed a 0.9 x 0.9 cm vegetation. After the patient was medically stabilized, he underwent evaluation by cardiothoracic surgery with eventual successful replacement of the aortic valve. Patient completed his course of antibiotics and was sent to cardiac rehab.

IMPACT/DISCUSSION: This case was notable for several reasons. Granulicatella, a rare and dangerous oral flora streptococcus variant, only accounts for 5-6% of endocarditis cases and has a mortality of 17%. Susceptibilities to penicillins is reported to be around 33%, while susceptibility to aminoglycosides is almost universal. While dental procedure antibiotic prophylaxis is only indicated in high risk patients, granulicatella exhibits high resistance rates to the most common choice, amoxicillin.<span style="font-size:10.8333px"> </span>This case also highlights a rapidly declining clinical situation commonly seen in granulicatella infection, severe enough to eventually require valve replacement.

CONCLUSION: Granulicatella adiacens is not covered under the typical dental prophylaxis or empirical treatment for endocarditis. This case highlights the importance of obtaining early blood cultures before treatment to ensure adequate coverage with the correct antibiotics.

In patients with a septic presentation with symptoms of new onset heart failure without an otherwise identifiable source, suspicion for endocarditis should remain high on the differential even with initial negative signs on TTE.

CASE SERIES ON NEAR-MISS MG DIAGNOSIS: MISSED MYASTHENIA: TACKLING OUR DIAGNOSTIC WEAKNESS

Veronica R. Jacome Lopez¹; Marsha M. Mcleod¹; Doo Woong Choi¹; Darrian Reyes²; Fausto G. Lisung³

¹Englewood Hospital and Medical Center, Englewood, NJ; ²Rowan University School of Osteopathic Medicine, Stratford, NJ; ³Medicine, Englewood Hospital and Medical Center, Englewood, NJ. (Control ID #3868997)

CASE: 87 year old female with history of Breast cancer, Hypertension, Hypothyroidism, and frequent falls for the two months, presented to the emergency room with a 2-day history of generalized weakness, right sided eyelid drooping and with difficulty to maintain her neck up. Upon arrival to the ED, patient was not in acute distress but further neurological examination showed notable right sided ptosis. CT head and CTA head and neck ruled out any acute process. During hospitalization the patient was noted to have worsening

bilateral ptosis in the afternoon. Vital capacity (VC) and Negative Inspiratory Force (NIF) were reduced, acetylcholine receptor blocking, modulating and binding antibodies were elevated. Patient was started on prednisone and pyridostigmine with marked improvement of her symptoms

A 62 years old male with history of anxiety and hyperlipidemia, who was initially admitted to the hospital for difficulty standing up straight. Further exams did not show any acute pathology, and his clinical symptoms were attributed to anxiety. However, during the hospital course the patient reported dysphagia. Stroke workup was negative and acetylcholine receptor antibodies were positive. Hospitalization was complicated with COVID infection requiring mechanical ventilation. Myasthenia gravis was managed with plasmapheresis and he was discharged on steroid tapering course

IMPACT/DISCUSSION: Myasthenia Gravis is a neuromuscular disorder that often mimics other neurological diagnoses, especially cerebrovascular accidents (CVA). In elderly patients with other comorbidities the chances of misdiagnosis are even higher and the consequences of delayed diagnosis and treatment can be detrimental. For our second patient especially, failure to diagnose myasthenia earlier resulted in placing non-needed consults such as Psychiatry, and a complicated progressive course, such as a myasthenic crisis with respiratory failure and a near fatal hospital course.

Often patients are subjected to unnecessary tests and medication that come with separate consequences. Several cases have been reported in literature of Myasthenia being initially treated as a CVA because of bulbar or muscular weakness even when history is suggestive of possible Myasthenia

CONCLUSION: Myasthenia gravis is easy to miss diagnosis. At the same time, it imposed unnecessary CVA workup and ICU level care.

It is important to avoid anchoring bias when evaluating elderly patients even when they have risk factors that may seem to clinch a particular diagnosis. An adequate history with a detailed physical exam is strongly encouraged and could guide us into the most assertive diagnosis.

With these cases, we want to highlight the importance of an early diagnosis for myasthenia gravis, avoiding unnecessary harm to our patients

CAVITARY PNEUMONIA IN AN IMMUNOSUPPRESSED PATIENT

Rashmi Thimmapuram¹; Nathan Ziman¹; Aamer Naofal¹; Mikel Etchegaray²

¹Internal Medicine, Baylor College of Medicine, Houston, TX; ²The University of Texas MD Anderson Cancer Center, Houston, TX. (Control ID #3874541)

CASE: 51 year-old male with active cigarette use (31 pack years) and recent initiation of immunosuppressants presents with shortness of breath, weight loss, and fatigue. 9 months prior to presentation he was started on adalimumab and leflunomide for suspected rheumatoid arthritis (RA). After 4 months of therapy, he experienced decreased appetite and a 60-pound unintentional weight loss. 2 weeks prior to admission he developed progressive shortness of breath, pleuritic chest pain, and fatigue leading to admission. He did not have fever, cough, or night sweats. At initial presentation to the hospital, he was afebrile with an oxygen saturation of 94% on room air. Laboratory analysis showed hyponatremia (Na 131), normal liver function tests, and normal white blood cell count. He was treated for community acquired pneumonia with a 5-day course of ceftriaxone and azithromycin without improvement in symptoms. Computerized tomography (CT) chest revealed a large pleural-based and perifissural cavitary mass in the right lower lobe of the lung and multiple right lower lobe pulmonary nodules. He underwent endobronchial ultrasound showing mucopurulent secretions obstructing the right middle lobe and right lower lobe, and bronchoscopy with pathology negative for malignancy, however bronchial wash cultures returned positive for Legionella pneumophilia. He was treated with levofloxacin for 21 days, but developed worsening shortness of breath and repeat CT scan showed progression of pneumonia with increased cavitation. Work-up for secondary pathogens including tuberculosis, histoplasma, blastomycoses, cryptococcus, and aspergillus was negative. Levofloxacin was continued and he was started on azithromycin for 4 weeks, resulting in partial symptomatic and radiographic improvement.

IMPACT/DISCUSSION: CT scan of the chest in Legionella pneumonia typically shows multifocal consolidative changes and/or ground glass opacities, however the presence of cavitary pneumonia in immunosuppressed patients should prompt evaluation for Legionella pneumonia. Although tumor necrosis factor (TNF)-alpha inhibitor use itself has been associated with Legionella pneumonia, there are no reported cases of cavitary pneumonia due to Legionella pneumophilia in patients with RA on immunosuppressive therapy. Case reports on cavitary Legionella pneumonia in patients with systemic lupus erythematosus (SLE) on chronic immunosuppressive therapy have proposed a mechanism related to defect in cytotoxic CD8 T-cells and CD4 T-cells with resultant defective humoral immune response. In this patient with RA on a TNF-alpha inhibitor, we suspect a similar mechanism of impaired T-cell, neutrophil, and macrophage response, which may warrant further investigation.

CONCLUSION: Although CT chest findings in Legionella pneumonia most commonly show lobular consolidations, cavitary lesions may be seen in immunosuppressed patients. For patients on TNF-alpha inhibitors, include Legionella testing as part of the work-up of cavitary pneumonia.

CECAL DIEULAFOY LESION AS A RARE CAUSE OF LOWER GASTROINTESTINAL BLEED

Bibek Saha¹; Divya Takkellapati²; Thomas J. Beckman¹

¹Internal Medicine, Mayo Clinic, Rochester, MN; ²Mayo Clinic Alix School of Medicine, Rochester, MN. (Control ID #3876924)

CASE: An 81-year-old male with a history of atrial fibrillation on warfarin, HFmrEF (EF 44%), coronary artery disease status post CABG, pulmonary hypertension (pHTN; RVSP 59 mmHg), moderate-severe tricuspid regurgitation (TR), and obstructive sleep apnea presented with a one-day history of bloody bowel movements. He also reported epigastric abdominal pain which had resolved, along with stable chronic dyspnea and leg swelling. He denied dyschezia, hematemesis, and lightheadedness. His last colonoscopy was performed 16 years before presentation.

On exam, he was afebrile (36.8°C), normotensive (101/63mmHg), with normal heart (73bpm) and respiratory rates (18breaths/min) and oxygen saturation of 90% on home 3L oxygen. Cardiopulmonary and abdominal exam were normal. Rectal exam showed bright red blood with positive stool guaiac test but no hemorrhoids. He had 3+ pitting edema of the lower extremities.

Labs revealed a supratherapeutic INR of 3.1, a creatinine of 1.37 (baseline 1.1-1.3mg/dL), and a normal hemoglobin (12.9g/dL). CT abdomen and pelvis was negative for gastrointestinal bleeding.

Vitamin K was administered for warfarin reversal; however, he continued to have hematochezia. He then developed new small-volume hemoptysis/hematemesis with hemodynamic stability but had increasing oxygen requirements of 4-6L. Chest imaging revealed a new, small, focal consolidative opacity in the left lower lung lobe representing possible hemorrhage. Bronchoscopy revealed old blood in the left lower lobe, with no active source of bleeding. On colonoscopy, a solitary, 2mm cecal Dieulafoy lesion with spurting bleeding was discovered and clipped; also found was a nonbleeding deep mucosal AVM. EGD showed erosive gastropathy. He had no recurrence of hematochezia nor hemoptysis.

His hospital course was complicated by acute kidney injury, with peak creatine at 2.38mg/dL. The cause was thought to be cardiorenal syndrome due to acute exacerbation of HFmrEF, given severe pitting edema and new TTE showing enlarged IVC with reduced inspiratory collapse. Additionally, his RVSP had increased to 72 mmHg and the TR was now severe. He responded well to diuresis with an 8kg reduction in weight upon discharge.

IMPACT/DISCUSSION: We report a rare case of cecal Dieulafoy lesion causing a lower gastrointestinal bleed (LGIB). In contrast to previously reported cases, our patient developed concomitant bleeding from the oral orifice placing a brisk upper gastrointestinal bleed (UGIB) higher in the differential. However, this was found to be hemoptysis most likely due to significant pHTN.

CONCLUSION: 1. Cecal Dieulafoy lesion is a rare cause of LGIB.

2. In patients bleeding from both oral and anal orifices, a brisk UGIB – as well as independent causes involving the gastrointestinal and respiratory tracts – should be considered depending on comorbidities, as in this patient with pHTN.

CEFEPIME INDUCED ENCEPHALOPATHY

Ashley Turek²; Sheena Bhushan^1,2; Brenton Otey²; Mushtaq Qureshi²; Vaishali Jadhav²

¹Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA; ²Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, GA. (Control ID #3877557)

CASE: Background

^{Toxic-metabolic encephalopathy (TME) is defined as global neurologic dysfunction in the absence of} structural brain disease or CNS infection. It is most commonly seen in critically ill patients and can be caused by infections, medications, hyperammonemia, and much more. Acute TME is a rare but serious adverse effect of cefepime, a fourth-generation cephalosporin used frequently in the inpatient setting. Here, the authors describe a rare case of acute cefepime-induced TME in an elderly male.

Case Presentation

A 76-year-old male with a past medical history of insulin-dependent type II diabetes mellitus, paroxysmal atrial fibrillation, hypertension, hyperlipidemia, a myocardial infarction status post coronary artery bypass graft, and a cerebrovascular accident presented to the emergency department for worsening left lower extremity cellulitis despite adherence to his outpatient antibiotic regimen. On arrival, his vital signs were unremarkable and he was awake, alert, and oriented. Pertinent laboratory work included a white blood cell count of 12.5 x 109/L, blood urea nitrogen (BUN) of 14.0 mg/dL, and creatinine (Cr) of 1.06 mg/dL. The patient was admitted to the hospital and initiated on vancomycin and cefepime. On day 6 of this regimen, he developed an acute kidney injury (AKI) with a BUN of 19.0 mg/dL and Cr of 1.81 mg/dL. Vancomycin was stopped and the patient was started on intravenous fluids. Despite these measures, his renal function continued to worsen with a BUN and Cr of 22.0 mg/dL and 2.36 mg/dL, respectively. On day 8, the patient was noted to be encephalopathic, aphasic, and responsive with eye opening only to repeated stimuli. Repeat labs showed an elevated but stable renal function. CT, MRI, and MRA of the brain were insignificant for any acute findings. An EEG revealed generalized 1-2Hz periodic discharges with triphasic morphology typically seen in TME, and a working diagnosis of cefepime-induced encephalopathy was made. Cefepime was discontinued and the patient was started on lacosamide for seizure prevention. The patient improved and returned to his baseline mentation 2 days after discontinuing cefepime.

IMPACT/DISCUSSION: Discussion

The most common adverse event of cefepime in the CNS is seizure. Cefepime-induced encephalopathy, however, is rarely reported. The spectrum of manifestations of cefepime-induced neurotoxicity is dependent upon concentration and includes confusion, altered consciousness, aphasia, agitation, convulsions, non- convulsive status epilepticus, and coma. The latency of encephalopathic onset from time of drug exposure varies, but typically occurs within 4 days of antibiotic initiation and regresses within 2 days of cessation.

CONCLUSION: Because cefepime is renally excreted, acute TME is more likely in the setting of AKI or other kidney disease, therefore, cefepime should be used with caution in those who are renally impaired. If cefepime-induced encephalopathy is not detected and reversed early, consequences can be serious.

CENTRAL RETINAL ARTERY OCCLUSION IN PATIENT WITH MIGRAINE

Sally Tayel¹; Umair Ahmad²; Valerie Cluzet³

¹Internal medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ²Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ³Medicine/Infectious Diseases, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #3848171)

CASE: A 46-year-old female with history of chronic migraine and hypothyroidism presented to our hospital with sudden onset of painless vision loss in her left eye few hours after an episode of generalized bitemporal headache. On presentation, the patient was vitally stable. Laboratory work showed microcytic anemia (hemoglobin 10.3 gm/dL, MCV 72.9 fL) and elevated ESR 25 mm/hr. The patient was admitted for possible stroke, so was started on aspirin and statin therapy; however, CT head showed no acute intracranial abnormality and CTA head and neck showed no significant stenosis, aneurysm or dissection. MRI brain had no significant findings. EKG revealed no arrythmia and echo bubble confirmed no ASD/PFO or cardiac thrombus ruling out cryptogenic stroke. Ophthalmology evaluation reported a cherry red spot with macular whitening and edema consistent with central retinal artery occlusion (CRAO), but no Hollenhurst plaque noted. Hypercoagulable workup including CEA, CA 125, CA 19.9, CA 15-3, CA 27.29, lipid profile, homocysteine level, protein C, protein S, antithrombin III, factor VIII activity and HgbA1c were normal. Rheumatological work up for SLE, RA and APS was negative. Given the negative imaging and hypercoagulable workup findings, the patient’s CRAO was speculated to be due to migraine.

IMPACT/DISCUSSION: Migraine is a neurological condition usually characterized by recurrent pulsating headache on one side of the head. The exact etiology of migraine remains unknown but is thought to be the result of abnormal brain activity affecting nerve signals and chemicals, such as vasospasm secondary to serotonin or meningeal inflammation secondary to calcitonin gene-related peptide protein release. Ocular migraine or migraine with aura is associated with flashes, blind spots or brief attacks of vision loss. According to a recent retrospective cohort study, migraine, and especially migraine with aura, was shown to be associated with increased risk of CRAO. The cause of such risk remains unclear, but some hypotheses include retinal vasculitis, underlying coagulation abnormalities, or vasoconstrictive properties of migraine abortive medications. Our patient developed CRAO after an episode of migraine with no aura. In the absence of underlying hypercoagulability, arteriovascular disease or signs of inflammation; the patient’s CRAO was attributed to vessel spasm in the setting of her migraine. In the acute setting, CRAO is treated as cryptogenic stroke with tissue plasminogen activator as irreversible damage can happen if the symptom persists more than 240 minutes; however, there is no documented evidence of it’s use in migraine.

CONCLUSION: This case raises awareness among physicians about the association of CRAO and migraine. Furthermore, it highlights the need for additional studies to investigate the underlying pathophysiology of CRAO in patients with migraine, to develop preventive methods and improve patients’ outcomes.

CEREBRAL FAT EMBOLISM IN A YOUNG WOMAN WITH HBSC DISEASE ASSOCIATED WITH VASO-OCCLUSIVE CRISIS AND COVID INFECTION

Zachary Buxo²; Astha Saini^1,2; Cullen Hudson²; Diane L. Levine^3,2

¹Internal Medicine, Detroit Medical Center, Detroit, MI; ²Wayne State University School of Medicine, Detroit, MI; ³Internal Medicine, Wayne State University, Detroit, MI. (Control ID #3875281)

CASE: A 27-year-old woman with sickle cell HbSC and class 2 obesity presented with severe diffuse bilateral leg pain and cough. Initial vital signs showed mild tachycardia but no fever. The remainder of the exam was normal. She was admitted for vaso-occlusive crisis (VOC) secondary to COVID-19. On day 2, was found to be unresponsive, with asymmetrical pupils and decorticate posturing. CT head was negative for infarct or hemorrhage. She began to have seizure-like activity and was intubated for airway protection and empirically started on antiepileptics. Chest x-ray revealed new bilateral opacities, likely secondary to an aspiration event. Labs revealed acute thrombocytopenia with a decrease from 100,000 platelets/μL to 32,000 platelets/μL. On day 3, brain MRI revealed numerous bilateral infarcts in small vessel distribution involving juxtacortical white matter and deep grey. From day 4 to 6, a long-term video electroencephalogram revealed no seizures. Workup for disseminated intravascular coagulation, thrombotic thrombocytopenia, and hemolytic uremic syndrome were all negative. CT thorax for pulmonary embolism was negative, however, it showed new bibasilar pneumonia. On day 7, she had a red blood cell exchange transfusion. There was delay in securing blood products due to the numerous antibodies detected in the type and crossmatch. A repeat MRI for neuro-prognostication revealed evolving infarcts and new infarcts located in the corpus callosum consistent with fat embolism syndrome (FES). The patient remained ventilator dependent with no neurological improvement. As per her family’s wishes a tracheostomy and PEG tube were placed and she was discharged to a long-term care facility.

IMPACT/DISCUSSION: Patients with HbSC disease are at increased risk for VOC. Stroke and acute chest syndrome are feared complications when patients are admitted for acute VOC. FES is most commonly associated with orthopedic trauma. However, individuals with sickle cell hemoglobinopathy are at increased risk for non-trauma related FES. FES is a rare complication of sickle cell disease with an incidence of 87 cases from 1987 to 2018 that predominantly affects patients with HbSc or HbSβ+. The proposed mechanism is vaso-occlusive bone marrow necrosis releasing fat emboli into the venous circulation. The instance of FES is well documented in cases related to Parvovirus B19, however there are no reports documenting COVID-19 and FES in sickle cell disease patients. Diagnosis requires MRI as early changes are not apparent on CT scan. Prompt red blood cell exchange transfusion has been shown to improve survival and decrease neurological deficits.

CONCLUSION: FES is a rare complication of sickle cell hemoglobinopathy. Providers should have high suspicion for FES in individuals with neurologic deficits who are in VOC. COVID-19 has been reported in obese patients. More research is needed to further explore the developing theories explaining this phenomenon in patients with both VOC and COVID-19.

CHEST PAIN, AN UNCOMMON CASE OF STEMI DURING PREGNANCY

Konner Feldhus¹; Kirstin Hesterberg²

¹Internal Medicine Residency, National Jewish Health Saint Joseph Hospital, Denver, CO; ²Cardiology, National Jewish Health Saint Joseph Hospital, Denver, CO. (Control ID #3877067)

CASE: An otherwise healthy, G4P3 32-year-old female at 13 weeks of gestation presented with exertional substernal chest pain and was found to have an inferior STEMI. Transthoracic echocardiogram (TTE) showed suspected patent foramen ovale (PFO). Coronary angiogram and intravascular ultrasound showed no atherosclerosis, but an occluded RCA. Drug-eluting stent (DES) was placed. She received one month of dual anti-platelet therapy (DAPT) before transition to therapeutic low molecular weight heparin (LMWH), given presumed embolic event. She remained under close monitoring by a multi-disciplinary team that included obstetrics, maternal-fetal medicine, and cardio-obstetrics. She had no further complications during pregnancy and gave birth to a healthy baby. After delivery, a transesophageal echocardiogram (TEE) showed a

secundum atrial-septal defect (ASD). A paradoxical embolus causing STEMI is a complex clinical situation requiring revascularization and eventual closure of the PFO or ASD. Given procedural risk during pregnancy, closure was delayed and anticoagulation was initiated to prevent recurrence. Modification to post-STEMI medications is needed, given the paucity of data relating to these therapies. Finally, careful consideration of monitoring during and after delivery is required.

IMPACT/DISCUSSION: Ischemic heart disease represents <2% of pregnancy-related cardiovascular complications. Given risks to mother and to fetus, a multidisciplinary approach shall be used to provide ideal management. This case should inspire the physician to embrace collaborative clinical decision-making in this setting. To our knowledge, case vignettes of STEMI during pregnancy due to undiagnosed congenital heart disease are limited.

CONCLUSION: STEMI in a pregnant female is rare

When the cause is undiagnosed congenital heart disease, further consideration for short term and definitive management requires a multidisciplinary approach

CHRONIC TRANSFUSIONS LEADING TO A DIAGNOSIS OF PURE RED CELL APLASIA

Lillian Sangha¹; Benjamin Ravichander¹; Iuliia kovalenko¹; Venkataraman Rajagopalan²; Irina Mishagina¹

¹Internal Medicine, UPMC Central PA, Harrisburg, PA; ²Hematology Oncology, UPMC Hillman Cancer Center, Harrisburg, PA. (Control ID #3860705)

CASE: A 75-year-old male with history of diabetes mellitus, atrial fibrillation and hypertension presents to the hospital with generalized weakness. He was found to have a significant anemia with hemoglobin of 6.5 g/dL. He has had multiple life-long admissions for anemia, and in the last year has required over twenty blood transfusions. A complete blood count showed normocytic anemia with a markedly reduced reticulocyte count of <0.5%. Further workup of iron studies, folic acid, vitamin B12, LDH, haptoglobin, Direct and Indirect Coombs testing, and fecal occult blood testing were unremarkable apart from elevated transferrin. He was evaluated for underlying infection, with viral and bacterial workup being negative. He was also evaluated for plasma cell disorders with negative workup. The patient underwent further invasive investigation by means of commuted tomography angiography of the chest, abdomen, and pelvis, upper and lower endoscopies, and a bone marrow (BM) biopsy which continued to be unrevealing in the etiology of his anemia. He was noted to have elevated inflammatory markers and a significantly elevated antinuclear antibody titer of 1:1280; however, the remaining autoimmune workup was unremarkable. He was started on hydroxychloroquine by rheumatology. However, due to persistent anemia, he was referred for a repeat bone marrow biopsy which was diagnostic for pure red cell aplasia (PRCA). Hydroxychloroquine was discontinued, and cyclosporine 200 mg twice daily and weekly intravenous dexamethasone was initiated. Over the next few months, his cyclosporine was tapered to 50 mg twice daily and his dexamethasone tapered off without any need for repeat blood transfusions. With time, his hemoglobin normalized, and his symptoms improved.

IMPACT/DISCUSSION: PRCA is a rare form of bone marrow suppression where autoantibodies are formed against red blood cell (RBC) precursors or erythropoietin, which then interfere with RBC production.

It can be associated with various diseases, including myeloproliferative and lymphoproliferative disorders, autoimmune diseases, thymoma, medications, and infections. PRCA should be considered in the differential in patients with isolated anemia and reticulocytopenia in the presence of normal platelet and white cell count. A BM biopsy that shows an absence or reduced number of erythroblasts is diagnostic. In this case, the patient needed a second BM biopsy to prove he had PRCA. The mainstay of management of PRCA is immunosuppressive medication. This is achieved by cyclosporine, a potent immunomodulatory agent that inhibits the production of cytokines involved in regulation of T-cell activation.

CONCLUSION: This was a case of an acquired PRCA in an elderly male who has had chronic anemia with recurrent blood transfusions for the past 20 years. It is vital to know that PRCA has an incidence rate of 1.06 patients per million per year. As a result, PRCA is noted to be extremely rare and prompt treatment should be initiated to avoid further transfusions.

CHYLOTHORAX DUE TO SUPERIOR VENA CAVA OCCLUSION IN SETTING OF A METASTATIC ANTERIOR MEDIASTINAL MASS

Kelly S. Schulte¹; Kavanya Feustel¹; Jeffrey Ramsey¹; Michele Basche²

¹Internal Medicine, Sky Ridge Medical Center, Lone Tree, CO; ²Rocky Mountain Cancer Center - Denver Midtown, Denver, CO. (Control ID #3875480)

CASE: A 41 year old female with a past medical history signficant for stage IV right sided invasive ductal carcinoma with metastasis to bone, lung, and mediastinum status post bilateral mastectomy and chemoradiation presented with several days of shortness of breath and progressive swelling of the bilateral arms, face, and neck. She was recently diagnosed with acute deep vein thrombosis in her internal jugular and innominate veins and initiated on apixaban. Physical examination revealed decreased bibasilar breath sounds and edema consistent with her chief complaint. CT angiography showed bilateral brachiocephalic vein occlusion from the mass with collaterals and bilateral pleural effusions. She was treated with therapeutic enoxaparin and octreotide. Thoracentesis and a pleural catheter removed chylous fluid with triglycerides of 1666 mg/dL and cytology negative for malignancy. The patient was diagnosed with superior vena cava syndrome and chylothorax secondary to her anterior mediastinal mass obstructing the thoracic duct and compressing the bilateral brachiocephalic veins.

IMPACT/DISCUSSION: Malignancy is the most common cause of non-traumatic chylothorax. Large chylothorax can present with progressive breathlessness and pressure from mass effect. Thoracentesis can be both diagnostic and therapeutic. Triglyceride levels will be greater than 110 mg/dL. A high protein, low fat diet with medium chain triglycerides reduces the production of chyle. Octreotide can reduce lymphatic flow via decreasing gastric blood flow. Therapeutic thoracentesis or placement of indwelling pleural catheter can be considered before thoracic duct ligation/embolization should conservative management be ineffective. Her history of chest cavity radiation precluded consideration of thoracic duct ligation/embolization. Superior vena cava (SVC) syndrome can occur from tumor extrinsic compression. This presents with upper extremity and head edema. Upper extremity DVT can occur due to compression of the subclavian veins. Management includes elevating the head to reduce venous pressure, endovascular therapy, anticoagulation, and antineoplastic therapy. Bilateral brachiocephalic veins were stented and she was treated with 3 months of enoxaparin anticoagulation and radiation therapy for her mediastinal mass.

CONCLUSION: Both chylothorax and SVC syndrome can occur from an underlying malignancy. In this case, the anterior mediastinal mass metastatic from her breast cancer was the culprit for both presentations simultaneously. Patients will present with face/upper extremity edema with dyspnea. While the dyspnea could be from severe SVC syndrome, considerations should be made for chylothorax in the setting of active malignancy. Management should include conservative management of diet modification, octreotide infusions, thoracentesis/pleural catheter placement as well as anticoagulation, endovascular therapy, and radiation for chylothorax and SVC syndrome, respectively.

CLOT VERSES BLEED: APPROACH TO SEVERE THROMBOCYTOPENIA IN THE METASTATIC CANCER PATIENT

Sarah Falta

Department of Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #3877069)

CASE: RJ is a 58-year-old male who presented with acute bilateral vision loss noted upon waking up. Patient and family denied any facial droop/asymmetry, dysarthria/aphasia, limb weakness, eye pain or headaches. He had a complicated medical history including HLD, HTN, metastatic NSCLC complicated by multiple CVAs, pulmonary embolism, marantic endocarditis with aortic insufficiency, HFrEF and atrial fibrillation. He started treatment with chemotherapy/immunotherapy, but this was stopped after he developed HLH. 2 months prior to presentation he developed thrombocytopenia and underwent treatment for ITP with steroids and rituximab. Family history was noncontributory. The patient was a Jehovah’s witness and denied any alcohol, smoking or drug use. Current medications did not include any blood thinners, heparin products, immunosuppressive medications or steroids. Vital signs were normal. Physical exam demonstrated diffuse bruising and vision loss with bilateral intact pupillary light reflexes. The rest of the exam was normal. Initial labs showed and AKI with Cr of 2 (baseline 1.5), normal CMP, CBC showing thrombocytopenia to 8k, Hb 11.9, INR of 1.9. UA was positive for RBCs. Hematologic labs showed a LDH of 622, haptoglobin <30, absolute reticulocyte count of 115k, fibrinogen <70 with fibrinogen degradation products present, ADAMTS13 of 56 with negative antibodies, APLS antibodies negative and blood smear showing moderate schistocytes. MRI brain showed multiple acute infarcts throughout the cerebellum, and cerebrum. He was treated with steroids, IVIG, romiplostim, fibrinogen replacement and 1 treatment of plasmapheresis. He declined all blood products. Patient unfortunately experienced flash pulmonary edema during his hospital course and was admitted to the ICU where he passed away. His final diagnosis was DIC secondary to his malignancy.

IMPACT/DISCUSSION: DIC has a known association with malignancy, however it has diverse presentations making it difficult to diagnose. This case was unique in that the presenting complaint was acute thrombotic CVAs with severe thrombocytopenia without overt signs of bleeding, anemia or organ disfunction. This patient’s complicated past medical history made his diagnosis difficult with the key being in approaching the thrombocytopenia systematically and obtaining a full laboratory workup to assess hemolysis, coagulopathy, and fibrinogen level.

CONCLUSION:

DIC can present in heterogeneously including bleeding, arterial/venous thrombosis and organ failure making it important to keep it on the differential for patients with high-risk conditions such as malignancy who present with any of the above complications.

DIC can be distinguished from other thrombocytopenic disorders by the characteristic pattern of thrombocytopenia, ± anemia, prologued coagulation studies, evidence of hemolysis and low fibrinogen level.

COCAINE INDUCED ANEURYSMAL DILATION OF LEFT MAIN CORONARY ARTERY Lawrence Zhou¹; Rajeev V. Seecheran²; Majd Kayali²; Rhythm Vasudeva²; Wassim Shaheen²

¹Medicine- Pediatrics, University of Kansas School of Medicine Wichita, Wichita, KS; ²Internal Medicine, University of Kansas School of Medicine Wichita, Wichita, KS. (Control ID #3877114)

CASE: A 30-year-old female with no significant past medical history except substance abuse with cocaine, most recently two days prior, presented to the emergency department for acute chest pain and shortness of breath upon awakening. Her EKG on presentation showed non-specific ST-T wave changes in the inferior leads. She was found to have a high sensitivity Troponin (hs-T) level of 27 ng/L that trended up to 182 ng/L, D-dimer 1216 ng/mL, and BNP 633 pg/mL. Prompted by elevated D-dimer, subsequent CT angiography (CTA) of the chest was negative for pulmonary embolism. She was admitted to the ICU and started on heparin infusion along with aspirin and atorvastatin. Within 12 hours, her hs-T peaked at 34,060 ng/L.

A transthoracic 2D echocardiogram showed a normal left ventricular ejection fraction of 55-60%. Coronary angiography revealed an obtuse marginal artery with 90% stenosis, left circumflex artery with 90% stenosis, and mid-left anterior descending artery (LAD) with 50%-60% stenosis with aneurysmal dilatation. As a result, a coronary artery bypass graft (CABG) was performed.

An underlying autoimmune process was suspected given her young age. While the erythrocyte sedimentation rate was elevated at 36 mm/hr and anti-U1-ribonucleoprotein antibody elevated at 1.1 AI, other inflammatory and autoimmune markers were negative. In addition, CTA of the head, neck, chest, and abdomen did not show evidence of vasculitis or other aneurysms. An artery biopsy could not be obtained during surgery, and ultimately further workup was deferred to an outpatient setting with cocaine use as the plausible etiology.

IMPACT/DISCUSSION: Coronary artery aneurysms are uncommon phenomena but are increasingly diagnosed in the age of angiography. Their etiology are more often acquired than congenital, most commonly as a sequela of Kawasaki disease but also seen in autoimmune vasculitis such as polyarteritis nodosa or Takayasu arteritis, or cocaine abuse such as the case presented here. Most cases of coronary artery aneurysm are asymptomatic, while the manifestations of symptomatic aneurysms are frequently related to an underlying pathology. With cocaine use, it is suspected that episodic severe hypertension and vasoconstriction leads to ischemia and endothelial weakening, leading to aneurysm formation over time.

CONCLUSION: Careful history taking is essential to uncover less common causes of coronary aneurysm formation, such as drug use or an underlying autoimmune process, especially in younger patients.

COLO-PANCREATIC FISTULA; A LATE NECROTIZING PANCREATITIS COMPLICATION Anass Dweik¹; Sadia A. Tanami²; Mustafa Al-Bayati¹; Falah I. Abu Hassan³; Mahmoud Elmahi¹; James ". Walker^4,1

¹Internal medicine, Texas Tech University Health Sciences Center School of Medicine Amarillo, Amarillo, TX; ²Internal Medicine, Texas Tech University System, Lubbock, TX; ³Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX; ⁴Internal Medicine, Texas Tech, Amarillo, TX. (Control ID #3858433)

CASE: A 45-year-old male with a recent history of necrotizing pancreatitis was admitted to the hospital for generalized weakness along with nausea and vomiting. He was treated conservatively initially as the he tested positive for COVID and the concern was for early viremic prodrome. However, he was consistently febrile and his WBC count was up trending; hence, blood cultures were ordered and grew streptococcus viridans and antibiotics were started. The source of his bacteremia was unclear and ID recommended an echocardiogram which was within normal limits. Given his history of complicated pancreatitis, the decision was made to get a CT scan of his abdomen and pelvis that revealed multiloculated abscess-like collection near the left kidney with few foci of air concerning for fistulous connection with the colon at the splenic flexure. A repeat CT

scan with rectal enema later confirmed the fistulous tract. He was then taken for surgery where they found extensive inflammatory changes and adhesions of the splenic flexure to the retroperitoneum and tail of the pancreas. A left colectomy with closure of the colo-pancreatic fistula was performed. Patient tolerated the procedure well and he was later discharged home on antibiotics.

IMPACT/DISCUSSION: Acute pancreatitis is an acute inflammatory process of the pancreas that is often categorized based on its histopathological characterization as either interstitial or hemorrhagic-necrotizing pancreatitis. Necrotizing pancreatitis usually carries a worse prognosis as compared to interstitial pancreatitis with a mortality rate of 17% versus 3% accordingly. Colonic complications are uncommon. The overall incidence ranges between 3-6% of acute pancreatitis cases. According to few case reports published, the incidence of colo-pancreatic fistula ranges between 3-10% of patients with severe acute pancreatitis. The reported time of diagnosis of the fistula from the time of acute pancreatitis ranges from 10 to 180 days. Our patient developed it approximately 5 months after the diagnosis of acute pancreatitis. The left side of the colon seem to be more commonly involved in these cases due to anatomical proximity. Clinical presentation is variable and ranges from colonic symptoms ie bleeding and/or diarrhea to common pancreatitis-like symptoms including nausea/vomiting. CT scans with or without contrast and endoscopy are two efficient diagnostic modalitis. Colonic fistulas often carry a higher risk for complications including persistent infection, severe hemorrhage, or perforations. They are also less likely to close spontaneously as compared to upper GI fistulas. No clear guidelines are published so far with regards to treatment; hence, plan should be tailored based on the surgeon’s clinical expertise.

CONCLUSION: Colonic complications of acute pancreatitis are uncommon but are potentially serious. A low threshold should be set when a patient with history of pancreatitis is having resolving symptoms and when there is unexplained leukocytosis or sepsis.

COMFORT MEASURES ONLY: ETHICAL CONSIDERATIONS IN GUILLAIN BARRE SYNDROME

Aneeqah H. Naeem^1,2; Karl Herman²; Zain Chaudry³; Kaitlyn P. Lew⁴; Arkadiy Finn²

¹Brown University Warren Alpert Medical School, Providence, RI; ²Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI; ³University of Vermont Larner College of Medicine, Burlington, VT; ⁴The Center for Bioethics, Harvard Medical School, Boston, MA. (Control ID #3876878)

CASE: A 73-year-old female presented to the hospital one day after a fall. She had two days of progressive muscle weakness after having an upset stomach one week prior. She was an avid biker and shocked by her inability to ambulate, swallow, and speak. Her physical exam was notable for lower leg weakness, numbness and tingling of her hands, and a lack of reflexes. An initial lumbar puncture was unremarkable. She initially started on IVIG with a concern for Guillain Barre Syndrome (GBS).

As her symptoms acutely worsened, she developed increased work of breathing. Her condition prompted a discussion of measures to protect the patient's airways. At that time, her husband seriously considered stopping all life-saving measures. After a shared decision-making discussion between the medical team and husband, he agreed to a trial of BiPAP and plasmapheresis. She experienced rapid improvement in movement of her upper extremities but slower improvement in her lower extremities. The patient and her husband seriously considered transitioning her care to comfort measures only (CMO), despite extensive discussions from the primary, neurology, and palliative care teams about the favorable prognosis of GBS. Given how much she prioritized walking and biking, she remained questionable about her prognosis. But she decided to “give rehab a try” despite these frustrations. Through these conversations, she was always deemed to have capacity to make medical decisions.

The patient agreed to attend rehab for a limited time course of two weeks to see if her symptoms improved. However, the day before her discharge, she had an acute GI bleed. With the husband’s support, the patient changed her mind and decided on hospice care. Her strength continued to improve in the hospice setting and there were discussions that she may graduate out. However she slowly declined to eat and passed away 3 weeks later

IMPACT/DISCUSSION: The challenge in this case is balancing the bioethical principles of beneficence, doing good for the patient, and nonmaleficence, doing no harm to the patient, with respect for autonomy. Centering care around the patient and identifying what matters most to the patient can help avoid imposing unwanted medical recommendations and paternalism. GBS has a very good prognosis and limited time course, with more than half of patients returning to their full baseline status. Despite extensive education and discussions with palliative care, the patient was frustrated with her inability to walk, in which being active was an important part of her goals and identity, and felt this disease represented her ultimate decline. An overfocus on health and survival as a primary goal, may exclude the importance of emotions and lived experience as part of a disease process no matter the eventual prognosis.

CONCLUSION: Providers must balance beneficence, nonmaleficence, and respecting patient autonomy regardless of disease process to assist goals of care conversations with patients.

COMING STRAIGHT FROM THE HEART: UROTHELIAL CARCINOMA PRESENTING AS CARDIOEMBOLIC STROKE

Jabra Zarka, Nikhita Chahal, Michael Simonson

Department of Medicine, UPMC Presbyterian-Shadyside, Pittsburgh, PA. (Control ID #3875218)

CASE: A 63-year-old woman with a history of chronic tobacco use was admitted to the hospital with sudden onset slurred speech, confusion, and word finding difficulty. Upon arrival, brain MRI showed acute left-sided lacunar and small focal left anterior temporal lobe infarcts. A transthoracic echocardiogram (TTE) showed a 1.8cm mobile left ventricle mass adherent to midportion of the interventricular septum. Subsequent cardiac MRI demonstrated a 5 x 2.5 cm mass in the right ventricle with infiltration into the septal myocardium and extension into the left ventricle with heterogeneous perfusion suggesting areas of high vascularity, as well as areas of necrosis and thrombi. Given these findings, there was high suspicion for metastatic disease. CT scan of her chest, abdomen, and pelvis revealed a renal mass, multiple masses in bilateral upper and lower lung fields, and adrenal enlargement. A biopsy of the renal mass confirmed high-grade urothelial carcinoma. She was diagnosed with metastatic urothelial carcinoma with skeletal and cardiac metastases. Her hospital course was further complicated by episodes of ventricular tachycardia, attributed to her cardiac mass, for which she was started on amiodarone. She was discharged on apixaban and initiated on cisplatin gemcitabine two weeks later.

IMPACT/DISCUSSION: This case describes a patient who initially presented with a cardioembolic stroke, found to be the result of metastatic urothelial carcinoma and associated ventricular thrombus.

Multifocal acute ischemic strokes, as was seen with this patient, should raise concern for a central or cardioembolic source. A cardiac source should be considered in all patients with embolic strokes, even in the absence of heart disease. Atrial fibrillation is the most common etiology for thromboembolic strokes, but other causes of embolism are important to identify and investigate. In this case, underlying metastatic urothelial carcinoma was identified.

Urothelial carcinoma is the most common form of bladder cancer in the United States. It can present with typical urinary symptoms such as gross or microscopic hematuria and difficulty voiding; however, other symptoms or complications can also be present. Approximately 25% of patients with urothelial cancer present with metastatic disease, often to adjacent pelvic organs, bone, liver, or lung. Cardiac metastasis, as seen in this patient, is uncommon but has been described in case reports. Urothelial carcinoma can also present with thrombotic complications such as venous thromboembolism (VTE) or arterial thrombosis. The risk for VTE in this population is similar to other metastatic cancers, occurring in 5-10% of patients.

CONCLUSION: Patients with multifocal cerebral infarcts should be evaluated for cardiac pathology. Urothelial carcinoma is often diagnosed after metastasis and is associated with risk for thromboembolic events. Physicians must not underestimate the potential for high-grade neoplasm when considering the cause of cardioembolic stroke.

COMPLICATIONS AND CO-INFECTIONS IN MONKEYPOX: MRSA BACTEREMIA IN A PATIENT WITH UNDERLYING ECZEMA AND HIV

Daniel Resnick¹; Elizabeth Y. Kim²; Amalia Aldredge²; Ashley McDowell¹; Anandi Sheth³

¹Internal Medicine, Emory University School of Medicine, Atlanta, GA; ²Infectious Diseases, Emory University School of Medicine, Atlanta, GA; ³Infectious Diseases, Emory University School of Medicine, Atlanta, GA. (Control ID #3873705)

CASE: A 22-year-old man with untreated HIV (CD4 count 297 cells/mm³) and eczema presented with 3 days of constitutional symptoms and a new pruritic rash. He had one male sexual partner in the past 3 months and no sick contacts.

He was ill-appearing, febrile to 39.3^oC, tachycardic to 107, and had a lactic acid level of 3.0 mmol/L. Physical exam was notable for large, eczematous plaques on the extremities’ flexor surfaces, fine papules on the back and abdomen, numerous ~1-2cm pustules on his skin diffusely, and an ulcer on the penile glans.

We initiated a broad infectious workup and swabbed the lesions for orthopoxvirus testing. Admission blood cultures grew methicillin resistant Staphylococcus aureus (MRSA). He was also diagnosed with rectal gonorrhea and late latent syphilis. We treated him with vancomycin, ceftriaxone, penicillin, antiretroviral therapy, and symptomatic therapy for the rash. On hospital day 3, orthopoxvirus PCR resulted as positive, consistent with human monkeypox virus (MPXV). Given his comorbidities, we initiated tecovirimat. The patient responded well to treatment and discharged on hospital day 6.

IMPACT/DISCUSSION: The 2022 global outbreak of MPXV has been labeled by the United States and World Health Organization as a public health emergency. 5-13% MPXV cases require hospitalization, and general internists must understand how to diagnose MPXV and manage its complications. This patient presented with the typical progression of MPXV symptoms and developed a significant complication (sepsis from MRSA bacteremia). MPXV often begins with constitutional symptoms before the appearance of a papular, vesiculopustular, or ulcerative rash that may affect all body areas. In the ongoing global outbreak, anogenital and/or mucosal lesions are common. Infections have clustered among men who have sex with men, and co-occurring sexually transmitted infections have been diagnosed at rates as high as 50%.

Bacteremia is a rare complication of MPXV. Comorbid eczema can increase the severity of orthopox viruses, such as MPXV, and may have contributed to the development of bacteremia. Treatment with the antiviral medication tecovirimat may be considered for individuals with or at high risk for severe disease. This patient carried several indications for treatment, including immunocompromised state (HIV), co-morbid eczema, and a severe complication (bacteremia). Tecovirimat may also be considered for pregnant individuals, lesions that have a high potential for scar/ stricture, proctitis, or other severe symptoms. Tecovirimat is approved by the FDA for human smallpox disease treatment; its use for other orthopoxvirus infections is available under a non-research expanded access Investigational New Drug protocol held by the Centers for Disease Control and Prevention.

CONCLUSION: With the emergence of MPXV in the US and globally, this case helps identify MPXV complications that require hospitalization and potential indications for antiviral treatment.

CONSIDER A BROKEN HEART POST STATUS EPILEPTICUS

PALLABI SHRESTHA¹; Aaron Bertolo¹; Iniya Rajendran²

¹Internal Medicine, The University of Arizona College of Medicine Tucson, Tucson, AZ; ²Cardiology, The University of Arizona College of Medicine Tucson, Tucson, AZ. (Control ID #3877252)

CASE: 71-year-old female with recent left MCA stroke with right-sided hemiplegia and aphasia presented to the hospital with status epilepticus. Neurology was consulted and patient was managed with levetiracetam. She was admitted to CCU service for EKG demonstrating anteroseptal ST elevation with elevated troponins. Repeat EKG showed resolved ST elevations. Given her stroke and an unclear neurological status at the time of presentation, and possible completion of myocardial infarction, coronary angiogram was deferred, and medical therapy was continued. Echocardiogram showed an LVEF of 20 to 25% with regional wall motion abnormalities (decreased from 70% a year ago) that could represent LAD territory infarction or Takotsubo cardiomyopathy. Patient improved clinically with medical management. Cardiac MRI was done to evaluate for viable tissue which showed no myocardial infarction or overt fibrosis, but significant myocardial edema concerning for features of Takotsubo Cardiomyopathy.

IMPACT/DISCUSSION: Takotsubo Cardiomyopathy (TC) is an acute stress-induced cardiomyopathy, diagnosed based on criteria which include anatomical features, ECG changes, cardiac biomarker, reversibility of myocardial dysfunction and absence of coronary lesion on angiography. TC is typically associated with stressful emotional or physical event, which are well-described in approximately 2/3 of all cases. The pathophysiology of TC has not been confirmed, however, the two most supported theories include catecholamine-induced cardiotoxicity and microvascular dysfunction. It has been demonstrated that serum catecholamine concentration is 2-3x higher in patients with TC. Epileptic seizures induce substantial catecholamine release. Moreover, cortical regions regulate the autonomic activity that modulates the cardiac activity. Thus, epileptic seizures affecting the brain and nervous system bring about transient and long-term changes affecting the structure, microvasculature and functioning of the heart inducing propensity for TC. As of 2019, approximately 50 cases of TC described were related to seizure activity. Seizures may induce TC immediately or delayed, often present without typical symptoms of chest pain and dyspnea (like in our patient) and can be overlooked. There are studies associating complications from TC resulting in Sudden Unexpected Death in Epilepsy Phenomena (SUDEP). Hence, it is very important to establish this connection for proper surveillance and monitoring of the patients.

CONCLUSION: It is important for physicians to remember the association between seizures and TC, and to complete a thorough investigation for TC in patients who present with seizures. Diagnostic work-up should include ECG, cardiac enzymes, echocardiogram, and possibly even coronary angiogram or cardiac MRI. Accurately diagnosing TC and implementing effective management on time may help save lives in patients who present with seizure

CONVERTING FROM A HYPERTHYROID TO A HYPOTHYROID STATE: THE JOD-BASEDOW EFFECT WITH AN INTERESTING TWIST

Rachel A. Zielinski¹; Martha Dillon²; Plukshi J. Bhatt³; Alvaro Ayala²; Kyle Bogusz¹; Madura Saravanan¹

¹Primary Care Internal Medicine, University of Connecticut, Storrs, CT; ²Internal Medicine, University of Connecticut School of Medicine, Farmington, CT; ³Internal Medicine, UConn Health, Farmington, CT. (Control ID #3875512)

CASE: A 79-year-old female with a past medical history of type 2 diabetes mellitus, coronary artery disease, hyperlipidemia, hypertension, and diastolic heart failure presents to her primary care physician’s office 3 months after she was hospitalized for chest pain, nausea, and vomiting. During her admission, she received a CT abdomen/pelvis with IV contrast as part of her workup. In follow-up, she endorsed an unintentional weight loss of 36 pounds over 2 months, frequent crying, decreased appetite, daily vomiting, decreased concentration and memory loss. These symptoms were initially attributed to depression as her sister recently passed from COVID-19 and her daughter had suffered a stroke. On exam, her speech was slow and she displayed inattention. Her labs revealed elevated free T4 3.1 ng/dL [0.5-1.3] and T3 8.0 pg/mL [1.5-4.1], suppressed TSH < 0.02 IU/L [0.35-5.50], elevated TSH receptor binding 9.84 IU/L [<2.0] and antithyroglobulin >500 IU/mL [<4.0] antibodies. She was started on propranolol 20 mg twice a day and referred to Endocrinology. There she endorsed night sweats, increased appetite, diarrhea, fatigue and nausea. Exam was notable for left eye exophthalmos with lid lag and enlarged thyroid. Thyroid uptake scan showed 53% uptake at 24 hours [10 to 30%] and diffusely increased iodine trapping without nodules. She was diagnosed with Graves’ disease (GD) and started on methimazole with improvement in her symptoms. Six months later, repeat labs showed elevated TSH. This was initially attributed to the methimazole, which was then stopped. However, her TSH continued to increase and she had worsening symptoms including memory loss, weight gain, lethargy, hair loss and constipation. Exam was benign but labs showed low normal free T3 and T4. She was diagnosed with hypothyroidism and started on levothyroxine 25 mcg daily, which was titrated every 6 weeks until TSH was normal.

IMPACT/DISCUSSION: The diagnosis of iodine-induced hyperthyroidism, or the Jod-Basedow effect, should be suspected in patients who present with hyperthyroid symptoms weeks to months after iodine exposure, often with CT scans. GD is an autoimmune disease that typically presents with hyperthyroidism. Rarely, some patients can switch from a hyperthyroid to a hypothyroid state. However, this is a rare phenomenon and usually occurs several years after the initial episode. In this case, our patient likely had previously undiagnosed GD which was precipitated by the iodine load and after just 6 months she switched to a hypothyroid state spontaneously.

CONCLUSION: Literature shows that patients with GD typically have only TSH receptor-stimulating antibodies. However, it is being increasingly recognized that both TSH receptor-stimulating and thyroid- inhibiting antibodies can be produced in the same patient. Based on the concentration of the stimulating and inhibitory antibodies, the patient can present with symptoms of hyperthyroidism or hypothyroidism.

COULD COBALT BE THE CULPRIT

Lindsey Blackmon²; Claire Goode³; Nathan Douthit¹

¹internal medicine, East Alabama Medical Center, East Alabama Medical Center, Opelika, AL, US, hospital, Auburn, AL; ²Internal Medicine Resident, East Alabama Medical Center, Opelika, AL; ³Edward Via College of Osteopathic Medicine - Auburn Campus, Auburn, AL. (Control ID #3873042)

CASE: A 58-year-old male with a history of right metal on metal (M-o-M) total hip arthroplasty (THA) 9 years prior to admission with partial revision 6 years later, presented to the ED with dyspnea on exertion, weight loss and generalized weakness. Two years prior to admission, he developed hearing loss, visual impairment, peripheral neuropathy and hypothyroidism. Four months prior, he was treated for cardiac tamponade. On exam, the patient had almost complete deafness, partial blindness, intermittent diminished dorsalis pedis and radial pulses, and tachycardia. Labs showed Cr of 1.2 mg/dL, lactic acid of 8.6 mmol/L, calcium of 12 mg/dL, WBC of 3.7 x103 /mcL and PLTs of 63 x103 /mcL. On echocardiogram, EF was 15%, reduced from 1 month prior (25%). Serum cobalt level was elevated at 609.4 mcg/L (normal 0.1-0.4 mcg/L). Replacement of the M-o-M hip replacement was recommended as definitive management. Chelation therapy with N-acetyl cysteine was initiated as well. Replacement of the M-o-M joint was not feasible due to multiorgan failure. Ten days after admission, the patient died, 9 years after the initial M-o-M THA. IMPACT/DISCUSSION: Cobalt can induce gross tissue necrosis and macrophage toxicity via DNA fragmentation and production of reactive oxygen species. Systemic toxicity manifests months to years after joint replacement, and clinical features fall into three categories: neuro-ocular toxicity, cardiotoxicity and thyroid toxicity—all present in our patient. Neuro-ocular toxicity results from reactive oxygen species producing demyelination and destruction of axons. Clinical signs include peripheral neuropathy, sensorineural hearing loss and vision loss. Clinical signs of cardiotoxicity include dyspnea on exertion, impaired diastolic and systolic function, dilated cardiomyopathy and pericardial effusion. Toxic levels of cobalt impair the uptake and oxidation of iodine, resulting in hypothyroidism. Toxicity occurs with varying cobalt levels. In a 2014 review of 18 clinical cases, the mean cobalt concentration when toxicity was present was 398 mcg/L. Another article from 2013 stated prosthetic hip-associated cobalt toxicity was more likely to be diagnosed when serum cobalt levels approach values >100 mcg/L. True toxicity can be distinguished from benign elevations in cobalt levels by three criteria: (1) elevated serum or whole blood cobalt levels, (2) at least two confirmed findings consistent with cobalt toxicity and (3) exclusion of other etiologies. While chelation therapy may be useful in reducing levels of circulating cobalt levels, there is limited evidence of response to this therapy. The definitive treatment is removal of the metal containing prosthesis eliminating the cobalt source.

CONCLUSION: Cobalt toxicity secondary to M-o-M articulations from THAs fall into three main categories: neuro-ocular, cardiac and thyroid toxicity.

Definitive management of cobalt toxicity is only achieved by replacement of the M-o-M prosthesis, although chelation may play a role.

COVID-19 ANCHORING BIAS RESULTING IN NEAR-MISS OF DISSEMINATED HISTOPLASMOSIS

Nilesh Kapoor¹; Benjamin P. Buettner²

¹College of Medicine, The Ohio State University, Columbus, OH; ²Division of Hospital Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #3854217)

CASE: A 60-year-old incarcerated male with hypertension and recent SARS-CoV-2 exposure was evaluated for syncope. He had no respiratory symptoms but reported ongoing unintentional 30-pound weight loss. He was tachycardic and chronically ill-appearing. Chest x-ray showed bilateral reticular opacities. Labs revealed leukopenia of 3300 cells/mm³ with absolute lymphopenia of 200 cells/mm³. RT-PCR for SARS-CoV-2 was negative on three separate days. He received remdesivir for presumptive Covid-19 and was discharged on dexamethasone and azithromycin.

He was re-admitted two days later with confusion and continued syncope. Streptococcus, Legionella, and a viral PCR panel including SARS-CoV-2 were all negative. Chest CT revealed a 2.2 cm lingular nodule and widespread micronodular foci concerning for malignancy. Fifth generation HIV testing was reactive for HIV-1. Viral load was 3.9 million copies and CD4 was 15 cells/mm³. Infectious workup was broadened. Serum and urine Histoplasma antigens were positive beyond quantification. Fungal cultures from bronchoscopy with bronchoalveolar lavage also grew Histoplasma. He improved clinically with itraconazole and was discharged on bictegravir-emtricitabine-tenofovir for treatment-naïve HIV.

Two weeks later, he was re-admitted with progressive dyspnea and headaches despite treatment adherence. Brain MRI was unremarkable. Repeat chest CT showed interval worsening, prompting a transbronchial biopsy which showed necrotizing granulomas and florid yeast forms morphologically consistent with Histoplasma. Blood and CSF cultures obtained in prior admission also returned positive for H. capsulatum. He was initiated on amphotericin B.

Following six-weeks of amphotericin, he was continued on maintenance itraconazole. He is currently alive and asymptomatic. After seven months of antiretrovirals, his CD4 has increased to 178 cells/mm³ and viral load has decreased to 130 copies.

IMPACT/DISCUSSION: This case highlights the consequences of incomplete workup and diagnostic delays secondary to the availability heuristic and anchoring biases introduced by Covid-19. Disseminated histoplasmosis and undiagnosed/untreated HIV are inevitably fatal. To combat anchoring biases while grappling with diagnostic uncertainty, this case speaks to the success of continuous, conscious consideration of alternative etiologies. Furthermore, HIV screening and treatment is suboptimal for many incarcerated patients, and this case shows how cognitive biases inadvertently exacerbate pre-existing disparities in their care. Finally, biopsy is reasonable when presented with a miliary pattern on imaging as it is commonly seen in M. tuberculosis and lymphangitic carcinomatosis, both of which were also on the differential.

CONCLUSION: Providers are reminded to test for HIV in patients admitted with suspected infection and/or a history of inadequate preventative healthcare. Presumptive Covid-19, despite multiple negative RT-PCR tests, should be considered and treated only as a diagnosis of exclusion.

COVID-19 INDUCED BRADYCARDIA

Ryan Arispe¹; Neetal Kumar¹; Jessie Wagner²; jennifer Beal²; Nisha Dhanabalsamy¹; Srinivasan Rajaganapathy¹

¹Internal Medicine, Medical City Fort Worth, Fort Worth, TX; ²University of North Texas, Denton, TX. (Control ID #3868749)

CASE: Our patient is a 75 year old female with a past medical history of Hypertension, Chronic Systolic Heart Failure, Hyperlipidemia, History of Tobacco Use, Anxiety and Depression who reported having fatigue and severe dyspnea on exertion while waiting for her plane at the airport associated with fatigue, lightheadedness and dizziness requiring her to be transported out of the airport in a wheelchair. While at home, the symptoms persisted and her apple watch notified her that her heart rate was in the 30s prompting her to present to the ED. She denied any episodes of loss of consciousness. Initial vitals revealed blood pressure 139/58, oxygen saturation 95% on room air with a respiratory rate of 29, temperature of 98.2F, a heart rate of 33 bpm and an EKG was performed that showed idioventricular rhythm with a rate of 33. On further questioning, the patient denied any previous bradycardic episodes in her past and reported having COVID 3 weeks prior for which she was not hospitalized and was treated outpatient with Paxlovid. She denied any other medication changes with her home medications including Amlodopine, Atorvostatin, Entresto, Bisoprolol and Spironolactone. Her magnesium was slightly low at 1.7 mg/dL and BNP was elevated at 354 pg/mL. All other labs including troponin, TSH, potassium, calcium, were within normal limits. Echocardiogram was performed and showed normal systolic function with no regional wall motion abnormalities. The patient was admitted to the intensive care unit, and started on a Dopamine drip. Cardiology was consulted and her home medication bisoprolol was discontinued. Repeat EKG showed persistent sinus bradycardia. She was started on Theophylline and her heart rate improved to the 60s through the night with sinus rhythm on telemetry. She was discharged home in stable condition.

IMPACT/DISCUSSION: COVID-19 impacts more than just the pulmonary system with this case emphasizing the burden on the body, including the heart’s conduction system even with treatment. This unvaccinated patient had a mild COVID-19 infection that was able to be treated for with Paxlovid and sent home. Her escalation to involvement of her heart’s conduction system further emphasizes the importance of prevention and for evaluation of the vaccination’s usage for prevention or minimization of long-term COVID symptoms.

CONCLUSION: Our case is unique as it represents a case of SA Node dysfunction following a recent COVID-19 infection and treatment while taking a beta blocker. It is not fully known how COVID-19 leads to an impaired conduction system or chronotropic response, but it could possibly be related to viral uptake in cardiac myocytes through the spike protein and an inflammatory response leading to conduction abnormalities. As our patient’s heart rate resided higher than 60 beats per minute prior to COVID-19, while on a beta blocker, it’s likely that the COVID-19 effect on her heart was synergistic with the medication’s effects and caused an aberrant conduction abnormality

COVID-19 INFECTION AND THE SURPRISE GUILLAIN BARRE SYNDROME DIAGNOSIS Neil Gerts, Trevor Owens, Preetivi Ellis, Venkat Aachi, Jasprit Takher

Internal Medicine, Los Robles Regional Medical Center, Thousand Oaks, CA. (Control ID #3867927)

CASE: A 39-year-old male with no past medical history presented with acute onset bilateral lower extremity paralysis and left eye proptosis. The morning prior, he awoke with a fever at 102°F, a headache, and paralysis from his bilateral waist down to his lower extremities, with numbness in his genitourinary region and inability to walk. The following morning he awoke with new onset numbness in his bilateral hands, proptosis of his left eye, and blurry vision, leading him to the ED. Patient denied any recent illness, but did state his son was sick two weeks ago with COVID-19. He denied any prior COVID-19 or Flu vaccinations, and any IV drug use. In the ED, vital signs were stable and the patient was afebrile. No leukocytosis was noted and BMP was within normal limits. CT head, CT C-spine, CT L-spine negative were all negative. On initial physical exam, the patient was noted to have significant left eye proptosis, lack of sensation in bilateral lower extremities from the waist to the toes, and 0/5 reflexes in lower extremities. He did have 5/5 muscle strength in all extremities. No nuchal rigidity was appreciated. He was noted to have decreased wrinkles on his left forehead. He was then found to be COVID-19 positive. MRI with and without contrast of the brain and spine were negative with no evidence of nerve compression. A LP demonstrated elevated protein CSF at 159, normal glucose, and white blood cell count. Due to albuminocytological dissociation seen, there was a concern for Guillain-Barré Syndrome. The patient was then started on IVIG 400 mg/kg/dose x 5 doses daily. Gram stain of CSF, CSF culture, and blood cultures were all negative. On day of discharge, he was noted to have resolution of his lower extremity paralysis, numbness in his hands, blurry vision and proptosis of his left eye.

IMPACT/DISCUSSION: Guillain-Barre Syndrome is associated with GI and respiratory infections, and as COVID-19 continues to spread throughout the world, it is important to associate the infection with GBS. Prior to the COVID-19 pandemic, there was little association between prior Coronaviruses and GBS, but there has been an increase in the number of patients with GBS who are found to be COVID-19 positive. It is important to rule out other viral causes of GBS in order to strengthen this association. A lumbar puncture is diagnostic, which will demonstrate albuminocytological dissociation. Treatment consists of IVIG or plasmapheresis, and in this case, the course of IVIG rapidly resolved the patient’s symptoms. As the patient was not hypoxic, no treatment for the COVID-19 infection was necessary. Overall, given the recent introduction of COVID-19, it is important to note its association with GBS, and the diagnostic workup and treatment associated with it.

CONCLUSION: As new information is being discovered about COVID-19, we hope to demonstrate the association between COVID-19 and GBS.

Treatment consists of either IVIG or plasmapheresis, while also addressing the underlying cause, in this case COVID-19.

COVID-19 INFECTION INDUCED ACQUIRED AMEGAKARYOCYTIC THROMBOCYTOPENIA Sukhila B. Reddy¹; Ilmaben Vahora¹; Javier Corral²

¹Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX; ²Texas Tech University Health Sciences Center El Paso, El Paso, TX. (Control ID #3875554)

CASE: A 75 years old hispanic female patient with no known past medical history presented to the emergency department with complaints of difficulty finding words, right handed numbness which spontaneously resolved in a few minutes. She reported a history of COVID-19 infection 3 months ago, with platelets in the 50s which downtrended to 30s. Patient was vitally stable with normal neurological examination. Petechiae were noted on the abdomen and all extremities. Laboratory evaluation showed mild leukocytosis of 13.89 x 109/L, severe thrombocytopenia of 18 x 109/L, otherwise unremarkable labs. Differential showed large platelets with normal morphology. On imaging, CT head was unremarkable, MRI brain showed acute supratentorial subarachnoid haemorrhage. Immune thrombocytopenic purpura (ITP) was suspected, work up for infective and toxic causes was negative. IV dexamethasone and intravenous immunoglobulin (IVIG) was started. Multiple units of platelets were transfused and eventually rituximab was started. Platelet count failed to improve on steroids, IVIG and rituximab. Bone marrow biopsy was performed, which showed amegakaryocytic thrombocytopenia. Diagnosis of acquired amegakaryocytic thrombocytopenia secondary to COVID 19 infection was made. Eltrombopag was started and steroids were tapered. Platelet count normalised and the patient did not develop any repeat episodes of thrombocytopenia.

IMPACT/DISCUSSION: Amegakaryocytic thrombocytopenia (ATP) is a rare bleeding disorder that causes severe thrombocytopenia due to selective reduction/absence of bone marrow (BM) megakaryocytes with preserved hematopoiesis of other cell lineages. It could be congenital or acquired. Acquired amegakaryocytic thrombocytopenia (AATP) is caused by infective causes like Ebstein Barr virus (EBV), parvovirus B19, hepatitis C virus, cytomegalovirus and toxic causes like alcohol abuse, interferon therapy, benzene exposure, radioiodine therapy. AATP secondary to COVID-19 infection has not been reported in literature so far.

Pathophysiology of AATP remains uncertain. It is suspected to be due to antibodies formed against antigens on megakaryocyte progenitor cells, granulocyte monocyte colony-stimulating factor or megakaryocyte colony-forming unit. Bleeding, easy bruising, fatigue are the usual presenting complaints. Purpura, petechiae, ecchymosis are seen on examination. AATP is a diagnosis of exclusion. It should be suspected in patients who present with bleeding and are diagnosed with ITP but fail to respond to steroids and IVIG. Bone marrow biopsy is required to make the diagnosis. Isolated reduction of colony-forming units-megakaryocyte (CFU-Mk) may be seen. No standard therapy has been consensually defined to date.

CONCLUSION: The authors report the first case of acquired amegakaryocytic thrombocytopenia secondary to COVID-19 infection, which showed excellent response to Eltrombopag which adds value to the existing literature.

COVID-19 INFECTION PRECIPITATES KWASHIORKOR AND PANCYTOPENIA FROM PROTEIN-CALORIE MALNUTRITION AND SEVERE MICRONUTRIENT DEFICIENCIES YEARS AFTER BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH

Akul Yajnik, Sarah Jones

General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #3876966)

CASE: The patient is a 48 year-old woman with history of class III obesity status post biliopancreatic diversion with duodenal switch (BPD/DS) in 2009, multiple abdominal hernias complicated by small bowel resection and abdominal abscesses, and COVID-19 infection requiring inpatient dexamethasone one month before presentation with anasarca and weight gain.

For six months, she endorsed a significantly decreased appetite. Two weeks after COVID-19 infection, she had worsening fatigue and generalized edema, describing puffiness in her legs, arms, face, and eyes associated with increased thirst. Weight increased by 30lbs despite adherence to daily furosemide. She presented with diffuse anasarca including 3+ pitting edema to the bilateral thighs, 3+ edema of the upper extremities, and swollen palpebrae.

Laboratory evaluation was significant for acute on chronic hypoalbuminemia and hypoproteinemia. Urine protein/creatinine ratio, urine albumin, BNP were normal. She had normal liver morphology on CT four months ago with repeat CT showing new significant hepatic steatosis. Multiple micronutrient deficiencies included serum iron, copper (32ug/dL), selenium, and vitamins A, D, and E. Parenteral iron and tube feeds were initiated.

Shortly after admission, she developed pancytopenia and neutropenia with absolute neutrophil count from 3100 to 670. Hematology attributed this to hypocupremia. She received parental copper and was discharged on copper, iron, B12, thiamine, and trace mineral supplementation with subsequent recovery of her cell counts, protein levels, and hepatic steatosis.

IMPACT/DISCUSSION: This case illustrates the multivariable impact of micronutrient and protein deficiencies. Notably, her presentation with severe malnutrition and kwashiorkor included a presentation with new hepatic steatosis, which is typically attributed to metabolic excess of fat energy stores. However, hepatic steatosis has also been observed in patients with kwashiorkor attributed to mitochondrial or peroxisome dysfunction, and in patients after severe infections including COVID-19. While BPD/DS is performed infrequently given risk for nutritional deficiencies, similar cases of late onset hepatic steatosis with decompensation have been reported after the more common roux-en-Y gastric bypass. Additionally, bone- marrow suppression is a common presentation for copper deficiency which typically resolves with treatment. Acute illness from COVID-19 infection acutely worsened this patient’s malnutrition yielding a presentation with kwashiorkor and new secondary hepatic steatosis as well as bone marrow suppression from copper deficiency that all resolved with nutritional support.

CONCLUSION: In patients at risk for malnutrition, such as those with a history of bariatric surgery, nutrition may acutely worsen after catabolic illnesses like severe COVID-19 infection.

Hepatic steatosis may develop from kwashiorkor or severe infection.

Pancytopenia is a common presentation of copper deficiency.

COVID-INDUCED RIME DISEASE

Farhana Begum¹; Jared Honigman²

¹Internal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; ²Hospitalist, Northwell Health, New Hyde Park, NY. (Control ID #3859967)

CASE: 75 y/o F with metastatic anal cancer to lungs status post right lung lobectomy on leucovorin, oxaplatin and fluorouracil every 2 weeks, HTN and SLE presents with 3-day history of weakness, sore throat, and mouth sores. Pt was in the Dominican Republic for 10 days and upon return, endorsed fatigue and sore throat which progressed to lip swelling and then purulent/pustular lip lesions. Associated symptoms included diarrhea and lightheadedness. Of note, the patient began chemotherapy 4 months prior with her last session 2 weeks ago. Chronic medications include hydralazine and labetalol. She denied any toxic habits or sexual activity. Vital signs were notable for persistent fevers up to 103F. Skin exam revealed hemorrhagic and yellow crusting of the lips, erosions of the buccal mucosa and nontender pink papules with purple to dusky centers, some coalescing, on body including palms, sparing the face. Vaginal exam showed some similar ulcerations. Positive labs included COVID PCR and ANA. However lupus flare and vasculitis serology, and extensive infectious work-up for bacterial, viral and parasitic causes were all negative. Dermatology was consulted, had low suspicion for SJS and offered a broad differential including vasculitis, disseminated HSV/VZV, and reactive infectious mucocutaneous erosions (RIME) disease. Punch biopsies demonstrated extensive interface dermatitis resulting in subepidermal separation with overlying epidermal necrosis, narrowing the differential to SJS and RIME. Given her nontoxic appearance, a diagnosis of RIME disease was made and was started on Prednisone 1 mg/kg x3 days and clobetasol ointment with clinical improvement. Patient discharged on steroid ointment with dermatology follow-up.

IMPACT/DISCUSSION: RIME disease was formerly known as Mycoplasma-induced rash and mucositis (MIRM) disease because it was thought to be characterized by mucositis of 2 or more sites, and either no skin changes or a sparse vesiculobullous and/or targetoid eruption, typically associated with Mycoplasma pneumonia. Since the categorization of this disease in 2015, other infectious triggers have been found including other viruses. Few case reports in the literature have recently linked COVID to RIME. Our patient’s presentation supports COVID-induced RIME disease. This case will add to the literature for patients with mucositis and skin lesions in the setting of COVID. This case highlights teaching points to help differentiate SJS and RIME. RIME disease has predominantly mucosal involvement with variable cutaneous involvement, and good prognosis while SJS is characterized by rapidly progressive painful lesions encompassing a greater percent of body surface area, with an inciting trigger, and a poor prognosis.

CONCLUSION: When managing a patient with mucositis and significant cutaneous skin lesions, an internist must diligently rule out medical emergencies such as SJS/TEN. Being aware of COVID-induced RIME can help internists reach a correct diagnosis and provide proper management.

COVID-PRECIPITATED AUTOIMMUNE ENCEPHALITIS COMPLICATED BY RESIDUAL COGNITIVE DEFICITS

Jamie Yao

Hospital Medicine, University of California San Francisco, San Francisco, CA. (Control ID #3856120)

CASE: Mr. L is a 42 year old man with end stage renal disease on peritoneal dialysis presenting with abdominal pain for one day and found to be hypoxic to the mid-80s. He was diagnosed with methicillin- sensitive staph aureus peritonitis and COVID pneumonia, for which he was treated with intraperitoneal cefazolin and remdesivir respectively. On hospital day 2, he developed significant encephalopathy most notable for short-term memory loss. This persisted despite improving cell counts on subsequent peritoneal fluid studies and resolution of his hypoxia.

His recall deficits were disproportionate to inattention and hospital delirium. His neurologic exam was otherwise normal. Reversible dementia labs and non-contrast head CT were unremarkable. MRI Brain with and without contrast showed "symmetrically increased FLAIR signal and diffusion in the bilateral hippocampi.” Lumbar puncture revealed WBC 2, glucose 57, protein elevated at 77, IgG index at upper limit of normal at 0.65, and positive oligoclonal bands at 3. Other studies of VZV IgG/IgM/PCR, HSV PCR, NMDA-R antibody, and autoimmune encephalitis panel were negative. EEG did not show seizure activity or slowing. Differential diagnosis was antibody-negative autoimmune encephalitis possibly precipitated by COVID vs less likely seizure or toxin.

Neurology recommended empiric treatment of autoimmune encephalitis with methylprednisolone 1g daily for 5 days, with no subsequent change in mental status. Thus a five-day course of IVIG 2g/kg was added; on day 4 of this therapy, his mental status started improving. He was discharged after extensive peritoneal dialysis teaching and family and home health nursing involvement. On outpatient testing, he had interval improvement in memory with persistent deficits in naming, word fluency, and attention. He was started on monthly IVIG with serial MRI imaging to determine course duration. Eight months later, he was hospitalized for expedited transition to hemodialysis given inability to perform his peritoneal dialysis correctly.

IMPACT/DISCUSSION: The most likely etiology for this patient’s encephalopathy with hippocampal hyperintensities was autoimmune encephalitis given his COVID infection, presence of positive oligoclonal bands, and diffuse nature of the MRI findings. Fentanyl toxicity was also considered, but both the patient and his family denied fentanyl use, and normal EEG reduced suspicion for seizure. It was thought that subtle cognitive deficits preceding hospitalization may have led patient to use unsterile technique while performing peritoneal dialysis at home, thus causing the peritonitis.

CONCLUSION: Autoimmune encephalitis can present with a wide variety of neuropsychiatric symptoms, including short-term memory problems and focal seizures.

Treatment consists of various combinations of immunotherapy such as glucocorticoids, IVIG, plasma exchange, cyclophosphamide, and rituximab

Prognosis varies widely, from complete recovery to permanent deficits to death. Earlier treatment can improve recovery

DANGEROUS DISTENTION: A RARE CASE OF ISOLATED ABDOMINAL WALL RHABDOMYOLYSIS

Miko de Bruyn²; Kari Esbensen²; Rebecca Pankove¹

¹Emory University School of Medicine, Atlanta, GA; ²Department of Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #3876583)

CASE: A 54-year-old female with history of Roux-en-Y gastric bypass surgery presented with 3 days of severe abdominal pain, progressive distention, and tea-colored urine. Physical exam revealed a tense, distended abdomen with diffuse rebound tenderness and tympany. There was no shifting dullness. Admission computed tomography (CT) scan showed post-surgical changes of gastric bypass with no evidence of bowel obstruction. Her initial labs were notable for an aspartate aminotransferase (AST) level of 273 U/L and alanine aminotransferase (ALT) level 67 U/L. Creatine kinase (CK) level was checked given her disproportionate elevation of AST and found to be 24367 U/L. Urinalysis showed “large” blood but few red blood cells. She denied recent trauma, strenuous exercise, or substance use. CK levels improved mildly after 3 days of aggressive intravenous fluids (IVFs) but remained elevated (12600 U/L), prompting investigation into unusual causes of rhabdomyolysis, including metabolic. On hospital day 4, with no definite cause identified for her distention, she was initiated on empiric simethicone for symptomatic relief and spent the night passing gas. The next morning, her abdominal distension had resolved, CK dropped from 12600 to 7249, despite stopping IVFs the day before, and her AST normalized. She complained only of persistent abdominal wall “soreness” as her rhabdomyolysis fully resolved prior to discharge.

IMPACT/DISCUSSION: Early recognition of rhabdomyolysis and initiation of treatment with aggressive fluid resuscitation is important to prevent associated kidney injury. Commonly recognized causes of rhabdomyolysis include crush injury, prolonged immobilization, physical overexertion, seizures, and inherited disorders of metabolism. Rhabdomyolysis isolated to the abdominal wall muscles is rare with fewer than ten prior reported cases in the literature and has exclusively been associated with intensive exercise. Abdominal distention caused by intestinal gas and bloating has not before been reported as an etiology of rhabdomyolysis. In this patient with a complicated past intra-abdominal surgical history, bowel obstruction and anastomotic leak were first considered and ruled out as causes of abdominal distention and pain. However, rhabdomyolysis was able to be identified and managed in parallel due to the recognition of its characteristic laboratory abnormalities, even before its etiology was elucidated.

CONCLUSION: Rhabdomyolysis isolated to the abdominal wall is rare and has previously only been reported in settings of extreme exercise. This case highlights the importance of recognizing rhabdomyolysis as a possible consequence of significant abdominal distention. This is relevant to internists who manage abdominal distention secondary to multiple causes including hypervolemia, bowel obstruction or ileus, and malignancy.

DAPTOMYCIN INDUCED EOSINOPHILIC PNEUMONIA

Wilson S. Sango, Pooja Shekar, Moshe Zutler

Internal Medicine, UConn Health, Farmington, CT. (Control ID #3877194)

CASE: A 59-year-old male with history of osteomyelitis of left foot, alcohol use disorder, tobacco use, COPD, hypertension, diabetes presented with fever, hypoxemia, hypotension, and chronic productive cough. Patient recently completed 28-day treatment with daptomycin and ertapenem for left calcaneal osteomyelitis. Lung exam was significant for rhonchi audible over right lower base. Initial lab work was significant for leukocytosis with elevated absolute eosinophil count of 2.14 Thou/uL. Prior CBC from one month ago showed no evidence of eosinophilia. Blood cultures were sterile. Chest x ray showed prominent right lung interstitial and alveolar infiltrates compared to left lung, suggestive of pneumonia. Influenza, RSV and COVID tests were negative. CT chest showed extensive coarse reticular opacites greater on the right than left with regions of consolidation in posterior right upper lobe, caudal right middle lobe and bilateral lower lobes. There was no evidence of honeycombing. There was concern for daptomycin induced hypersensitivity pneumonitis due to CT scan findings and eosinophilia. The patient’s respiratory status worsened and required intubation for acute hypoxic respiratory failure after rescue BiPAP. Subsequently started on methylprednisolone for concern of acute eosinophilic pneumonia and temporarily on meropenem with azithromycin. Eosinophilia resolved following steroid use and patient was extubated the following day. Patient eventually discharged on prednisone taper with outpatient follow up with pulmonology.

IMPACT/DISCUSSION: Daptomycin induced eosinophilic pneumonia (DIEP) should be suspected in patients with serum eosinophilia, fever, hypoxic respiratory failure and recent daptomycin use. Drug induced eosinophilic pneumonia is rare, however DIEP is even rarer with a rate of approximately 4.8%. Risk factors include males, renal dysfunction, elderly, and 2.8 weeks of therapy. There's no correlation between dose/duration and onset of DIEP. Fever and fine crackles were the most common clinical manifestations. Bronchoscopy with BAL may show greater than 25% eosinophils which is a criteria for diagnosis of drug- induced eosinophilic pneumonia however more than half of patients may now show this finding. Imaging may show reticulonodular infiltrates, diffuse bilateral pulmonary infiltrates with ground glass opacities. A large portion of patients may have pleural effusions which is associated with acute eosinophilic pneumonia. Management involves daptomycin discontinuation, systemic glucocorticoid therapy, and possible mechanical ventilation.

CONCLUSION: Clinicians should have a high suspicion of DIEP in patients with eosinophilia, fever, hypoxia, and recent daptomycin use. Withdrawal of daptomycin is crucial in management along with starting systemic glucocorticoids. Bronchoscopy with BAL may not always show greater than 25% eosinophils. Therefore, clinical presentation, eosinophilia and imaging should all be used to make a diagnosis.

DELAYED DIAGNOSIS OF ACUTE CORONARY SYNDROME MANIFESTING AS SHOULDER PAIN

Shelley Burge¹; Jennifer Schmidt²

¹Internal Medicine, Washington University in St Louis, St Louis, MO; ²Internal Medicine, Washington University in St Louis School of Medicine, St Louis, MO. (Control ID #3872114)

CASE: A 70-year-old man presented to resident primary care clinic with left shoulder pain radiating to the neck for one week. Pain was moderate to severe, dull, intermittent, worsened by swinging the arm while walking and by lying in bed at night. He denied recent trauma. He had a distant 5 pack year smoking history and did not drink alcohol. Vitals and BMI were within normal limits. A thorough shoulder exam was unremarkable. Lab studies were notable for mild hyperlipidemia (LDL 113, total cholesterol 200); CBC, BMP, and A1c were within normal limits. Shoulder X ray demonstrated mild glenohumeral and acromioclavicular joint osteoarthritis. His pain was attributed to arthritis and treated conservatively with analgesics and referral to physical therapy. These measures were ineffective and the patient called the clinic several times describing the pain as “excruciating”. Analgesics were escalated and he was referred to a pain management specialist, who noted “the pain is mainly triggered by prolonged walking to the point when the pain becomes debilitating and he must stop all activities to rest.” He was prescribed a muscle relaxant and additional imaging ordered. Six weeks after initial presentation, the patient presented to the emergency room in severe pain. EKG demonstrated ST elevations in leads II, III and AVF. He was taken immediately to the cardiac catheterization lab where a stent was placed for a 100% occlusion of the right coronary artery. After intervention his shoulder pain rapidly resolved and he was able to resume prior activities.

IMPACT/DISCUSSION: It has been estimated that up to 30% of patients with acute coronary syndrome do not endorse chest pain. In another study, 51.7% of unstable angina patients had “atypical” symptoms including shortness of breath, nausea/indigestion, sweating, palpitations and pain in the shoulder, back or arm, as seen in our patient. Although this patient lacked most traditional cardiovascular risk factors, his 10- year ASCVD risk was 13.6% due to age and male sex. However no cardiac workup was completed prior to STEMI presentation. Factors contributing to delayed diagnosis include anchoring bias, fragmentation of care, and time pressure in the resident clinic setting. The patient was treated by at least three different primary care residents and a pain management specialist. Lack of continuity may have prevented his pattern of red flag symptoms from being identified sooner. In addition, the diagnosis of arthritis supported by imaging contributed to premature closure and anchoring bias.

CONCLUSION: -Red flags: Severe pain unresponsive to treatment, acute onset, pain out of proportion to exam/imaging, exertional component

-Anchoring bias and fragmentation of care in this case led to diagnostic error with severe, avoidable consequence

-Clinicians should have a low threshold for investigating a cardiac cause of musculoskeletal pain or other atypical ACS symptoms in high-risk patients and those with potential red flag symptoms

DELAYED PRESENTATION OF OSMOTIC DEMYELINATION SYNDROME TREATED WITH PLASMAPHARESIS

Arjan Singh, Roman Karkee, Muhammad Waqar Sharif, Joud Enabi, Raghavendra Sanivarapu, Maida Faheem

Internal Medicine, Texas Tech University Health Sciences Center, Permian Basin, Odessa, TX. (Control ID #3874186)

CASE: A 42-year-old male with history of chronic alcoholism presented to ED with a 3-day history of recurrent falls and intermittent episodes of choking. Fourteen days prior, he was admitted for severe hyponatremia (Na 97 mEq/L) secondary to beer potomania. Serum osmolality, urine osmolality, and urine sodium were 208 mOsm/kg, 90 mOsm/kg, and <5 mmol/L respectively. The Na was corrected at an optimal rate of <8-10 meq/L/day and patient was discharged on the eighth day of admission with Na of 131 mEq/L, and serum osmolality of 270 mOsm/kg. No neurological deficits were noted at time of discharge. During this visit he was admitted to ICU for respiratory failure secondary to aspiration pneumonia requiring endotracheal intubation. Off sedation, neurological assessment showed spontaneous eye opening with left gaze preference and decreased power of 1/5 in all extremities. Labs revealed Na 134 mEq/L and serum osmolality of 293 mOsm/kg. Initial MRI brain was remarkable for acute central pontine myelinolysis without mass effect and IV methylprednisolone was initiated. Repeat MRI brain revealed evolving subacute central pontine myelinolysis with mass effect.

After a review of literature, five sessions of plasmapheresis (PP) was performed. Clinically, patient remained non-verbal but showed progressive improvement in neurological motor function, from 1/5 power in all extremities to 4/5 on the right side and 3/5 on left side extremities. MRI brain following treatment showed stable findings. The patient was ventilator-dependent requiring tracheostomy and PEG tube placement and was discharged to a long-term facility where he was successfully decannulated and was able to ambulate, currently undergoing physical therapy.

IMPACT/DISCUSSION: Osmotic Demyelination Syndrome (ODS) is a rare condition, usually seen following rapid correction of sodium. Patients generally have concomitant risk factors like chronic alcoholism, as in our patient. Although most cases present between 2-6 days after rapid sodium correction, our patient developed ODS after 14 days of optimal sodium correction. Clinical manifestations like quadriparesis and bulbar weakness have been reported in 9.8-28.8% and 3.2 -11.5% respectively. According to literature, PP, IVIG, and steroids alone or in combination have shown neurological recovery in patients with ODS. These interventions reduce myelotoxic agents, which prevent oligodendrocyte injury and demyelination. The treatment outcome with PP varies and depends on when the treatment is initiated. Although our patient received PP on the 10th day of admission, he showed considerable neurological recovery following treatment with PP and methylprednisolone. This case emphasizes the importance of PP in treating ODS.

CONCLUSION: ODS should be anticipated in severely hyponatremic patients even with optimal sodium correction. We recommend early treatment with plasmapheresis alone or in combination with steroids as these interventions reverse neurological sequelae in ODS.

DEXAMETHASONE-INDUCED HICCUPS (DIH)

Alhussain Saeed, Mina Rasheed, Nahil Matti, Diane L. Levine

Internal Medicine, Wayne State University, Detroit, MI. (Control ID #3876342)

CASE: A healthy fit 34-year-old man with no past medical history presented with severe left lower jaw pain and fever. He was on no medications and had no history of substance use. On exam he was febrile. Exquisite tenderness and mild swelling were noted on the left lower mandible, there was no lymphadenopathy. The remainder of the exam was normal. The patient was diagnosed with a dental infection and prescribed oral penicillin and dexamethasone 4 mg oral Q12. He took the first dose at 10 PM. Upon awakening at 6 AM, he noted the development of hiccups. After trying different maneuvers (drinking water, breath-holding), hiccups would resolve for about an hour and return at the same rate. Hiccups became persistent occurring at a rate of approximately 5 to 7 per minute. Two 2 days later, Penicillin was replaced with clindamycin with no effect on the rate of hiccups. The next day, Dexamethasone was stopped, and the hiccups rate gradually decreased with complete resolution 20 hours later.

IMPACT/DISCUSSION: Hiccups are mostly a minor transient inconvenience and are frequently under- evaluated. However, if hiccups persist, this seemingly trivial symptom may become more distressful, causing several other symptoms such as insomnia, depression, and dyspnea. Nearly 4000 patients are hospitalized due to hiccups every year in the U.S.

Hiccups can be caused by many factors, including stress, diet, and phrenic nerve irritation from tumors or medications. Dexamethasone, a popular corticosteroid, is commonly reported to cause hiccups. Although the mechanism of action is not well understood, it has been proposed that corticosteroids lower the synaptic transmission threshold in the midbrain and directly stimulate the hiccup reflex arc. DIH can be controlled in most cases by discontinuing dexamethasone or switching to other corticosteroids (e.g., methylprednisolone or prednisolone). In some patients, the latter resolved the hiccups while maintaining adequate control of chemotherapy-induced nausea and vomiting (CINV). This was achieved without changing the rest of the antiemetic regimen, chemotherapy doses, or the use of other medications. The only drug with FDA approval for hiccups treatment is chlorpromazine. However, it has limited use due to adverse effects such as hypotension, sedation, urinary retention, and glaucoma. Low dose oral metoclopramide 10mg TID may prevent hiccups in some patients. Also, Baclofen or Haloperidol can be used to control hiccups.

CONCLUSION: There are many uses for steroids in medicine and dentistry, and clinicians should be attentive to any possible side effects of the medications prescribed. This case explains the correlation between hiccups and steroid treatment. Although drug-induced hiccups have not been absolutely confirmed with controlled studies, the incidence is sufficient to raise questions by many practitioners. Fortunately, most cases of corticosteroid-related hiccups appear to be transient and usually end after the drug is withdrawn.

DIABETIC KETOACIDOSIS CAUSING DISSEMINATED INTRAVASCULAR COAGULATION Khadijah Sajid^1,2; Omar Z. Syed¹; Aayushi Sood¹; Lakshmi Priyanka Pappoppula¹; Lekha Yadukumar¹; Mohammad Najmuddin¹; Sarasija Natarajan¹

¹Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA; ²Shalimar Medical and Dental College, Lahore, Pakistan. (Control ID #3875099)

CASE: A 35-year-old female with a past medical history of poorly controlled type 1 diabetes with multiple episodes of diabetic ketoacidosis (DKA), asthma, stroke with no neurological deficits, DVT, PE, GERD, acute infective cholangitis s/p ERCP, stent placement with biliary sphincterotomy, polysubstance use disorder was admitted with altered mental status. She also endorsed the use of fentanyl and methamphetamine on the day of admission. Lab work revealed anion gap metabolic acidosis (pH of 6.8, bicarb 5, anion gap of 32, lactic acid 3.8, blood glucose 992) acute kidney injury, and elevated transaminases. UDS was negative.

Urinalysis revealed glucosuria and ketonuria. The patient had to be intubated due to respiratory failure and was managed for diabetic ketoacidosis with IV fluids, bicarbonate, and insulin drip, along with one dose of Narcan. She was also noted to have leukocytosis but no signs of infection and started empirically on vancomycin and Zosyn. Subsequently, a rapid decline in the platelet count since admission was noted. Sepsis- induced/DIC/TTP drug-induced thrombocytopenia was suspected. Further workup showed normal fibrinogen, LDH, haptoglobin, negative Direct Coombs test, and elevated PT/PTT and D-dimer. Zosyn was switched to cefepime with no improvement in platelet count. The acute kidney injury resolved, and transaminases normalized. Antibiotics were discontinued following negative cultures, and later DKA resolved, platelet count gradually improved and she was discharged home. At the follow-up visit, ADAMS TS 13, cardiolipin antibody, came back negative.

IMPACT/DISCUSSION: DIC is a consumptive syndrome, which presents as thrombocytopenia, decreased fibrinogen, elevated D-dimer, and prolonged PT/PTT due to a depletion of factors. It can be caused by infectious and non-infectious etiology that results in an imbalance between coagulation pathways. Sepsis was unlikely in our patient as he was afebrile and had a negative fever workup. Few cases describing the association of DKA and DIC were found in the literature. It is suggested that Increased levels of free fatty acid and hyperglycemia in DKA contribute to enhancing platelet aggregation by increasing platelet adhesiveness mediated by ADP and thrombin. Treatment options that are known to improve survival for such conditions include plasmapheresis for TTP and secondary TMA and anticoagulant protein therapies, such as activated protein C for DIC.

CONCLUSION: DIC in the setting of DKA would require ruling out more probable causes while at the same time it has been shown in our case that the resolution of DKA would resolve thrombocytopenia and DIC while continuing supportive measures such as transfusion or Protein C therapy.

However, the severest forms should be evaluated for ADAMTS 13 deficiency, which should be treated accordingly.

DIABETIC KETOACIDOSIS WITH CONCURRENT HYPERTRYGLYCERIDEMIA-INDUCED ACUTE PANCREATITIS AS INITIAL PRESENTATION OF DIABETES MELLITUS

Basheer Mohammed¹; Sadia A. Tanami^2,1; Falah I. Abu Hassan^3,1; Mustafa Al-Bayati¹; Gnanashree Dharmarpandi¹; Amaka Odimegwu¹; Tarek Naguib^4,1

¹Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, Texas, Amarillo, TX; ²Internal Medicine, Texas Tech University System, Lubbock, TX; ³Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX; ⁴Internal Medicine, Texas Tech University Health Sciences Center - Amarillo, Amarillo, TX. (Control ID #3856237)

CASE: A 50yr old man with no significant past medical history presented to the emergency department because of a 3-week history of progressive body weakness and increasing frequency of urination and nocturia. He denied any fever or dysuria. Two days prior to presentation, he developed dull aching upper abdominal pain. He smokes half a pack of cigarettes daily and occasionally drinks beer. Upon presentation, his vitals were stable. Physical examination revealed moderate dehydration, mild tenderness in the epigastrium, no xanthoma, and no hepatomegaly. He was found to be in Diabetic Ketoacidosis (DKA) with a blood sugar of 700mg/dl, anion gap metabolic acidosis, lactic acidosis and ketonuria. Further investigation revealed a lipase of 703U/L and triglyceride of 2639mg/dl. CT abdomen showed evidence of mild pancreatitis. HbA1c was 12.4%. He was admitted to the intensive care unit and aggressively treated with IV fluids, insulin, pain control, and fibrates. By day 2, his abdominal pain had subsided, and he was tolerating oral diet. Triglycerides trended down to 312mg/dL upon discharge on day 3.

IMPACT/DISCUSSION: Diabetes mellitus (DM) is a chronic metabolic disorder caused by an absolute or relative deficiency of insulin. DKA is an acute life-threatening complication of diabetes characterized by hyperglycemia, metabolic acidosis with an elevated anion gap, and ketonemia. During an episode of DKA, insulin deficiency results in the breakdown of adipose tissue leading to increased release of free fatty acids (FFA) delivered to the liver and accelerating very-low-density lipoprotein (VLDL) production. This results in hypertriglyceridemia. The release of FFA is toxic to pancreatic acinar cells and vascular endothelium of pancreatic capillaries leading to hypertriglyceridemia-induced pancreatitis. DKA with concurrent hypertriglyceridemia-induced acute pancreatitis triad is extremely rare as the first presentation of diabetes mellitus and can be potentially life-threatening because these patients require more aggressive fluid resuscitation, tighter hyperglycemic management, and pain control to prevent a fatal outcome. It is important to know that acute pancreatitis can also trigger DKA because of acute beta cell dysfunction resulting in transient insulin deficiency. DKA patients can present with abdominal pain and non-specific elevation of lipase which can conceal acute pancreatitis. A high index of suspicion is crucial for prompt diagnosis of acute pancreatitis with imaging. Most patients are managed with fluid replacement, intravenous insulin, bowel rest, lipid-lowering agents, and pain control. Urgent plasmapheresis may be required in patients with severe hypertriglyceridemia and multiorgan failure who fail to respond to standard treatment.

CONCLUSION: DKA can result in hypertriglyceridemia leading to acute pancreatitis. Diagnosis can be challenging as presentation overlap. This rare triad can be potentially fatal if not recognized early and treatment instituted.

DIAGNOSIS CRITICAL: THE IMPORTANCE OF THE HIV TESTING ALGORITHM

Micah Secor²; Aliza Norwood¹

¹Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; ²Dell Medical School, Dell Seton Medical Center at The University of Texas, Austin, TX. (Control ID #3873656)

CASE: A 38 year old asymptomatic woman presented to an outpatient HIV clinic on 6/17/21 to initiate antiretroviral therapy after she was diagnosed with HIV due to a positive HIV-1/2 Antigen/Antibody Immunoassay (HIV-1/2 Ag/Ab) on 5/7/21 at a substance use rehabilitation center. HIV risk factors included sharing needles for intravenous drug use and condomless sex with multiple partners. Her last potential HIV exposure was one month prior to HIV testing. She took no medications and past medical history was significant for a history of cervical dysplasia status post cone biopsy and excision.

At the 6/17 visit, baseline HIV labs were collected including CBC, CMP, HIV viral load (VL) and CD4 count. All labs returned within normal limits and VL was undetectable. Review of labs from 5/7 uncovered that the positive HIV-1/2 Ag/Ab screening assay was not confirmed. A new blood sample was collected on 7/9/21 and sent for HIV-1/2 Antigen/Antibody Immunoassay with reflex confirmatory HIV-1/HIV-2 Antibody Differentiation Assay (HIV-1/2 Ab Assay) and a repeat VL. The HIV-1/2 Antigen/Antibody Assay returned positive but reflex HIV 1/2 Ab Differentiation Assay was negative and VL was again undetectable, consistent with a false positive HIV screening test.

Prior medical records obtained later showed a reactive HIV-1/2 Ag/Ab in 2011 at an obstetrics visit in Mississippi. This resulted in temporary HIV treatment, which was discontinued after further testing revealed an unreactive HIV-2 Ab, undetectable VL and a negative Western blot (WB), results consistent with a false positive HIV screening test.

IMPACT/DISCUSSION: The CDC recommends routine HIV screening for all adults aged 13-64 and at least annual repeat screening for those at high risk. Primary care physicians are often the first to receive HIV screening results. A recent systematic review found that suboptimal testing strategies were the most common factor in studies reporting HIV misdiagnoses. Following the CDC HIV testing algorithm can prevent misdiagnoses.

HIV-1/2 Ag/Ab assays test for HIV-1 Ab, HIV-2 Ab, and HIV P24 Ag. Both sensitivity and specificity of these tests are >99% but must still be confirmed. If positive, the test should reflex to a HIV-1/2 Ab Assay with the same blood sample. If that test is positive, HIV is confirmed; if it is indeterminate or negative, VL should obtained. If VL is negative, the most likely diagnosis is a false positive HIV screening test, as was the case with this patient who had a history of repeat false positive HIV screening tests. In rare cases, “elite controllers” living with HIV may have an undetectable VL, but their HIV Ab testing should be positive.

False-positive HIV Ag/Ab results may be due to autoimmune or inflammatory diseases.

CONCLUSION: HIV-1/2 Ag/Ab are highly sensitive and specific for HIV but positive results must be followed up with confirmatory testing. The HIV-1/HIV-2 Antibody Differentiation Assay is recommended for HIV confirmatory testing.

DIARRHEA DILEMMA AND THE PROCESS OF ELIMINATION

Dylan D. Fortman¹; Casey N. McQuade²

¹Internal Medicine, UPMC, Pittsburgh, PA; ²Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #3859010)

CASE: The patient is 63 year-old male with MGUS, chronic pain on opioid therapy, heavy tobacco use, and cervical stenosis who presented with chronic weight loss (30-lbs) and dysphagia for one year and was found to have a posterior hypopharyngeal fistula with prevertebral leak and concern for C4-C5 osteomyelitis on CT scan. Laryngoscopy with biopsies were negative for malignancy but grew P. aeruginosa and S. marcescens. He was started on broad-spectrum antibiotics and made strict NPO with placement of eventual gastric tube for tube feeding. He had no other gastrointestinal symptoms prior to admission.

After starting tube feedings and antibiotics, he developed profuse, watery, non-bloody diarrhea occurring up to 25-times per day. C. difficile testing was negative twice. Despite additions of fiber, diphenoxylate/atropine and loperamide, the diarrhea did not improve. He was started on TPN, and tube feeding was held which did not result in improvement of his diarrhea. Workup for GI-pathogens, ova and parasites, Celiac’s disease, hyperthyroidism, amyloidosis, gastrin-secreting tumor, neuroendocrine tumors, and VIPoma were negative. CT-Abdomen was unremarkable except for diarrheal state. Flexible sigmoidoscopy and biopsies were unremarkable. EGD/colonoscopy with biopsies demonstrated increased mucosal eosinophils. Malabsorption workup revealed decreased pancreatic elastase, evidence of chronic pancreatitis and ansa pancreatica on MRI-Abd imaging. The patient was subsequently started on budesonide for eosinophilic gastroenteritis, pancrealipase for malabsorption and bolus-type tube feeds which ultimately resulted in resolution of patient’s diarrhea.

IMPACT/DISCUSSION: Chronic diarrhea can be broken down into osmotic, secretory, and inflammatory causes. This case highlights an atypical presentation of multifactorial diarrhea that began after hospitalization. While tube feed-associated diarrhea (osmotic diarrhea) is the most likely cause for someone newly started on enteral feeding, this was only a partial contributor for this patient. His diarrhea also had features of malabsorption from pancreatic insufficiency and inflammation, given his bowel eosinophilia.

Ansa pancreatica is a rare cause of acute, recurrent pancreatitis in literature and likely predisposed this patient to pancreatic insufficiency. Eosinophilic gastroenteritis can present with varying clinical manifestations; treatment options are based on limited data and varies based on symptom severity. This case highlights the need for continued clinical reasoning when patients develop new issues in the hospital that progress towards persistent or chronic problems after unsuccessful initial management.

CONCLUSION: - Evaluation of acute diarrhea should begin with infectious and iatrogenic etiologies - Evaluation of persistent or chronic diarrhea should include a broad differential diagnosis and workup with endoscopic assessment

- Ansa pancreatica is a rare predisposing factor for recurrent pancreatitis, leading to malabsorption

DID YOU SEE THAT? AN EYE-OPENING CASE OF LINEZOLID INDUCED NEUROPATHY Kate L. Amodei¹; Jordan See²

¹Internal Medicine, UPMC, Pittsburgh, PA; ²General Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #3875038)

CASE: A 69 year old male with multiple sclerosis (MS) and cholangiocarcinoma status post resection complicated by recurrent liver abscesses on linezolid suppression presented with progressive, painless, bilateral vision loss and acute worsening of chronic peripheral neuropathy. Two weeks prior to presentation his vision seemed dimmer, objects appeared less sharp, and his color vision worsened. His baseline peripheral neuropathy progressed with new glove and stocking numbness. He denied any scalp or jaw tenderness, rashes, double vision, dry mouth, fevers, chills, weakness, or difficulty ambulating. His last MS flare was ten years ago. On admission, his vital signs were normal without fever. Physical exam revealed decreased visual acuity with right eye 20/125 and left eye 20/60. His visual fields were full, and pupils were equal, round, and reactive to light without afferent pupillary defect. He had decreased sensation to light touch, vibration, and temperature in bilateral lower extremities below the knee and decreased sensation to light touch in his fingertips. Reflexes and strength were normal throughout upper and lower extremities. A basic metabolic panel and complete blood count were normal. MRI brain showed moderate white matter burden consistent with known diagnosis of MS without evidence of active demyelination. MRI orbits showed no evidence of optic neuritis. MRV head and neck showed no dural sinus thrombosis or hemodynamically significant stenosis. Lumbar puncture was performed with negative infectious work up. Given the negative evaluation for primary ophthalmologic, neurologic, or rheumatologic etiologies and that his symptoms began after five months of linezolid use, he was diagnosed with linezolid induced optic and peripheral neuropathy. Linezolid was discontinued. His symptoms improved at outpatient follow up.

IMPACT/DISCUSSION: Linezolid is a bacteriostatic antibiotic that works against gram positive organisms like methicillin-resistant staphylococcus aureus and vancomycin-resistant enterococci. It offers an oral option for treatment of drug-resistant pathogens; however, the safety profile has only been established for up to 28 days of use. In addition to myelosuppression, lactic acidosis, and serotonin syndrome, linezolid has been associated with peripheral and optic neuropathies. These side effects are time and dose dependent. Peripheral neuropathy has a glove and stocking sensory impairment while optic neuropathy presents with scotomas and diminished color and visual acuity. Symptoms improve after drug discontinuation. For patients receiving linezolid longer than 28 days, routine ophthalmologic and neurologic assessments should be performed.

CONCLUSION: While linezolid is a potential treatment option for infections with multidrug-resistant organisms, safety concerns limit its use for extended durations of therapy. Patients receiving longer courses of linezolid should have routine laboratory monitoring as well as ophthalmologic and neurologic assessments.

DILEMMA IN DIGITS: A CASE OF PURPURA FULMINANS (PF) CAUSED BY GROUP C STREPTOCOCCUS

Harsha Sai Sreemantula, Sabah Iqbal, Krishna Desai, Tharika Shraddha RajMohan, Aisha Abdul Sattar, Vignesh Sundaram, Rajesh Thirumaran

Internal Medicine, Mercy Fitzgerald Hospital, Darby, PA. (Control ID #3876286)

CASE: 45-year-old female patient with history of endocarditis due to intravenous drug abuse (post aortic and mitral valve replacement), methamphetamine abuse, untreated hepatitis C, and severe pulmonary hypertension presented with fever and diffuse rash. Physical exam was notable for painful dusky purple rash involving tip of the nose, extremities with large 10-15 cm bullae, petechiae on the chest, and hemorrhagic blistering of right thigh. Work-up revealed white count 5.9, platelets 64,000, PT 25 seconds, PTT 53.7 seconds, INR 2.3, D-dimer >2000, fibrinogen 289, haptoglobin 33, and lactate of 4.9. CT abdomen was significant for multiple splenic infarcts, noted on previous admissions. Peripheral smear was evident for microangiopathic hemolytic anemia along with toxic granulation and bandemia, concerning for DIC. Empiric management of endocarditis was initiated with vancomycin, gentamicin, and cefazolin. Blood and urine cultures grew group C beta-hemolytic streptococci. To cover for the inoculum effect clindamycin was added later. CT Aorta with Runoff Angiography reported no large vessel occlusion/stenosis. Patient was transferred to tertiary center to undergo TEE and a multidisciplinary team including vascular surgery, hematology, dermatology, hepatology, and rheumatology were consulted. The patient had significant hepatitis C viremia and was started on pan-genotypic agent which was later stopped, given the absence of cryoglobulins. Other workup revealed low antithrombin III, low protein C, negative anticardiolipin antibody, negative DAT, normal complement levels, and negative autoimmune panel. Right thigh biopsy showed thrombotic vasculopathy from DIC secondary to bacteremia. TEE showed no endocarditis, patient was treated with antibiotics and discharged with dermatology and vascular surgery outpatient follow-up.

IMPACT/DISCUSSION: Pathophysiology of PF is mainly associated with inherited and acquired abnormalities of proteins C and S, less commonly an infectious pathology associated with mainly gram- negative organisms and lastly idiopathic which is rare. Pathogenesis of DIC is thought to be secondary to endotoxins from gram-negative bacteria. However, little is known about the pathogenesis of streptococcal- induced DIC, causing PF, especially with hepatitis C. Management primarily comprises aggressive resuscitation and treatment of the underlying cause. PF is often confused with other pathologies such as thrombotic thrombocytopenic purpura, sick shock syndrome, calciphylaxis, Henoch-Schönlein purpura and necrotizing fasciitis. Hence a high degree of suspicion is encouraged amongst physicians to improve morbidity and mortality.

CONCLUSION: Purpura fulminans (PF) is a rare and rapidly progressive thrombotic condition involving the microvasculature of the skin, characterized by skin necrosis and disseminated intravascular coagulation (DIC). Immediate diagnosis and management are required for this true dermatological emergency.

DISCONTINUING EMPIRIC ANTIBIOTICS IN FEVER OF UNKNOWN ORIGIN

Aliza Green, Khin-Kyemon Aung

Internal Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #3872457)

CASE: A 54-year-old female presented with four weeks of fevers in the setting of six months of rash and polyarthritis. Pertinent medications included prednisone and adalimumab for presumed seronegative rheumatoid arthritis. Physical exam was notable for diffuse maculopapular rash and bilateral knee effusions. Labs were notable for leukocytosis and elevated ESR/CRP. CT chest, abdomen, and pelvis were unremarkable. She was started on cefepime and metronidazole.

The patient underwent a broad infectious workup. Pan-cultures, viral studies, parasite smear, and tick-borne studies were negative. Rheumatologic evaluation included a skin biopsy with nonspecific findings, a PET CT with multiple areas of FDG uptake consistent with an inflammatory process, and an MRA without evidence of vasculitis. The oncology team reviewed her PET and cross-sectional imaging and felt her presentation was not consistent with a paraneoplastic syndrome or malignancy.

One day after admission, antibiotics were discontinued. Ultimately, a presumptive diagnosis of Adult-Onset Still’s Disease was made. She was initiated on a prednisone burst with taper with symptomatic improvement and was discharged with rheumatology follow up.

IMPACT/DISCUSSION: Patients presenting with fever of unknown origin (FUO)–defined as unexplained fevers for more than three weeks–create a diagnostic dilemma for clinicians. This is particularly true in the setting of rheumatologic illness and immunosuppression, when both infectious and inflammatory etiologies are plausible. In these circumstances, it is critical for physicians to have an approach not only to initiating empiric antimicrobials but also to discontinuing them.

While there are no guidelines on when to stop empiric antibiotics for FUO in non-neutropenic patients, several studies have proposed evidence-based frameworks to aid decision-making. There is consensus that clinicians should seek to establish a diagnosis prior to antibiotic initiation unless the patient is neutropenic, immunocompromised, or unstable, in which case antibiotics should not be delayed. Evidence suggests that only around 10-50% of FUO is due to infection and that many patients in which FUO remains undiagnosed have an excellent prognosis and may have spontaneous remission.

In cases when the initial history and evaluation suggests a non-infectious etiology, clinical judgment should be used to determine the appropriateness of continuing antibiotics. In this case, the medical team used a variety of factors to inform their decision to stop antibiotics: clinical stability, the relapsing and remitting nature of her symptoms, extensive negative infectious workup prior to and during admission, and lack of a unifying infectious etiology based on her epidemiologic risk factors to explain her symptoms.

CONCLUSION: FUO creates diagnostic uncertainty for clinicians. In the absence of guidelines for antibiotic discontinuation, providers must use their clinical judgment to determine the appropriate time to stop antimicrobials.

DISCOVERING HIDDEN PATHOGENS: CHALLENGES WITH IDENTIFYING GLOBICATELLA SANGUINIS

Ifeoluwa Afon¹; Damian Casadesus²

¹School of Medicine, St. Georges's University, Hampton, GA; ²Internal Medicine, Jackson Memorial Hospital, Miami, FL. (Control ID #3877040)

CASE: A 63-year-old male presents with right-sided weakness, slurred speech, and a headache that started one day prior. Other focal neurological deficits included lateralized facial weakness and lower extremity paresthesias. Cardiopulmonary examination showed tachycardia and HTN, and remaining systems were negative. Medical history included uncontrolled HTN, HLD, HIV, ESRD with a tunneled central venous line, and DM type 2. He currently has a cardiac loop recorder that was placed after a recent CVA. He reports an extensive smoking and EtOH history. Blood cultures were initially positive for Streptococcus viridans, but repeat blood cultures isolated another pathogen inciting bacteriemia: Globicatella sanguinis. Imaging from TEE showed a 0.26mm pedunculated echodensity noted adjacent to the central venous catheter tip on the inferior right atrium wall, likely fibro thrombotic.

IMPACT/DISCUSSION: Globicatella Sanguinis is a surfacing pathogen that can unknowingly be mistaken for a similar microbe, Streptococcus viridans. Specialized diagnostic tools, specifically the Vitek 2 system, MALDI-TOF MS and 16S rRNA sequencing, can accurately isolate and identify the pathogen compared to other routine diagnostic methods. The prompt identification of this agent is critical in the management because its susceptibility and resistance to antimicrobials can be atypical compared to other streptococcus genera. The therapeutic and clinical responses to medications are dependent on the ability to correctly identify the offending agent. Due to the newly advancing identification techniques, it is likely that this microbe was incorrectly identified as S. viridans in patients with varying etiologies. G. sanguinis causes a wide range of diseases and its limited literature makes it difficult to identify unique patterns helpful for diagnoses. Patients who are immunocompromised and those presenting resistance to antibiotics for S. viridans may be infected with G. sanguinis and warrant additional testing. G. sanguinis has shown to have a higher minimal inhibitory concentration. This understanding should raise the awareness of the need for prompt and accurate identification to distinguish the best care and treatment for patients. As technology in laboratories continues to advance, we can expect the identification of more pathogens and tailored antimicrobial treatment. Advanced identification will also provide specific diagnostic clinical features about varying offending agents. Our understanding about G. sangunis's clinical importance, position in the flora, and antibiotic resistance will also be expanded. This will have therapeutic and diagnostic significance.

CONCLUSION: G. sanguinis is a rare pathogen causing bacteremia. It is a challenging microbe to distinguish and warrants further investigation in patients presenting with antimicrobial resistance to S. viridans, a similar microbe. Future technological modalities will allow for better isolation and influence more literature regarding this pathogen.

DISREGARDING TINNITUS IN A PATIENT WITH CISPLATIN-INDUCED NEPHROTOXICITY Nicole Xu¹; Gautham Pavar¹; Diane L. Levine²

¹Medical Education, Wayne State University School of Medicine, Detroit, MI; ²Internal Medicine, Wayne State University, Detroit, MI. (Control ID #3873431)

CASE: A 54-year-old man with recently diagnosed T3N1M0 squamous cell carcinoma of the tongue started the first cycle of cisplatin chemotherapy 1 week prior to presentation. He endorsed mild intermittent nausea. Creatinine measured in the outpatient oncology clinic rose from 1.05 to 2.25 despite daily prophylactic fluid infusions and he was referred to the ED. He denied fatigue, dysphagia, odynophagia, and changes in urination. On review of systems, he endorsed bilateral tinnitus. He had no other medical history and denied taking any other medications or having any allergies. His only surgery was a lymph node biopsy. He had a

30-pack-year smoking history. On exam, he was well-appearing. Oral mucosa was moist and a non-tender 1 cm lymph node was palpated in the left posterior cervical chain. Heart, lung, and abdominal exams were normal. Urine electrolytes demonstrated a FENa of 3%, suggesting an acute intrinsic kidney injury. Due to the creatinine elevation after his first dose of cisplatin, the most likely diagnosis was acute tubular necrosis from cisplatin nephrotoxicity. The patient was placed on normal saline. Creatinine improved to 1.7 by discharge. Tinnitus was not further evaluated. We did not appreciate the significance of tinnitus until reading about this side effect after the patient’s discharge.

IMPACT/DISCUSSION: Tinnitus is a common problem seen in 15-20% of adults. Yet there is a broad differential diagnosis for this problem including drug toxicity. While one of the most common side effects of cisplatin is dose-dependent nephrotoxicity, cisplatin can damage the cochlea. 40% of patients develop tinnitus; of those 40-80% develop permanent hearing loss.

Tinnitus is significantly correlated with a reduced hearing threshold at all frequencies. Undiagnosed hearing loss may make it harder for patients to participate in conversations and be safe while crossing a road. Our patient would have benefited from audiometry screening.

Tinnitus is an indicator of ototoxicity, a major dose-limiting side effect of cisplatin therapy. The onset of ototoxicity requires medication change or accepting potentially permanent hearing loss. However, our team and the referring oncology clinic were focused on the patient's nephrotoxicity and disregarded his tinnitus, missing opportunities for further evaluation and potential prevention of ototoxicity.

CONCLUSION: The field of cancer therapy has made numerous advances. While this is exciting for clinicians, commonly used cancer drugs still have many adverse effects, and taking a thorough history and physical is paramount. This case shows that clinicians should not be complacent after identifying one chemotherapy drug side effect. Since chemotherapy has numerous side effects, clinicians should try to identify other adverse effects and manage the treatment of them all.

DISSEMINATED NOCARDIA IN A PATIENT RECEIVING IMMUNOTHERAPY

Christina Rudolph¹; Sara Turbow²

¹Internal Medicine, Emory University School of Medicine, Atlanta, GA; ²Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #3876403)

CASE: An 81-year-old woman with stage IV NSCLC currently on vinorelbine presented with fever, fatigue and productive cough for two days. She was tachycardic to 104 and had scattered expiratory wheezing on exam. Labs showed white blood cell count elevated to 22/109 mL. CXR revealed a left lower lobe infiltrate. She was started on vancomycin, cefepime, and anidulafungin on admission because she was recently treated with immunotherapy. The next day, based on infectious disease recommendations, she was narrowed to ceftriaxone and azithromycin for treatment of community acquired pneumonia. She had bronchoscopy showing acute inflammation but negative respiratory culture.

Five days into admission, blood cultures drawn on arrival resulted with gram-positive cocci in one of two bottles. This result was changed to branching gram positive bacilli the next day. Repeat cultures drawn after the initial cultures resulted as positive were negative, so the original culture results were suspected to be contaminant. The patient was continued on CAP coverage. The original cultures were however finalized as a Nocardia species. The patient was started on trimethoprim-sulfamethoxazole, resulting in hyperkalemia and AKI, so she was transitioned to linezolid. An MRI brain was done due to the potential for hematogenous spread of Nocardia and showed multiple new ring-enhancing lesions, which were suspected to be CNS involvement of her Nocardia infection. The culture ultimately speciated to Nocardia Farcipica/Kroppenstdtii. She was discharged on a six-week course of tedizolid because it has a better safety profile for longer term use than linezolid.

IMPACT/DISCUSSION: Immunotherapy is increasingly common for treatment of many cancers, including melanoma, NSCLC, and bladder cancer. It is estimated that in 2011 only 1.5% of patients qualified for check point inhibitor immunotherapy, but in 2018 43.6% of patients qualified¹. In many hospitals, patients on immunotherapy are admitted to GIM services, so it is important to understand that these patients have impaired cell-mediated immunity and are at high risk for opportunistic infections.

1. Haslam, A., & Prasad, V. (2019). Estimation of the Percentage of US Patients with Cancer Who Are Eligible for and Respond to Checkpoint Inhibitor Immunotherapy Drugs. JAMA network open, 2(5), e192535. https://doi.org/10.1001/jamanetworkopen.2019.2535

CONCLUSION: This patient had an opportunistic Nocardia infection. She was initially thought to have CAP, and blood culture findings of one of two bottles with branching bacilli were suspected to be contaminant. Nocardia, however, is a slow-growing and often difficult to isolate opportunistic pathogen, that can take several days to isolate. In immunocompromised patients, especially those with pulmonary symptoms, bacilli on culture should raise suspicion for pulmonary nocardiosis and not be discounted as contaminant.

DISSEMINATED NOCARDIOSIS MISINTERPRETED AS A METASTATIC MALIGNANCY: AN EDUCATIONAL CASE

Astha Koolwal¹; Nneka U. Chukwu¹; Olushola Ogunleye¹; Nili Gujadhur²

¹Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ²medicine, Nuvance Health, Lagrangeville, NY. (Control ID #3876496)

CASE: A 71-year-old female presented to the ER with cough and confusion. She had a history of myelodysplastic syndrome status post stem cell transplant one year ago. She denied fevers with rest of the review of systems being negative. A 6 cm right upper lobe consolidation was identified on CT chest and treatment for presumed pneumonia was initiated. She was discharged from the ER on oral antibiotics. One month later, she presented again with increasing neurologic complaints including persistent confusion, headache and tremors. Patient endorsed that she started having memory issues especially worsened in the two weeks before presentation. Additionally, she had a 20-pound weight loss. Outpatient CT scan had revealed white matter edema which prompted her oncologist to send her to the ER for further evaluation. No focal neurological deficits were elicited. Her labs were significant for mild megaloblastic anemia and mild derangement in her serum creatinine. Her CT brain and MRI revealed multifocal scattered sub centimeter ring-enhancing brain lesions. Given persistent mass-like lung consolidation, lung cancer metastatic to the brain was ascribed the prime suspect on the radiologic report, aligning with the dominant clinical suspicion. CT abdomen/pelvis was performed to search for any other masses/focus of infection/malignancy which was negative. Multidisciplinary team including neurology, neurosurgery, oncology was formulated, and infectious etiology was considered a strong second differential prior to proceeding to biopsy. Patient's CSF and blood were negative for tested infectious agents including CMV, Aspergillus and toxoplasma. Bronchoscopy with BAL came back positive for Nocardiosis, which was supported by subsequently positive blood cultures. Appropriate treatment with amikacin, meropenem and Trimethoprim-sulfamethoxazole was instituted finally. Patient was eventually transferred to her transplant center for further management.

IMPACT/DISCUSSION: Brain lung syndromes can pose a diagnostic challenge, especially in immunosuppressed patients. This case highlights how infections such as Nocardiosis can mimic a malignancy given mass-like radiologic appearance and lack of clinical sepsis markers. Positive blood culture is a rarity and was clinching in this case.

CONCLUSION: Atypical infectious agents such as Nocardiosis are an important differential consideration for brain-lung syndromes in immunocompromised patients.

DISSEMINATED ZOSTER AS A PRESENTING SYMPTOM OF RECURRENT MYELODYSPLASTIC SYNDROME

Eric J. Nielsen, Nancy Lee, Shyam Patel

Medicine, University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #3875049)

CASE: A 52-year-old man with history of high risk Myelodysplastic Syndrome (MDS) s/p allogenic stem cell transplant 11 months ago presented to the emergency department with two days of full body rash. He described the rash as intensely pruritic and spreading quickly since it first appeared on the trunk. No one else has the rash at home, but his wife and son both contracted a self-limited viral URI in the last week. Examination showed papules and vesicles with involvement of the entire body, including the face, trunk, extremities, palms and soles. Bilateral inspiratory wheeze was present in all quadrants. He was hypoxic to 88% and required 2L O₂ by NC to maintain SpO₂ >94%. CXR showed a small right pleural effusion. Non- contrast chest CT showed greater than 50 nodules in the bilateral lungs.

He was started on IV Acyclovir and IV fluids on day 2. Dermatology and Infectious Diseases physicians were consulted for his care. A Tzanck smear of the lesion was positive. Aerobic, anaerobic and fungal culture of the unroofed lesions returned negative. VZV qualitative PCR of the lesions returned positive, while the HSV1 and HSV2 qualitative PCRs were negative. A plasma VZV PCR titer returned at 14,500. The diagnosis of disseminated Herpes Zoster with Zoster pneumonitis was made. He was treated with a 28-day course of IV Acyclovir. Follow up ophthalmologic examination did not show retinal necrosis. Follow up VZV DNA PCR was undetectable and he was placed on suppressive acyclovir 800 mg BID.

He had been off immunomodulators (mycophenelate, cyclosporine, ruxolitinib) for four months due to successful stem cell transplant and normocellular marrow. Unfortunately, his subsequent BM biopsy showed recurrence of MDS with his original 5q-, -7, 17p- karyotype with 10% plasma cells and 5% blasts. Analysis of peripheral blood showed 65% donor chimerism. A shared decision was made to start him on Inqovi (decitabine and cedazuridine).

IMPACT/DISCUSSION: Disseminated Herpes Zoster is defined by >20 vesicles outside single or adjacent dermatomes. It occurs most often in older or immunocompromised populations and is typically limited to skin infection. Severely immunocompromised patients, including those with AIDS, hematologic malignancy, transplant recipients and those on immunosuppressants are at risk for viremia, and spread to visceral organs, most commonly lung, liver and CNS.

Our patient had childhood chicken pox, but never had a Herpes Zoster reactivation. In reviewing his vaccine history, he only had one of two doses on recombinant Zoster vaccine, and was originally scheduled for dose #2 the day after his hospitalization. In addition to the recurrence of his MDS, our patient may have developed disseminated Zoster in part due to a significantly elevated percentage of T regulatory (CD4+CD25+FoxP3+) T cells.

CONCLUSION: This patient developed disseminated herpes zoster as a presenting symptom of the recurrence of his MDS after stem cell transplant.

DISTAL RENAL TUBULAR ACIDOSIS DISGUISED BY DIARRHEA

Isaac Davis¹; Alejandra Vargas Velasquez¹; Cameron D. Palmer²; Aaron Mills¹

¹Internal Medicine, Eastern Virginia Medical School, Norfolk, VA; ²Eastern Virginia Medical School, Norfolk, VA. (Control ID #3876808)

CASE: A 51-year-old female with a past medical history of ulcerative colitis and primary hyperparathyroidism status-post parathyroidectomy presented to the emergency department on recommendation of her gastroenterologist for severe hypokalemia. Other than chronic diarrhea, which was unchanged in volume or frequency, review of systems was negative, and physical exam was unremarkable. Initial lab results revealed sodium 134 mmol/L; potassium 2 mmol/L; chloride 103 mmol/L; bicarbonate 16 mmol/L; creatinine 1.7 mg/dL; urea 16 mg/dL; albumin 3.8 g/dl; albumin-corrected anion gap 12.5 mmol/L.

She was started on aggressive potassium replacement. After receiving 140 mEq over 6 hours, reassessment demonstrated modest improvement in to 2.6 mmol/L and further reduction in bicarbonate. Urine studies showed pH of 7; sodium 46 mmol/L; potassium 18 mmol/L; chloride 47 mmol/L and urine anion gap 17. Renal ultrasound demonstrated non-obstructing right nephrolithiasis. A diagnosis of distal renal tubular acidosis (dRTA) was made based on this information, and bicarbonate infusion was administered.

Inpatient work-up to determine the etiology of her dRTA was unrevealing. Review of medical records prior to admission was notable for three urinalyses with pH of 7.0 with concurrent non-anion gap metabolic acidosis and hypokalemia, which were attributed to UC flares. She was, however, later diagnosed with primary hyperparathyroidism. For this reason, it was determined that her dRTA was not new onset and was related to her primary hyperparathyroidism (PHPT), a well-established etiology of dRTA.

IMPACT/DISCUSSION: Distal renal tubular acidosis is characterized by diminished hydrogen ion secretion in the renal collecting tubules, which leads to non-anion gap metabolic acidosis, loss of serum bicarbonate, and other electrolyte imbalances. Unfortunately, these biochemical abnormalities are not entirely unique to dRTA and may be maskable by several other acute and chronic conditions, especially gastrointestinal disorders. However, approximately half of all cases of new-onset distal RTA in adults are caused by other underlying systemic conditions, such as hypergammaglobulinemia, malignancy, autoimmune disorders, and PHTP.

Based on review of the available literature, cases of dRTA attributed to PHPT demonstrated resolution of renal impairment and dRTA after parathyroidectomy. The case presented here is unique in that the etiology of the patient’s dRTA had been previously diagnosed and treated yet, her dRTA persisted.

CONCLUSION: We suggest that patients with hypokalemia and non-anion gap metabolic acidosis be screened for dRTA by testing urine pH and calculating urine anion gap. Following the diagnosis of dRTA, further investigation is necessary to determine if there is a previously undiagnosed etiology for it. Furthermore, regular follow-up is important to ensure resolution of dRTA even after treating the presumed etiology of it because, if left untreated, may lead to life threatening electrolyte abnormalities.

DISTRACTED BY DRESS: A CAUTIONARY TALE ON CAREFUL PHYSICAL EXAM AND PRESCRIBING OF DRESS-INDUCING AGENTS

Megan W. Creasman, Peggy B. Leung

Internal Medicine, Weill Cornell Medicine, New York, NY. (Control ID #3876237)

CASE: G.C. is a 23-year-old man with a PMH of morbid obesity and OSA who presented to the ED with a confluent rash and multisystem organ failure.

Two weeks prior to presentation he was prescribed sulfamethoxazole/trimethoprim DS BID and fluconazole weekly for right foot cellulitis. Although the infection initially improved, he also developed a new confluent facial rash, decreased urination, throat edema, and subjective fevers, raising suspicion for a drug reaction. On admission he received epinephrine and solumedrol. Soon after he was electively intubated for lip swelling and throat edema.

In the ICU, G.C. was treated for DRESS. The confluent rash that had spread across his chest and body improved with high dose steroids. He was eventually extubated. While awaiting transfer out of intensive care he became increasingly tachycardic without additional signs of instability. After five days of ongoing tachycardia (and soon after transfer to the floor) he became febrile and was found to be bacteremic with staph epi. The wound now showed signs of skin breakdown and purulent discharge. In retrospect, in focusing on treating DRESS, his right foot wound had been neglected, and then had the opportunity to brew in the setting of his immunosuppression. G.C. remained febrile through vanc/zosyn and was thus broadened to meropenem; unfortunately, the patient continued to rapidly decompensate. He developed rigors, respiratory distress, and tachycardia to the 170s. His blood cultures grew methicillin resistant Staph epidermidis. After an episode of projectile vomiting, desaturation, and emergent intubation, he had a cardiac arrest and could not be resuscitated.

IMPACT/DISCUSSION: This case highlights the importance of examining sites of soft tissue infection daily, even if they are presumed to be improving. In this patient, the original reason he was prescribed outpatient antibiotics was overshadowed, with significant downstream consequences. His decompensation was likely from incompletely treated cellulitis in the setting of significant immunosuppression. In retrospect, closer attention should have been paid to his rising heart rate and evolving foot wound.

The Liverpool adverse drug reaction avoidability assessment tool (LAAT) is one strategy for both systems- wide and individual-level changes in prescribing behavior. Refining and testing tools such as the LAAT that assess the avoidability of drug reactions may be valuable in changing clinician practice, both in prescribing DRESS-associated medications and identifying DRESS. An alternative empiric treatment for this patient’s initial cellulitis would have prevented this cascade of unfortunate events.

CONCLUSION: 1. Careful physical exam, including skin exam and attention to changes in vitals trends, is essential in patients hospitalized with DRESS.

2. Outpatient prescriptions with the potential to cause DRESS must be carefully monitored and, if possible, avoided.

DOES A NEGATIVE TEMPORAL ARTERY BIOPSY RULE OUT GIANT CELL ARTERITIS WITH LARGE VESSEL INVOLVEMENT?

Momin Samad¹; Ahmed Oudeif¹; Mustafa Mohammed¹; Ammad J. Chaudhary²

¹Internal Medicine, Henry Ford Hospital, Detroit, MI; ²Internal Medicine, Henry Ford Health System, Detroit, MI. (Control ID #3876559)

CASE: A 61-year-old female presented with initial symptoms of abdominal pain, nausea, vomiting, and weight loss. ESR, CRP, and WBC were elevated, and CT imaging revealed abdominal aortitis with retroperitoneal fibrosis and involvement of bilateral iliac arteries. The patient was initiated on high dose corticosteroids and had a negative workup for systematic vasculitis and infectious etiology during her hospital course. She continued an oral steroid regiment once discharged but discontinued her mediation five weeks later. Days after this, the patient presented to the ED with unilateral headache, blurry vision, and left upper limb claudication. Lab values and CT imaging were repeated which showed minimal change from prior admission. Clinical symptoms indicated giant cell arteritis and a temporal artery biopsy was pursued which was negative. The patient received IV corticosteroids, and she reported improvement in her symptoms, including her visual disturbances. She was transitioned to her initial high dose oral corticosteroid regiment and discharged home.

IMPACT/DISCUSSION: Small and large vessel vasculitis in giant cell arteritis is more rare than small vessel involvement alone. This case highlights that temporal artery biopsy in a patient with large and small vessel disease has limited sensitivity. Furthermore, prior glucocorticoid treatment modifies the sensitivity of a temporal artery biopsy in addition to other features of the test. This case emphasizes the diagnostic challenge of giant cell arteritis and the limited differential diagnoses for aortitis. Prompt treatment, while indicated, can complicate the investigation, making it difficult to distinguish if the aortic inflammation is part of an idiopathic or systemic process. The diagnosis of giant cell arteritis is critical to appropriate treatment and management with chronic high dose steroids.

CONCLUSION: Giant Cell Arteritis with small vessel involvement is generally diagnosed through temporal artery biopsy. However, when the disease involves both small and large vessels and treatment is initiated prior to biopsy, this can influence the diagnostic sensitivity of the biopsy, making the diagnosis challenging.

DON'T BE RASH: A CASE OF NEUROSYPHILIS PRESENTING AS TRUNCAL ATAXIA AND MACULOPAPULAR RASH

Tom Phan^1,2; Eduardo A. Mulanovich³

¹Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; ²Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX; ³General Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX. (Control ID #3873179)

CASE: A 62-year-old man with hypertension, hyperlipidemia, uncontrolled type II diabetes, and chronic kidney disease presented to primary care clinic with two weeks of acute onset fatigue and gait instability. Social history was notable for male sexual partners, with the last sexual encounter five months prior to the visit without condom use and prior encounters five years to that. Vital signs were pertinent for normal heart rate, afebrile, and blood pressure 82/44 mmHg. He was alert, oriented, and speaking in full sentences. He was found to have a diffuse maculopapular rash on his trunk, sparing the extremities. He had decreased strength in the left hip flexor, grossly intact sensation, cranial nerves II-XII intact, reflexes normal bilaterally, Romberg positive, and impairment on the left-sided heel-to-shin. He was able to ambulate with his cane but with an uncoordinated, widened gait. Labs were pertinent for WBC 7,030/cm, hemoglobin 9.1 g/dL (baseline), Vitamin B12 481 pg/mL, sodium 131 mmol/L, potassium 5.1 mmol/L, glucose 579 mg/dL, creatinine 2.52 mg/dL (baseline), ESR 82 mm/hr, ferritin 15, TSH 0.42, HIV nonreactive, treponemal CIA reactive, RPR reactive 1:256. The patient was called and informed to go to the hospital for further evaluation.

Upon admission to the hospital, He was given a single shot of IV penicillin G the day before LP. VDRL quant was reactive 1:2, 29 nucleated cells, 84 lymphs, glucose 163, protein 109. He was treated with penicillin G 4 million units q6h for 14 days without recurrence of symptoms. At clinic follow-up, he stated he felt much improved with his ambulation back to baseline with the resolution of the rash.

IMPACT/DISCUSSION: Our patient presented with neurosyphilis, as evidenced by cerebellar symptoms, physical exam findings, and reactive CSF VDRL. Neurosyphilis can be seen in any stage of syphilis. This patient most likely had secondary syphilis and originally contracted syphilis from his most recent sexual encounter months prior. He did not have tabes dorsalis, caused by dorsal root ganglia demyelination, as his ataxia would not have been reversible. While reversible ataxia has been reported in the literature, it is a rare finding in neurosyphilis.

A truncal maculopapular rash has a broad differential including infectious causes - such as scarlet fever, rubella, secondary syphilis, Lyme disease, parvovirus B19 - and allergic causes from medications. A secondary syphilis rash appears as rough reddish or brown papules and plaques, typically affecting the trunk and frequently the palm and soles.

CONCLUSION: A patient with a history of maculopapular rash, neurologic symptoms, and unprotected sexual encounters should be evaluated for syphilis.

Neurosyphilis can present at any stage of syphillis and is a distinct disease separate from tertiary syphilis.

Truncal maculopapular rash has a broad differential including infectious causes - such as scarlet fever, rubella, secondary syphilis, Lyme disease, parvovirus B19 - and allergic causes from medications.

DON'T SWEAT IT: A CASE OF HEAT STROKE INDUCED LIVER INJURY

Katherine Allyn, Jennifer Weintraub. Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #3876999)

CASE: SI is a 27 year old patient with no known past medical history who initially presented to the ED with confusion, hypotension, and a temperature of 108 F in the setting of marathon training. Initial work-up was notable for CPK elevation to 372, mild AKI, and transaminitis (ALT 260/AST 316). Mental status improved to baseline after cooling in the field. CPK downtrended and AKI resolved with fluid administration, but LFTs continued to rise precipitously to 4,611/3,400. Laboratory data was notable for uptrending INR and downtrending platelets. Liver transplant workup was initiated due to concern for the development of acute liver failure, and he was started on an N-acetylcysteine drip.

RUQ ultrasound with doppler did not show evidence of cirrhosis or portal hypertension. Viral hepatitis panel, ceruloplasmin, and iron studies were unremarkable. Acetaminophen, salicylate, and urine toxicology results were negative. The patient reported using whey powder and probiotics, but denied any additional supplements, performance enhancing drugs, recent antibiotics, new medications, alcohol, or recreational drugs. Reassuringly, his mental status remained at baseline and liver function tests began to demonstrate improvement by day four of hospitalization. He was discharged home with close follow-up and counseled on modifying his marathon training regimen while awaiting complete hepatic recovery.

IMPACT/DISCUSSION: This case highlights severe liver injury as a rare complication of exertional heat stroke (EHS). Heat stroke is defined by an elevated body temperature, typically greater than 104 degrees Fahrenheit, along with CNS manifestations. It can be categorized as nonexertional (typically occurring in

very young, elderly, or chronically ill patients) or exertional (affecting patients during periods of strenuous activity). EHS can cause liver dysfunction via direct damage to hepatocytes as well as hepatic ischemia secondary to splanchnic vasodilation. EHS induced liver injury is typically mild and self-resolves, but a few case reports in the literature have shown rare progression to severe acute liver injury (ALI) or liver failure (ALF). In patients with EHS who develop severe liver injury, monitoring for progression to ALF is essential as transplantation may be required. As this case demonstrates, N-acetylcysteine (NAC) can be used in management of EHS induced ALI. NAC is most commonly employed in treatment of acetaminophen induced liver injury, but has also been shown to confer benefit in ALI/ALF of other etiologies. It works by repleting glutathione, an antioxidant which can be protective against free radicals. EHS itself causes oxidative stress, suggesting that mechanistically, NAC is an appropriate component of management in this setting.

CONCLUSION: Exertional heat stroke is a rare cause of severe acute liver injury and acute liver failure.

Management of EHS associated liver injury consists of close monitoring for progression to ALF and consideration of N-acetylcysteine administration.

DON’T FORGET THE CK, A CASE OF STATIN-INDUCED AUTOIMMUNE NECROTIZING MYOSITIS

Zachary Boggs

Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA. (Control ID #3873941)

CASE: A 62 year old mechanic with obstructive sleep apnea, psoriasis, hypertension, and type 2 diabetes on metformin and atorvastatin was seen in clinic after a recent emergency department visit. He presented for dyspnea and swelling and was given diuresis for presumed heart failure. He was found to have elevated liver function tests (LFTs). His urinalysis showed moderate blood with 3-5 red blood cells and 1+ protein. The following day, he was feeling improved after diuresis, however felt fatigued and his urine was still dark. His exam was notable for 1+ bilateral edema and a chronic psoriasiform rash. His strength exam was normal, however he came in a wheelchair. His LFTs were repeated with an ALT of 332U/L and AST of 404U/L. A total creatine kinase (CK) was ordered as an add-on lab, which returned at 13,698U/L. Over the next few weeks, his muscle strength rapidly declined, and he eventually became wheelchair bound. His CK remained elevated despite stopping atorvastatin. Autoimmune work-up was negative including a myositis panel. Echocardiogram showed a low normal ejection fraction. Liver ultrasound demonstrated hepatomegaly with steatosis. MRI of his thighs showed symmetric edema. Rheumatology recommended muscle biopsy, which revealed myonecrosis. Anti-HMGCoA receptor antibodies returned positive. He was started on prednisone and mycophenolate mofetil. Despite treatment, his CK levels remained elevated thus was started on IVIG and subsequently rituximab. His strength has improved since starting therapy, however his CK level remains around 2,000U/L.

IMPACT/DISCUSSION: Statin-induced myopathies occur in about 2% of patients with most resolving after statin discontinuation. Our patient was diagnosed with statin-induced necrotizing autoimmune myositis which is much more rare with about 2 cases per million per year. The treatment usually requires immunosuppression in addition to drug discontinuation. It is more likely to occur after years of exposure. Our patient presented after having been on atorvastatin for two years. Interestingly, he did not present with severe weakness until weeks after his initial CK elevation was found. He did present with new clinical heart failure, likely a result of cardiac involvement of his myositis. Myositis or rhabdomyolysis were not considered diagnoses on initial evaluation in the emergency department. It is not routine practice to order a total CK in the work-up of elevated LFTs, but arguably should be considered to not miss this diagnosis. His diagnosis could have been delayed even longer if we had not ordered the total CK and solely attributed the LFT elevations to non-alcoholic fatty liver disease or hepatic congestion in the setting of heart failure.

CONCLUSION: This case illustrates the importance of obtaining a CK when LFTs are elevated, especially when there is diagnostic uncertainty.

Statin-induced autoimmune necrotizing myositis is very rare but should be considered when a patient presents with weakness after years of statin therapy.

DON’T GO CRASHING MY HEART

Jessica Loiodice²; Cooper Maselli²; James Ciancarelli¹; Kevin Marzo¹

¹Cardiology, NYU Langone Hospital - Long Island, Mineola, NY; ²Internal Medicine, NYU Langone Hospital - Long Island, Mineola, NY. (Control ID #3873581)

CASE: An 82-year-old female with a past medical history of hypertension presented with substernal chest pain following a motor vehicle accident. She denied any pertinent surgical, social, and family history. Initial vitals were stable and exam was unrevealing. Initial high sensitivity troponin was 177 ng/L and BNP 2235 pg/mL. Her electrocardiogram (EKG) revealed ST elevations in leads I, AVL and T wave inversions in III and AVF. Echocardiogram showed ejection fraction of 10% with apical hypokinesis and basal hyperkinesis. She quickly developed acute hypoxic respiratory failure and invasive hemodynamics were consistent with cardiogenic shock. Coronary angiography revealed normal coronary arteries and apical ballooning, consistent with stress induced cardiomyopathy (SIC). Intra-aortic balloon pump was placed however resulted in hypotension, thus was removed and phenylephrine was started. Given worsening cardiac function phenylephrine was stopped and dobutamine was initiated using echocardiography to monitor for left ventricular outflow tract obstruction (LVOTO). Diuresis was initiated with furosemide. Following improved hemodynamics, inotropic therapy was discontinued with initiation of goal directed medical therapy.

IMPACT/DISCUSSION: Stress induced cardiomyopathy (SIC) can be difficult to distinguish from acute coronary syndrome. However, it should be considered when EKG and echocardiogram abnormalities extend beyond normal coronary distribution and the degree of initial cardiac biomarkers are disproportionately low given presentation and extent of wall motion dysfunction, especially in the setting of a somatic or emotional stressor. The clinical course of SIC has generally been recognized as benign, however the risk and prevalence of more severe complications may be underappreciated. Transient LVOTO is a complication seen in SIC, particularly those who exhibited cardiogenic shock during their course. This is likely induced by the wall motion abnormalities causing systolic anterior movement of the anterior mitral leaflet, creating similar physiology seen in hypertrophic cardiomyopathy. This has significant clinical implications as presence of LVOTO is likely to change therapeutic management, particularly with the use of inotropic agents. We suspect the patient in this case developed transient LVOTO due to the quick development of hypotension when it was attempted to place an IABP, likely secondary to the reduction in afterload. For patients with severe LVOTO inotropes and nitrates should be avoided, and they may particularly benefit from alpha agonists (eg, phenylephrine) and/or beta blockers.

CONCLUSION: The clinical heterogenetiy of stress induced cardiomyopathy and prevelance of severe complications, such as cardiogenic shock, may be under appreciated. Assessing for development of LVOTO in this syndrome can help guide further management. Our case adds to the current literature of potential interventions and subsequent outcomes.

DOWN THE BLACK TUNNEL: A CASE OF ACUTE ESOPHAGEAL NECROSIS

Evelyn D. Capellan Vasquez, Maria F. Sanchez Carriel

Internal Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #3875165)

CASE: A 52-year-old woman presented with hypotension and active upper gastrointestinal bleeding (UGIB). Her past medical history included: T2DM, HTN, previous cardiac arrest with percutaneous endoscopic gastrostomy and tracheostomy placement, esophageal ulcers and several episodes of septic shock. On admission, blood pressure was 60/43 mmHg, heart rate 139 beats/min, and afebrile. On physical exam, the patient was spitting dark blood from her mouth. Initial blood work showed hemoglobin 6.6 g/dL, white blood cell 27.1k/uL, lactic acid 3.6 mmol/L, and INR 1.7. The patient tested positive for COVID-19.

She was admitted to ICU and had an emergent esophagogastroduodenoscopy (EGD) which revealed extensive, circumferential areas of ulcerative necrosis with active bleeding along the esophagus. A submucosal pulsating mass with active bleeding was found in the lower third of the esophagus, and EGD was aborted to prevent perforation. CTA chest and abdomen showed active UGIB from the distal third esophagus and gastric fundus. Embolization of the left gastric artery was done. However, due to her poor prognosis the patient was placed on comfort care and expired 9 days later.

IMPACT/DISCUSSION: Acute esophageal necrosis (AEN) is characterized by a diffuse circumferential darkening of the esophageal mucosa due to necrosis. Its prevalence is <1% in both autopsies and EGD series. Some risk factors are male sex (4:1 ratio compared to females), elderly age (average ±60 years old), chronic syndromes such as HTN and T2DM, sepsis, acute kidney injury, infections, and alcohol use.

One of the most popular causality theories is the “two-hit” hypothesis: an initial event of hypoperfusion predisposes the esophageal mucosa to a severe topical injury by gastric reflux. It is usually located in the distal portion of the esophagus, a poorly vascularized area. The most common clinical presentation is UGIB, with hematemesis or melena in up to 70-90% of cases. Previously only seen at time of autopsy, now it is usually discovered during EGD. Therapeutic approach is mostly supportive with intravenous fluid resuscitation and gastric acid suppression with intravenous proton pump inhibitors. Mortality risk has been proved high in these patients (13-35%), however, death is not usually directly attributed to AEN but to the underlying diseases that caused it.

Our case presents a female patient with multiple comorbidities and active UGIB. Following the “two-hit” hypothesis, both local (esophageal ulcers) and systemic (COVID-19 sepsis) causes were present. Usual treatment with fluid resuscitation and embolization of the primary bleeding source was followed. However, our patient’s poor general prognosis at time of presentation and direct admission to ICU meant her mortality risk was high.

CONCLUSION: AEN is a rare cause of UGIB but carries a high mortality risk. We conclude AEN should be included in the differential diagnosis of UGIB in patients with multiple comorbidities and initial hemodynamical instability.

DOWN TO THE WIRE – A CASE OF ICD LEAD-INDUCED SEVERE TICUSPID REGURGITATION

Haoxuan Yuan¹; Hillary Weisleder²; Devin Johnson²; Sofya Gindina¹; Gianni Carrozzi³

¹Medicine, Montefiore Medical Center, Bronx, NY; ²Internal Medicine, Montefiore Medical Center, Bronx, NY; ³Montefiore Medical Center, Bronx, NY. (Control ID #3874846)

CASE: A 61-year-old man with heart failure with preserved ejection fraction and implantable cardioverter- defibrillator (ICD) placement after ventricular fibrillation arrest 5 years prior presented with dyspnea for 10 days. He was recently admitted for acute decompensated heart failure. Since discharge, he continued to experience worsening dyspnea on exertion and lower extremity edema. He reported medication adherence and denied any recent infectious symptoms or changes in diet. On presentation, he was noted to be hypoxic with clear lungs and 2+ lower extremity edema on exam. A transthoracic echocardiogram (TTE) showed right ventricular (RV) failure, moderate-severe tricuspid regurgitation (TR), and normal left ventricular (LV) function. Severe TR was confirmed by transesophageal echocardiogram (TEE). Right heart catheterization (RHC) showed elevated right sided filling pressures and normal wedge pressure. In our patient with severe TR, no evidence of other structural disease, right heart failure, and an RV lead, the diagnosis of lead induced

tricuspid regurgitation (LITR) was made. His symptoms improved with diuretics and optimization of volume status. He was discharged with outpatient structural heart follow up.

IMPACT/DISCUSSION: Over 1.7 million cardiac implantable electronic devices (CIEDs) are implanted every year. Recent studies suggest lead-induced tricuspid regurgitation (LITR) may occur in up to 45% of device implants and manifest up to years after implantation. Development of severe TR, which results from lead impingement, perforation, or adherence to leaflets over time, carries an estimated 40-75% mortality rate in patients with CIEDs.

LITR is particularly challenging to diagnose, given that many patients have concomitant LV dysfunction. CIED lead interference with echocardiographic color-flow doppler signal may grossly underestimate TR. However, in patients with severe right heart failure in the setting of minimal left heart dysfunction and concurrent ICD placement, LITR should be considered alongside more common diagnoses such as pericardial disease, restrictive cardiomyopathy, or pulmonary hypertension.

TEE may offer better spatial definition for visualization of valve impingement by the lead itself. Other modalities, such as 3D-echocardiography and RHC, can also be similarly helpful in identifying the mechanism of LITR, evaluating the degree of right ventricular dysfunction, and guiding management.

Our patient’s ICD was implanted 5 years prior to development of severe TR. LITR and right heart failure may be reversible to some extent with interventions such as lead removal, reimplantation, or replacement, and valvular repair.

CONCLUSION: LITR is challenging to diagnose, as it may occur years after implantation. Given the high morbidity and mortality associated with significant TR, clinicians must remain vigilant in identifying lead- induced valvular disease as a cause of right heart failure in patients with CIEDs and otherwise normal left sided hemodynamic parameters.

DRUG ERUPTION OF ACETAMINOPHEN WITH UNDIAGNOSED SJOGREN’S SYNDROME Satoki Hatano¹; Kaihei Masuda¹; Keita Hibako¹; Mariko Shimazu²; Megumi Sano¹; Koki Kikuchi³; Kaito Nakamura¹; Kimi Kase⁴; Tetsuya Hoshi¹

¹General Internal Medicine, Teine Keijinkai Byoin, Sapporo, Hokkaido, Japan; ²Center of Education, Research and Clinical Trials, Teine Keijinkai Byoin, Sapporo, Hokkaido, Japan; ³Infectious Disease, Teine Keijinkai Byoin, Sapporo, Hokkaido, Japan; ⁴Dermatology, Teine Keijinkai Byoin, Sapporo, Hokkaido, Japan. (Control ID #3869094)

CASE: A sixteen-year-old female without any significant past medical history was admitted to our hospital for four day history of fever and appetite loss. Prior to this, she had suffered from chronic headache and abdominal pain, for which she frequently took acetaminophen.

On admission, physical examination was significant only for generalized faint skin rash. Lab data showed mild leukopenia as well as mildly elevated inflammatory marker and liver enzymes.

Initially, some viral infection was suspected, but bacterial infection, autoimmune disease, or drug fever could not be excluded. Therefore, medications other than some antipyretics were discontinued and the patient was placed under careful observation. Her fever remained persistent.

At about one week of admission, she started developing generalized maculopapular rash with oral lesions, which led us to strongly suspect drug eruption. Suspected causative drugs including acetaminophen were discontinued and systemic corticosteroid was initiated. Her condition resolved quickly and was discharged home after some additional tests. Results of the drug-induced lymphocyte stimulation test, autoantibody tests as well as skin and salivary gland biopsies confirmed drug eruption of acetaminophen and previously undiagnosed Sjogren’s syndrome.

Additional history revealed that she had experienced nausea and abdominal discomfort with acetaminophen, indicating she had already had allergic reaction to this drug before she developed this fever.

IMPACT/DISCUSSION: This case highlights the importance of careful history taking including the use of common medications. In this case, drug-induced fever was listed as an initial differential diagnosis, but acetaminophen was not suspected as the culprit. Had the information about her gastrointestinal symptoms with acetaminophen intake been obtained before the exacerbation of drug eruption, the use of acetaminophen after her hospitalization could have been prevented.

It should also be noted that drug allergy is reported as common complications of some autoimmune diseases such as Sjogren’s syndrome and SLE. According to previous reports, underlying autoimmune disease could be diagnosed with development of drug eruption as in this case. Therefore, autoimmune diseases should be kept in mind in cases of drug allergies.

This case is significant in that it includes nearly all phases of drug eruption in a patient with autoimmune disease. Moreover, detailed description of skin findings including pictures is valuable for all health caregivers engaged in general internal medicine.

CONCLUSION: ■ This was a case where almost all stages of drug eruption were observed in a hospitalized patient with previously undiagnosed autoimmune disease.

■ Careful history taking including detailed drug history is necessary, because drug eruption can occur with any medications.

■ Autoimmune diseases should be suspected in cases of drug eruption.

DRUG INDUCED AUTOIMMUNE LIVER DISEASE: A DIAGNOSTIC SPECTRUM IN THE SETTING OF DIPHENHYDRAMINE INGESTION

Umar Siddiqui¹; Jose I. De Arrigunaga¹; Sean E. Garcia²

¹Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ²Medicine, University of Texas Health Science Center San Antonio, Helotes, TX. (Control ID #3876980)

CASE: A 33-year-old female with no known past medical history presented to the emergency room for four days of worsening right-sided abdominal pain, nausea, and jaundice. The patient did not report fevers, weight loss, hematochezia, constipation, diarrhea, or vomiting. The pain was not associated with meals and was not radiating in nature. The patient denied use of illicit drugs, alcohol, and recent travel. Family history was negative for any liver disease or other autoimmune illnesses. The patient endorsed using acetaminophen 500 milligrams and Diphenhydramine (Benadryl). She stated she was using more Benadryl than “allowed on the bottle.” Lab results were significant for Aspartate Aminotransferase 820, Alanine Aminotransferase 574, Alkaline Phosphatase 210, Conjugated Bilirubin 14.7, and Total Bilirubin 18. Acetaminophen levels were less than 2. Magnetic resonance cholangiography confirmed cholelithiasis, but no evidence of acute cholecystitis or biliary dilation. Further workup showed nonreactive viral panels, negative liver kidney microsomal antibody, and positive Smooth Muscle Antibody. Hepatology was consulted and a liver biopsy was performed. Biopsy findings were consistent with both autoimmune hepatitis (AIH) and drug-induced liver injury (DILI). The patient was treated with methylprednisolone, which led to a decrease in her transaminitis. The patient was discharged with a prednisone taper and scheduled for follow-up with hepatology.

IMPACT/DISCUSSION: When considering causes of persistent transaminitis, the workup includes alcohol- induced hepatitis, Hepatitis C, DILI, AIH, and Drug Induced Autoimmune Liver Disease (DIAILD). There is limited literature on DIAILD, in which patients develop histologic findings of both DILI and AIH following medication or drug exposure. Even more limited is the literature on possible medication culprits that lead to DIAILD, especially Benadryl, one of the most common “over the counter” (OTC) medications. Benadryl is generally considered to have minimal hepatotoxic effects, although there are reports of DILI in the setting of co-ingestion with acetaminophen. This case highlights the importance of recognizing Benadryl as a possible facilitator of DIAILD based on the biopsy results from the case. Ultimately, these patients need to be treated with methylprednisolone. The patient in this case continued to have worsening transaminitis despite cessation of both Benadryl and acetaminophen, which is normally the therapy for DILI. Recognizing DIAILD as a spectrum between AIH and DILI in the context of chronic Benadryl use is an area with limited literature that needs to be investigated further.

CONCLUSION: In conclusion, this case highlights the importance of fully working up persistent transaminitis to treat the cause appropriately. Furthermore, it is important to consider DIAILD on the differential for various OTC medications, especially Benadryl. Further investigation of DIAILD is needed given the limited existing literature.

DRUG-INDUCED LIVER INJURY SECONDARY TO SUBOXONE USE

Niloy Ghosh, Oscar F. Borja Montes, Evan Kudron, Abu Baker Sheikh

Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM. (Control ID #3870347)

CASE: A 21-year-old male presented with abdominal pain and jaundice. He reported that symptoms have been ongoing for approximately five days, beginning with headache and cold sweats and eventually progressing to nausea and vomiting. Additionally, given his abdominal pain, he reported taking large amounts of Tylenol before stopping abruptly. Two weeks prior to his presentation, the patient reported receiving a new tattoo and injected Suboxone with a shared needle. Relevant medical history included myocarditis (in 2018) and polysubstance use disorder with IVDU. He denied any known family or personal history of autoimmune, liver or gallbladder disease.

On admission, all vital signs were within normal limits. Laboratory testing demonstrated severe transaminitis (AST 1220, ALT 2401) and direct hyperbilirubinemia (total bilirubin 5.7, direct bilirubin 4.3), and mild coagulopathy with INR of 1.54. Given the patient's admission of taking a large quantity of Tylenol, an acetaminophen level was sent and he was started on N-acetylcysteine on admission. GI was consulted, and a full hepatitis work-up including autoimmune hepatitis panel (negative), infectious hepatitis panel (positive for Hepatitis C), and screening for Wilson's disease (ceruloplasmin within normal limits) was carried out. While acute hepatitis C was initially high on the differential, the viral load was 6700 and the log PCR was 3.8, making it less likely to be the cause of the patient's acute hepatitis. Throughout the patient's hospitalization, transaminases down trended along with INR; thus, it was believed that the patient's symptoms were most likely due to a combination of hepatitis infection with toxic insult from the injected Suboxone causing ischemic hepatitis.

IMPACT/DISCUSSION: The majority of DILI are acute illnesses that resolved soon after the offending medication is stopped. Diagnosis is typically made by establishing a temporal relationship between exposure to the drug and development of signs and symptoms of liver disease. There are 3 types of DILI described in the literature: Hepatocellular, cholestatic, and mixed. Hepatocellular DILI carries a more severe prognosis, while the other two variants are more prone to chronic disease. The most common medication involved in DILI is acetaminophen, while other causes include anesthetics, NSAIDs, and antimicrobials. However, there have also been several cases described in the literature of buprenorphine induced DILI. Each describes a patient with a history of hepatitis C who developed a similar clinical presentation to our patient described in this report. In each case, the patient's had markedly elevated transaminases along with hyperbilirubinemia. Additionally, all LFTs returned to within normal limits after approximately two weeks from the time of injury.

CONCLUSION: It is vitally important to keep DILI on the differential, especially in cases of patients with underlying liver disease or previous injury.

DRUGS NOT BUGS: A CASE OF BACTRIM INDUCED ASEPTIC MENINGITIS

Fatima Anwar²; Phillip S. Hamilton¹

¹Hospital Medicine, The Ohio State University, Columbus, OH; ²College of Medicine, The Ohio State University College of Medicine, Columbus, OH. (Control ID #3877032)

CASE: A 21 year old male college student with a history of irritable bowel syndrome, eosinophilic esophagitis on omeprazole and acne vulgaris presented to the ED with acute onset fevers (Tmax 101.2), emesis, mid-epigastric pain, diffuse erythematous rash involving the face, neck, and chest, myalgias, rigors, severe frontal headache, photosensitivity, and nuchal rigidity about 10 minutes after taking Trimethoprim- sulfamethoxazole (TMP-SMX). He had been prescribed TMP-SMX for acne two weeks prior to presentation. Physical exam was remarkable for diffuse morbilliform rash, nuchal rigidity and positive kernig’s sign. Labs were notable for moderate neutropenia without eosinophilia, mildly elevated transaminases, and elevated lactate 3.2 mmol/L. CT head, abdomen and pelvis were unremarkable. He subsequently became hypotensive and was started on broad spectrum antibiotics for sepsis and meningitis coverage as well as methylprednisolone for concern for drug reaction with eosinophilia and systemic symptoms (DRESS). A lumbar puncture showed neutrophil-predominant leukocytosis with 264 nucleated cells/microliter, normal glucose, high protein, negative gram stain and viral studies suggestive of aseptic meningitis. His antimicrobials were stopped, and he experienced rapid improvement of his symptoms within 24 hours of admission. His infectious studies remained negative and he was continued on a short course of steroids. We concluded that aseptic meningitis secondary to TMP-SMX was the most likely diagnosis.

IMPACT/DISCUSSION: Drug-induced aseptic meningitis is a rare but simply treated syndrome associated with significant morbidity if not recognized early. This case highlights the diagnostic challenges associated with drug-induced aseptic meningitis, as the initial presentation prompted a wide differential, including bacterial meningitis, DRESS, and anaphylaxis. Compared to other reports in the literature, this patient’s initial neutropenia and diffuse rash were unique features of his presentation. His rash, elevated transaminases, and other systemic symptoms were concerning for DRESS as was the timing of his reaction two weeks after starting the antibiotic. However, the rapid resolution of the rash and symptoms within 24 hours, as well as the lack of eosinophilia, make DRESS unlikely. Quickly obtaining spinal fluid studies as well as consultation with dermatology expedited the final diagnosis.

CONCLUSION: Though aseptic meningitis is a relatively rare side effect of TMP-SMX, drug induced meningitis should be considered in patients presenting with signs of meningitis. Removal of the offending agent and supportive care can lead to rapid reversal of symptoms and good clinical outcomes.

DYSARTHRIA AND WEAKNESS IN A PATIENT WITH CIRRHOSIS

Kim Du¹; Lee Lu²

¹Internal Medicine, Baylor College of Medicine, Houston, TX; ²Internal Medicine, Baylor College of Medicine, Houston, TX. (Control ID #3875171)

CASE: A 40-year-old male patient from Honduras with depression, heavy alcohol use, and recently diagnosed cirrhosis who presented to our clinic with progressive generalized weakness, dyspnea, and dysarthria for three months. Patient reports previously working as a construction worker, but states he is no longer able to lift heavy objects due to shortness of breath and muscle fatigue. His slurred speech is inducible, and his wife is often unable to understand him by evening. Patient notes severe depression due to uncertainty of symptom etiology. He reports having a brother who died in his 30s of unknown cause.

In clinic, physical exam was significant for guttural dysarthria, fine resting tremor on both hands, strabismus, and numerous sub-centimeter skin nodules throughout the body which were also noted in his father and paternal uncles. Labs revealed negative hepatitis panel, normal ferritin and anti-nuclear antibody levels, and low ceruloplasmin and serum copper levels. 24-hour urine copper was elevated to 456 mcg. Right upper quadrant ultrasound revealed for cirrhosis and indeterminate 1 cm liver lesion. Liver biopsy by interventional radiology indicated portal inflammation with interface hepatitis, elevated hepatic copper concentration. Ophthalmology exam revealed Kayser Fleischer rings. Patient was diagnosed with Wilson’s disease and started on trientine.

IMPACT/DISCUSSION: Wilson’s disease is a rare autosomal recessive disorder caused by copper overload which is usually diagnosed between the ages of 5 to 35. Neurologic symptoms can vary widely and often mimic other disorders such as young-onset Parkinson’s disease, myasthenia gravis, and familial chorea. Dysarthria appears in as many as 90% of patients and can present with or without the prominent ataxic and hypokinetic features known to Wilson's. Psychiatric symptoms and depression can also manifest causing poor interpersonal relationships and declining school/ work performance. The Leipzig scoring system can distinguish and definitively diagnose Wilson's disease through criteria such as presence of Kayser Fleisher rings, urinary and liver copper levels, and hepatic/ neurologic symptoms. In our patient, cirrhosis was initially misdiagnosed and misattributed to heavy alcohol use. He underwent extensive neurologic, genetic, and hepatic workup which yielded inconclusive results, delayed diagnosis, and caused psychological distress. Wilson’s disease should be considered in any patient with unexplained hepatic disease with neuropsychiatric abnormalities. Prognosis is favorable with treatment, and chelating agents such as D-penicillamine and trientine can reverse hepatic and neuropsychiatric symptoms. First degree relatives of diagnosed patients should be screened for Wilson's disease.

CONCLUSION: Wilson’s disease should be considered in any patient with unexplained hepatic disease with neuropsychiatric abnormalities including dyarthria, weakness, and depression.

DYSPHAGIA UNCOVERS UNDIAGNOSED HIV AND MULTIPLE AIDS-DEFINING ILLNESSES Christina Hsiao, Helen Pope

School of Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #3875157)

CASE: A 30-year-old man with no significant past medical history presented with two months of dysphagia, weight loss, early satiety, a globus sensation of his throat and productive cough as well as three days of central abdominal pain, nausea and vomiting. He had recently immigrated from Honduras. Patient was cachectic, febrile, tachycardic, and had thrush in the posterior oropharynx and tongue and abdominal tenderness. Lungs were clear to auscultation and he was breathing well on room air. HIV-1 test was positive with a CD4 count of 50, COVID was positive, and blood cultures grew salmonella enterica. Chest x-ray demonstrated no acute abnormalities. CT scan showed diffuse tree-in-bud opacities with areas of confluent ground-glass opacities, greater in the upper lobe. Beta-D-Glucan noted to be minimally elevated. Pneumocystis smear was positive. He was treated with ciprofloxacin, fluconazole, trimethoprim/sulfamethoxazole, and started on HIV anti-retrovirals. At his two, four and six month follow- ups he was asymptomatic, eating well, and gaining weight.

IMPACT/DISCUSSION: Due to his status as an undocumented person, our patient was reluctant to seek care out of concerns for cost. As a result, he presented with uncontrolled HIV infection and multiple AIDS- defining illnesses. This case is an important example of providing low-barrier healthcare to those in need. The lack of access to preventative care, including HIV testing and education about prevention and management, delayed his diagnosis and treatment. Despite the CDC’s recommendation for HIV testing of all adults and adolescents at least once, it is estimated that 13% of people living with HIV in the US are undiagnosed. It can be difficult to find and navigate available resources that are affordable and language accessible. A timely diagnosis of HIV would have led to early initiation of anti-retroviral therapy and appropriate prophylaxis for opportunistic infections that would have greatly decreased the disease burden. While HAART has reduced the incidence of AIDS-defining illnesses, the prognosis of AIDS-defining illnesses remains poor. Even on HAART, HIV positive patients with AIDS-defining illnesses still experience higher mortality risk and lower quality of life than those without. Increased awareness and HIV testing can lead to earlier diagnosis and initiation of treatment, which may reduce morality and overall burden of disease.

CONCLUSION: The importance of early detection and treatment of HIV cannot be overemphasized. This case highlights how critical it is to have easily accessible and culturally-sensitive resources for underserved patient groups.

DYSPNEA IN A PATIENT WITH HISTORY OF LIVER TRANSPLANT: CONS-LIVER HEPATOPULMONARY SYNDROME

Amy S. Labar, Ronaldo Correa Fabiano Filho, Muhamad Khalid, Casey N. McQuade. Medicine, UPMC, Pittsburgh, PA. (Control ID #3874864)

CASE: A 58-year-old woman with medical history notable for hepatitis C cirrhosis status post remote liver transplant complicated by recurrent allograft cirrhosis and post-transplant diabetes mellitus presented to the emergency department with progressive dyspnea and bilateral lower extremity edema over one month.

She underwent cardiac surgery during childhood that was complicated by blood-transfusion-related hepatitis C, leading to cirrhosis and a liver transplant in her 30s. She had recurrent HCV treated with ledipasvir/sofosbuvir. She was maintained on cyclosporine for immunosuppression.

For her current presentation, she was in her baseline state of health until one month prior when she began gaining weight and experiencing progressive dyspnea on exertion. She saw her outpatient provider and was found to be hypoxic to oxygen saturation of 88% on room air. On admission, she was found to have greater than 20 pounds of weight gain with peripheral edema, clear lungs on auscultation, and vitals notable for oxygen saturation of 73% on room air, requiring 5L supplemental oxygen to achieve 92%. There was no difference in oxygen requirement from seating to supine position.

Transthoracic echocardiogram (TTE) with bubble study was notable for borderline pulmonary hypertension, borderline dilated right ventricle and dilated inferior vena cava with evidence of right-to-left intrapulmonary shunt. Chest CT angiography did not show any arteriovenous malformations to cause the shunt.

Technetium-99m macroaggregated albumin scanning showed severe right-to-left shunting elevated to 44% (normal value less <4%). Overall, the findings were felt to be consistent with hepatopulmonary syndrome (HPS) as the cause of her hypoxia.

Throughout admission, she required supplemental oxygen and desaturated significantly with exertion. She underwent diuresis to euvolemia in preparation for repeat TTE to re-evaluate pulmonary artery pressures to determine transplant candidacy, which were adequate. She was discharged with home supplementary oxygen and with plans for repeat liver transplant workup as an outpatient.

IMPACT/DISCUSSION: While hypoxemia and dyspnea on exertion are common chief concerns and cirrhosis is a relatively frequent comorbidity, HPS is rare and its diagnosis requires a high index of suspicion as well as the exclusion of more common hypoxic causes. In patients with liver disease and normal lungs, severe hypoxemia poorly responsive to supplemental O2 is a key clue to HPS. Detection of an intrapulmonary right-to-left shunt by echocardiogram is highly suggestive of the diagnosis.

CONCLUSION: In patients who present with dyspnea and have risk factors for liver disease, it is important to consider hepatopulmonary syndrome on the differential, especially when hypoxemia does not significantly improve with supplemental oxygen. Once identified, the only treatment for HPS is liver transplantation.

E. COLI STRIKES BACK

Josette M. Kamel¹; Humayra Mayat²; Matthew Shaines^3,2; Yogita Rochlani^1,2

¹Internal Medicine, Montefiore Medical Center, Bronx, NY; ²Medicine, Albert Einstein College of Medicine, Bronx, NY; ³Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #3873424)

CASE: A 47-year-old woman with end-stage-renal-disease (ESRD) on hemodialysis presented with productive cough and pleuritic chest pain for two days. She was febrile to 102.8 °F, tachycardic to 108, and saturating 96% on room air. She had a hemodialysis catheter in the right internal jugular vein and the site was clean and dressed.

Chest radiography revealed left lower lobe consolidation and the patient was initiated on piperacillin- tazobactam for presumed pneumonia. Blood cultures were positive for multi-drug resistant Escherichia coli and antibiotic coverage was changed to Meropenem based on susceptibilities. She continued to deteriorate from a respiratory standpoint and CT-chest obtained five-days later demonstrated a large pericardial effusion.

She subsequently underwent pericardiocentesis with placement of a pigtail catheter which drained over one liter of purulent fluid. Pericardial cultures grew multi-drug resistant E-Coli. Follow up echocardiography revealed persistent pericardial thickening and features of effusive constrictive pericarditis. She underwent anterior pericardiectomy with washout due to high risk of progression to constrictive pericarditis, and post- surgery had significant improvement in her hemodynamics. She was discharged home with plan to receive IV amikacin with dialysis.

IMPACT/DISCUSSION: The incidence of pericarditis is higher in ESRD patients largely due to accumulation of uremic toxins and is estimated to be around 5% in patients starting dialysis. The disease manifests differently than in the general population. Pleuritic chest pain is less frequently observed, and about a third of patients are asymptomatic. Interestingly, EKG changes are typically absent due to the lack of myocardial inflammation. Due to their chronically volume overloaded state, ESRD patinets also more prone to developing chronic effusions.

The incidence of purulent pericarditis has significantly declined with the emergence of targeted antibiotic therapy and is estimated to represent <1% of acute pericarditis cases. Patients with ESRD however are at a greater risk for procuring purulent pericarditis from hematogenous seeding due their elevated risk of developing bacteremia from infected dialysis instrumentation. Complete evacuation of purulent pericarditis is typically achieved through pericardiectomy which is indicated in patients with recurrent tamponade, persistent infection or who develop echocardiogram features concerning for constrictive pericarditis.

CONCLUSION: ESRD patients are often uremic and thus are prone to pericardial effusions. Addition of POCUS to initial assesment may allow discovery of a potential effusion sooner. These patients are also at risk for bacteremia due to instrumentation of their access sites. Thus despite the rarity of purulent pericarditis today it can be more likely within this population. Treatment decisions are difficult as clinicians must balance the risk of invasive procedures with further complications within a population with high morbidity.

EARLY REEVALUATION AND AGGRESSIVE ESCALATION OF THERAPY KEY TO PREVENTING DEVASTATING OUTCOMES IN PERSISTENT MRSA BACTEREMIA Alexandria Clarke Kregor¹; Yoonho Park¹; Spencer Deleveaux¹; Frances Boly²

¹Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL; ²Infectious Diseases, Advocate Christ Medical Center, Oak Lawn, IL. (Control ID #3877255)

CASE: 54-year-old male with no significant past medical history presented with acute onset back pain, fevers, and diaphoresis for four days prior to presentation. Computed tomography (CT) and magnetic resonance imaging (MRI) of the spine revealed no significant pathology. CT of the abdomen and pelvis was largely unremarkable. The following day, blood cultures grew methacillin-resistant staphylococcus aureus (MRSA) and the patient was initiated on intravenous (IV) vancomycin. Repeat blood cultures drawn 8 hours and 35 hours after the first dose of vancomycin remained positive for MRSA bacteremia. Two days after the initiation of IV vancomycin, blood cultures were negative, but were again positive on day 3. Transesophageal echocardiogram was negative for valvular vegetation. On Day 5, without a clear source of persistent bacteremia, a tagged white blood cell scan was obtained which was negative. At that time, vancomycin was discontinued, and combination therapy was initiated with IV daptomycin and ceftaroline. Blood cultures were negative approximately 24 hours after this transition in treatment. Repeat imaging revealed development of bilateral psoas abscesses, vertebral discitis, and an epidural abscess. Patient underwent a laminectomy without complication and completed a 21-day course of ceftaroline and daptomycin. He was discharged on daptomycin with an end-of-treatment date 6-weeks post-laminectomy.

IMPACT/DISCUSSION: Persistent MRSA bacteremia was traditionally defined as positive blood cultures after 7 days of appropriate antibiotic therapy, while more recent data suggests a shortened duration of 3 to 5 days. With the risk of mortality increasing the longer blood cultures remain positive after initiation of therapy, an aggressive approach is warranted. Holland et al suggested a “worry point” constituting a positive blood culture one calendar day after the initiation of appropriate antibiotics. This should prompt additional diagnostic testing to rule out endocarditis, metastatic sites of infection, and other occult abscesses. In our patient, initial imaging was unrevealing and blood cultures remained positive despite appropriate antibiotic therapy with IV vancomycin. Aggressive combination therapy with daptomycin and ceftaroline, which has been shown to be effective for persistent MRSA bacteremia, along with repeat imaging and surgical intervention, likely prevented a poor outcome in our patient. This case highlights the importance of careful reevaluation and additional diagnostic imaging in order to control this devastating infection.

CONCLUSION: MRSA bacteremia is associated with high morbidity and mortality. The ability to define and recognize persistent MRSA bacteremia early in order to escalate to appropriate therapy could reduce adverse outcomes. In certain cases, reassessing the most likely sources of infection despite an initially negative work up could uncover a targetable nidus.

EHRLICHIOSIS-ASSOCIATED NEUROMYELITIS OPTICA SPECTRUM DISORDER (NMOSD) Aastha V. Bharwad¹; Dylan Brittain²; Lisa Le¹

¹Internal Medicine, University of Kansas School of Medicine Wichita, Wichita, KS; ²University of Kansas School of Medicine Wichita, Wichita, KS. (Control ID #3877105)

CASE: A 25-year-old male with history of Sjogren’s syndrome presented with fever, chills, muscle aches, fatigue, nausea, vomiting, and double vision. He had recently returned from a trip to a lake in Missouri where he noted many ticks crawling on him. He was diagnosed with Ehrlichiosis and improved on doxycycline over two weeks. Brain MRI showed an increased T2 signal involving the anterior and posterior brain stem medulla. Ehrlichiosis titers returned equivocal.

A week later his symptoms returned, and doxycycline was restarted. Three days later he developed urinary retention and was admitted to hospital. Subsequently, he complained of profound lower extremity pain and weakness. Neurological exam showed bilateral 0/5 strength in lower extremities, absent deep tendon reflexes, and decreased sensation. He had decreased visual acuity bilaterally. MRI spine showed a T2 hyperintense signal extending from the T10 level to the conus. Repeat brain MRI revealed 11 mm area of increased T2 signal and enhancement of anterior aspect of cerebellar vermis.

Cerebrospinal fluid studies showed white cell pleocytosis with negative anti-aquaporin-4 (AQP4) antibodies.

Patient received five-day course of IV methylprednisolone followed by four-month taper of oral prednisone: five plasmapheresis treatments, and, six infusions of cyclophosphamide over six months. Visual acuity improved over four weeks. His urinary retention resolved after six weeks, and his motor function continued to improve. He had long-term impairments with neurogenic bladder, urgency, sexual dysfunction, and muscle stiffness with no relapses in the first year. Serum anti-AQP4 and myelin oligodendrocyte glycoprotein antibodies were negative eight months later. Currently, he is on hydroxychloroquine and baclofen.

IMPACT/DISCUSSION: This is a case of seronegative NMOSD onset by an ehrlichiosis infection with risk factor of Sjogren’s syndrome. Although ehrlichiosis titers were equivocal; the symptoms, labs, and history of recent tick exposure were all consistent with ehrlichiosis infection. Infections reported to cause NMOSD are usually viral in origin. This case of a tick-borne infection causing NMOSD is unique. The patient met diagnostic criteria for NMOSD with negative or unknown AQP4 antibody status: Acute transverse myelitis confirmed on MRI, acute brainstem syndrome, possible area postrema syndrome, and possible optic neuritis. The visual changes could have been caused by optic neuritis or brain stem involvement. Post-infectious NMOSD is usually seronegative and typically runs a monophasic course.

CONCLUSION: NMOSD is an immune-mediated, inflammatory disorder of the central nervous system causing severe demyelination predominantly targeting optic nerves and the spinal cord. Post-infectious and para-infectious causes of NMOSD have been noted in literature, although usually viral in nature. Sjogren’s syndrome is a risk factor for the development of NMOSD. Here we highlighted a case of ehrlichiosis- associated, seronegative NMOSD.

ENDLESS BLOODSHED BY GOLGO 13

Hiroshi Shiba¹; Fumio Mitsura²; Michihiro Tamai¹

¹Internal Medicine, Kumiairitsu Suwa Chuo Byoin, Chino, Nagano, Japan; ²Dermatology, Kumiairitsu Suwa Chuo Byoin, Chino, Nagano, Japan. (Control ID #3875031)

CASE: An 82-year-old Japanese man presented with continuous hemorrhage after surgery for a right arm adipose tumor surgery. He had prostate cancer recurrence 3 months prior and chronic kidney disease. He underwent laparoscopic cholecystectomy 4 months prior. He had no history of cirrhosis or hemorrhagic symptoms and no family history of hematologic disorders. He had been taking bicalutamide for 1 month. Preoperative laboratory data revealed normal prothrombin time (PT) and activated partial thromboplastin time (APTT), and mild thrombocytopenia.

The adipose tumor surgery was completed as scheduled. The surgical wound began to ooze the next day. A hematoma expanded despite compression and packing, thereby requiring a blood transfusion. Reoperation was performed on postoperative day 7. No active bleeding was found and oozing from vessels was once controlled. However, the postoperative hematoma recurred. We suspected acquired factor XIII deficiency (FXIIID) based on the laboratory findings and the clinical course. Fresh frozen plasma and Fibrogammin were immediately administered, which achieved hemostasis. Additional anticoagulation studies revealed reduced FXIII activity and normal factor VIII, factor IX, and von Willebrand factor levels. He was diagnosed with acquired FXIIID. Bicalutamide was discontinued without starting immunosuppressive therapy because of negative anti-FXIII inhibitors. The patient had no recurrence of bleeding and was discharged on day 22. The FXIII activity returned to normal during an outpatient follow-up.

IMPACT/DISCUSSION: Differential diagnoses for hemorrhagic diathesis with normal PT, APTT, and platelet counts are limited; platelet dysfunction, vasculopathy (hereditary hemorrhagic telangiectasia, scurvy, amyloidosis, vasculitis and others), and coagulopathy (von Willebrand disease and FXIIID). We used this diagnostic schema because the patient’s thrombocytopenia was not severe enough to cause persistent bleeding.

The diagnosis of acquired FXIIID is easily missed or delayed because of its rarity and specialized laboratory testing.

This disease is categorized as immune and non-immune mediated. Bleeding from the operation site reportedly accounts for 29% of autoimmune-acquired FXIIID. Additionally, FXIII hyperconsumption during surgery is one of the major causes of nonimmune mechanisms. Thus, postoperative hemorrhage is a typical presentation of acquired FXIIID. Prompt hemostatic treatment should be initiated when the disease is suspected to prevent further morbidity and mortality.

The mild decrease in FXIII activity and the absence of antibodies suggest nonimmune mechanisms such as medication. We suspected bicalutamide as the cause because the patient showed no abnormal hemostasis in the last surgery. The cessation of the offending agent can both confirm the diagnosis and be a causal therapy.

CONCLUSION: Acquired FXIIID should be suspected in persistent postoperative hemorrhage with normal platelet and coagulation test.

ENDOCARDITIS WITHOUT BACTEREMIA- A CASE OF ATRIAL-VENTRICULAR BLOCK FROM LISTERIA MONOCYTOGENES

Madeline Fowler¹; Christopher Polk²; Michael Leonard³

¹Internal Medicine, Atrium Health, Charlotte, NC;²Infectious Disease, Atrium Health, Charlotte, NC; ³Infectious Diseaes, Atrium Health, Charlotte, NC. (Control ID #3876619)

CASE: A 72-year-old female presented to the emergency department for evaluation of generalized weakness and bradycardia while undergoing hemodialysis. Her symptoms of generalized malaise developed over the past day and she denied any infectious symptoms such as cough, fevers, chills, or congestion. She had no recent syncopal episodes, chest pain, or shortness of breath. She had no known history of connective tissue disorders and was on no rate-controlling medications. She had a history of coronary artery disease with recent left heart catheterization with nonobstructive disease. She was afebrile and normotensive. Physical examination revealed an elderly female who appeared chronically ill. She was bradycardic and on auscultation and had a 3/6 systolic murmur best heart to right sternal border. An electrocardiogram was obtained and revealed a new onset third-degree heart block with a ventricular escape rhythm of 30 beats per minute. Prior electrocardiograms were reviewed and normal without prolonged PR interval or widened QRS. She was emergently taken for a right femoral vein temporary pacemaker with electrophysiology. Initial blood cultures obtained had no growth. A transthoracic echocardiogram revealed concern for aortic vegetation. Further workup was obtained with a transesophageal echocardiogram which revealed a heterogenous thickening consistent with an aortic root abscess. She was initiated on empiric antibiotics with Cefepime and Vancomycin. Repeat blood cultures were obtained and still had no growth. She was evaluated by the cardiothoracic surgery team and was not a candidate for aortic valve replacement or biopsy given her multiple comorbidities. A Karius Test was performed to help identify the pathogen and further tailor antibiotic therapy. The Karius Test returned positive for Listeria monocytogenes and she was transitioned to Ampicillin. She was discharged on outpatient Gentamicin given with her hemodialysis sessions.

IMPACT/DISCUSSION: This case demonstrates the importance of including infective endocarditis as a rare cause of atrial-ventricular heart block, especially in patients with increased risk factors. Other differential diagnoses of complete heart block include coronary artery disease, drug-induced from rate-controlling medications, infiltrating myocardial disease, collagen vascular disease, and infectious etiologies. This case also exhibits the importance of the Karius Test as a non-invasive modality to rapidly diagnose pathogens and to tailor therapies to decrease antibiotic resistance.

CONCLUSION: Atrial-ventricular block caused by infective endocarditis can be diagnostically challenging without bacteremia and a tissue sample. The Karius Test can detect thousands of pathogens utilizing bacterial cell-free DNA. This innovative tool is beneficial in diagnosing bacteremia when blood cultures are negative and without requiring an invasive biopsy.

ENDOGRAFT INFECTION AFTER ABDOMINAL AORTIC ANEURYSM REPAIR

Ugochukwu Akpara, Margaret McNairy

Internal Medicine, Weill Cornell Medicine, New York, NY. (Control ID #3877201)

CASE: A 78 year-old male with history of coronary artery disease with prior stents, abdominal aortic aneurysm with endovascular aneurysm repair (EVAR) six months prior, and heart failure presented to the emergency department with two weeks of abdominal pain and fatigue and was found in septic shock. On exam, he was afebrile, heart rate 74, and blood pressure 61/45. He endorsed peri-umbilical tenderness to palpation without signs of peritonitis or stigmata of endocarditis. Two sets of initial blood cultures were positive for Methicillin- Resistant Staph Epidermidis (MRSE) with CRP 9.1 and ESR 42. His blood pressure improved with fluids and initiation of vancomycin and piperacillin- tazobactam.

Computed Tomography (CT) imaging reported newly apparent periaortic soft tissue and fat stranding measuring up to 1 cm in thickness. Transthoracic echocardiography revealed no vegetation and stable

reduced ventricular function. Cultures remained positive for MRSE on hospital day 1 to 5. Positron Emission Tomography (PET) found periaortic soft tissue thickening extending along the aortic component of the graft suspicious for superimposed graft infection and without uptake suggestive of endocarditis. Infectious Diseases (ID) consult recommended six weeks of intravenous vancomycin and lifelong oral suppressive antibiotics, doxycycline, and deferring further imaging given native valve MRSE endocarditis is rare and blood cultures cleared on day 6. Vascular consult did not recommend explantation of graft at the time, and a repeat CT scan was planned for 4-6 weeks. Patient was then discharged.

IMPACT/DISCUSSION: Endograft infections after EVAR have a reported incidence <1%. Aortic graft infection after open surgical repair is well described with mean time to development of infection about six months and causative organism primarily Staphylococcus species (more so coagulase-negative). The positive predictive value of a prosthetic graft infection is around 97% when a suspected lesion on CT correlates with an area of FDG avidity on imaging, as was seen with our patient. Because of the low incidence, there is a lack of consensus on management and endograft infections are managed on a case-by-case basis.

Guiding principles of medical management include antibiotics and open surgical explantation should be considered in patients with life- threatening septic shock and persistently positive blood cultures. After discussion with ID and vascular surgery, we decided to attempt lifelong suppressive antibiotics with six-week course of IV antibiotics in lieu of acute removal as patient likely a poor surgical candidate because of comorbid history.

CONCLUSION:

- The diagnosis of an endograft infection requires a high index of suspicion, appropriate imaging, and lab tests including cultures and inflammatory markers.

- There is not a “gold standard” for management of infected endografts. For life-threatening septic shock, patients should be considered for open explantation in addition to antibiotics

ENDOPHTHALMITIS AS A SIGN OF KLEBSIELLA PNEUMONIAE INVASIVE SYNDROME (KPIS)

Priyanka Kumar, Alast Ahmadi, Kevin Chow, Garo Hagopian

Internal Medicine, University of California Irvine, Irvine, CA. (Control ID #3873567)

CASE: A 59-year-old Vietnamese man with diabetes presented from an outside hospital for orbital infection requiring ophthalmology care. At the outside hospital a few weeks ago, he had fevers, cough, and weakness. Chest x-ray showed pneumonia and he was given ceftriaxone and azithromycin. He also had klebsiella bacteremia. A few days later he became obtunded and developed new left eye swelling. CT showed multiple strokes. MRI showed pre-septal soft tissue and retrobulbar swelling concerning for infection. He was given vancomycin and amphotericin and transferred to our center for ophthalmological evaluation.

On arrival, the patient’s vitals were stable. Labs showed mild leukocytosis and anemia. He had left eye proptosis, edema, and purulent discharge. He was obtunded and had complete right-sided paralysis. Neurology and ophthalmology were consulted. Broad spectrum antibiotics were started for sepsis, initially thought to be from the orbit. Repeat infectious workup was sent. Ophthalmology confirmed endophthalmitis and the patient underwent an enucleation. CT revealed pulmonary nodules, liver abscess, and splenic infarcts. His liver abscess was drained and his antibiotics were narrowed to ceftriaxone based on outside hospital sensitivities. Unfortunately, he developed hemorrhagic conversion of his stroke with worsening edema and midline shift, and no viable neurosurgical intervention. Given his poor prognosis, the patient’s family decided on hospice care.

IMPACT/DISCUSSION: K. pneumoniae is well-known for causing lung, abdominal, and urinary tract infections, but can also cause a rare, life-threatening condition called Klebsiella pneumoniae invasive syndrome (KPIS). KPIS is caused by a highly virulent variant of K. pneumoniae (HvKP) and most commonly affects Asians and to a lesser degree Pacific islanders and Hispanics. It is characterized by primary liver abscess associated with metastatic infection. The most common sites of metastatic infection are the central nervous system, including the eyes, followed by the lungs, spleen, and musculoskeletal system. K. pneumoniae is usually susceptible to third generation cephalosporins. Abscess drainage is always recommended for source control.

Here, we describe a case of KPIS in a Vietnamese patient with diabetes, also an independent risk factor for K. pneumoniae associated liver abscess. The patient initially appeared to have a pneumonia; however, despite treatment, he worsened. He had multiple strokes and evidence of eye infection at the outside hospital. However, there was a delay in recognizing the eye was not the primary source of infection. Adequate source control was finally established when imaging revealed a liver abscess, which was drained. Unfortunately, delayed diagnosis and source control led to a fatal outcome for this patient. Our case highlights the need for early recognition and aggressive source control to treat KPIS.

CONCLUSION: Early recognition and definitive source control are required to prevent mortality from KPIS.

EPSTEIN–BARR VIRUS (EBV) ASSOCIATED ENCEPHALITIS IN YOUNG MALE

Naoshin Khan¹; Kashmira Wani¹; Mohamed Ramzi Almajed²; Abigail Entz²

¹Internal Medicine, Henry Ford Health System, Detroit, MI; ²Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #3877149)

CASE: A 22-year-old Yemeni male acutely presented with alerted mentation and confusion. Two days prior, patient endorsed subjective fevers, chills and fatigue. He has no pertinent medical history.

Upon presentation, patient was not alert nor oriented to time nor place. On examination, he was hypotensive with inability to follow commands or respond to stimuli. Laboratory work-up was largely unremarkable, including negative urine toxicology and urinalysis. Initial CT Head showed findings suggestive of idiopathic intracranial hypertension, but otherwise no acute process. Further CTA showed no evidence of intracranial arterial stenosis, occlusion, or aneurysm. Given concern for acute encephalitis, patient was empirically started on antibiotics and antiviral therapy. Lumbar puncture was obtained and demonstrated elevated lymphocytes and RBCs >2. CSF studies including CMV, VZV, HSV, and HIV were still pending.

Given little improvement with empiric treatment, further EEG was obtained which showed bilateral temporal diffuse polymorphic as seen in HSV encephalopathy. Therapy was de-escalated to antiviral therapy due to concern for HSV. Initial CSF studies resulted, demonstrating EBV in the CSF. Patient began to clinically improve, becoming more responsive and following commands appropriately. Repeat lumbar puncture showed elevated lymphocytes but otherwise negative. Further therapies were discontinued given that patient returned to his baseline mentation.

IMPACT/DISCUSSION: EBV is a common virus that has infected the majority of the world’s population. In adults, the virus typically causes a triad of fever, lymphadenopathy and pharyngitis, and less commonly hepatosplenomegaly and petechiae. However, in even rarer cases it can cause encephalitis or meningitis. Studies have shown that 1% of patients develop CNS sequalae with EBV.

Our case represents a rare presentation of acute encephalitis due to EBV as most cases are seen in the pediatric population unlike our patient. Also, neurological symptoms secondary to EBV are non-specific and may not present with common findings of infectious mononucleosis including cervical lymphadenopathy. Use of corticosteroids and acyclovir have been seen in some cases. However, no standard of treatment exists, and most patients improve with conservative management as seen in our patient.

CONCLUSION: Internists should be aware of the neurological complications in patients with symptoms suggestive of infectious mononucleosis. While it is more commonly seen in pediatric patients, complications can occur in adults. Therefore, it is important that we continue to share cases on EBV-related encephalitis in order to identify and properly manage these patients.

EPTIFIBATIDE INDUCED ALVEOLAR HEMORRHAGE - A RARE BLEEDING COMPLICATION OF GP IIB/IIIA INHIBITORS

Tyler Andrews

Internal Medicine, Henry Ford Health System, Detroit, MI. (Control ID #3877305)

CASE: A 64-year-old male with history of atrial fibrillation on apixaban with hospitalization one month prior for acute PE and ACS with PCI to LAD presented with acute heart failure exacerbation secondary to known severe aortic valve regurgitation. Once euvolemic, clopidogrel was transitioned to eptifibatide in anticipation of urgent surgical aortic valve replacement. However, the patient developed significant hemoptysis two days following the initiation of eptifibatide requiring endotracheal intubation for airway management. At that time, eptifibatide was inevitably discontinued and aspirin was continued as antiplatelet monotherapy. Chest x-ray demonstrated diffuse alveolar infiltrates and blood was visualized in all lobes on bronchoscopy. Topical lidocaine was injected with improvement of bleeding and apixaban was subsequently held. Patient received course of high dose steroids with gradual resolution of hemoptysis allowing for extubation. Autoimmune work up was negative and platelets remained stable. Ultimately, patient underwent successful coronary artery bypass grafting with aortic valve replacement and was discharged home.

IMPACT/DISCUSSION: As dual antiplatelet therapy has become protocol medical management following PCI, it does not come without intrinsic risk of major bleeding events. While major bleeding events are recognized, diffuse alveolar hemorrhage is a rare manifestation of bleeding complications associated with antiplatelet therapy. This case describes a case of eptifibatide induced diffuse alveolar hemorrhage in a post PCI surgical patient. DAH secondary to GP IIb/IIIa inhibitors has been previously documented, however, the volume of published cases remains seldom. The first documented case of GP IIb/IIIa inhibitor induced DAH was described by Stigles and Villa in 1997. Since, there has been an increase in reports of alveolar hemorrhage in relation to this class of antiplatelets. In 2012, Gou et al. composed a comprehensive list of published cases, including 21 isolated cases of GP IIb/IIIa inhibitor induced DAH, three of which were caused by eptifibatide. There have been several more cases describing DAH in patients receiving GP IIb/IIIa inhibitors, and antiplatelet medications in general. Reflecting, the true incidence of DAH due to antiplatelets has yet to be studied extensively. In retrospect, DAH may be a minority in major bleeding complications of antiplatelet therapy, however, it does present as a severe but treatable manifestation if recognized and addressed promptly. This may suggest that DAH should be understood as a potential adverse effect of antiplatelet use and providers must be aware of such presentations.

CONCLUSION: GP IIb/IIIa inhibitors have been associated with several instances of DAH as outlined in literature and providers should be aware of such adverse event.

Thorough history and coordination of patient care amongst consultants may prevent undesirable hospital courses, unnecessary exposures, and adverse events during admission.

ESR ISN’T EVERYTHING: A CASE OF GIANT CELL ARTERITIS WITH NORMAL INFLAMMATORY MARKERS

Megan R. D'Andrea, Lauren Peccoralo

Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3872388)

CASE: A 63-year-old woman with a history of osteoarthritis and cataracts presented to her primary care physician via televisit with one week of TMJ pain, frontal headache radiating to the jaw, and photophobia. NSAIDs did not relieve the pain. She also reported bruxism, posterior neck pain, and eye tearing (thought due to cataracts). Physical exam showed tenderness along bilateral temples, jaw, and above eyes with full neck range of motion. Her symptoms were attributed to arthritis and bruxism, with rebound headaches from NSAID use. She was told to decrease NSAIDs, use warm compresses and jaw relaxation, and call if symptoms did not improve in 48 hours.

A lack of improvement raised concern for Giant Cell Arteritis (GCA). Labs showed an ESR of 30 (0-38),

CRP of 39 (0-5), C4 of 56 (10-40), and normal ANA, anti-CCP and C3. Patient was started on prednisone 10 mg daily for presumed exacerbation of inflammatory arthritis. Steroids initially improved her symptoms, but were discontinued due to a rash. She was referred to rheumatology, where suspicion for GCA was low due to lack of jaw crepitus or tenderness, as well as normal ESR. New labs showed a rising ESR (46) and CRP (45). The patient was referred to neurology, where color doppler ultrasound revealed two dark spots, indicating ectasias, in bilateral temporal arteries. This finding, combined with history of jaw claudication and bifrontal headaches, prompted a temporal artery biopsy, which revealed active GCA. She was started on high-dose steroids with eventual symptom improvement.

IMPACT/DISCUSSION: GCA is the most common vasculitis involving small and medium arteries. Incidence peaks in the seventh decade, and it is commonly associated with polymyalgia rheumatica. Clinical presentation can include headache, monocular vision loss, jaw claudication, constitutional symptoms, and signs of vascular abnormalities. Temporal artery biopsy is the diagnostic gold standard, however color doppler ultrasound can be used as an adjunct or diagnostic alternative. Treatment of GCA requires high-dose systemic steroids, which should be started as soon as GCA is suspected. Tocilizumab can be used for patients requiring a steroid-sparing agent.

The inflammatory markers ESR and CRP are almost always elevated in GCA - only 4% of patients with GCA have ESR/CRP in the normal range. This case highlights a rare example in which the patient’s inflammatory markers were not markedly elevated, which likely delayed her diagnosis.

CONCLUSION: It is important for clinicians to recognize that symptoms of GCA can wax and wane, and that while elevated inflammatory markers are almost always seen in GCA, the presence of normal ESR/CRP should not preclude further evaluation. Furthermore, it is crucial to remember the association between polymyalgia rheumatica and GCA, and to have a high index of suspicion if GCA symptoms are seen in individuals with polymyalgia rheumatica. Color doppler ultrasound of the temporal arteries can be a helpful, noninvasive diagnostic tool.

ESSENTIAL THROMBOCYTHEMIA (ET) ULTIMATELY LEADING TO SEVERE BLOOD LOSS ANEMIA IN A JEHOVAH’S WITNESS PATIENT

Navina Mohan

Internal Medicine, NYU Langone Health, New York, NY. (Control ID #3875796)

CASE: A 30-year-old female with a past medical history of Janus Kinase 2 (JAK2) V617F mutation- positive ET (diagnosed in 2016, on warfarin) complicated by portal vein thrombosis (PVT) status-post thrombectomy (2017) and superior mesenteric vein thrombosis, presented with bloody diarrhea. Her stool was semi-formed with bright red blood. She had moderate fatigue, but no abdominal pain, no melena, no hematemesis, no nausea, and no vomiting. She has not had a prior endoscopy. She is warfarin-compliant, a never-smoker, a non-drinker, and takes no other drugs. She is a Jehovah’s witness (JW).

Vitals were initially normal. The physical exam was only significant for pallor. Initial labs include hemoglobin (Hgb) 10.4, platelets 411, stool Clostridium difficile infection (CDI) positivity, normal comprehensive metabolic panel, and INR 1.9. Initial abdominal imaging showed no gastrointestinal (GI) bleed source, but revealed cavernous transformation of the portal vein, along with chronic thrombosis of the superior mesenteric and now splenic veins. A colonoscopy was unremarkable. The patient received antibiotics for CDI.

The patient later became hypotensive with continued hematochezia and Hgb 2.8. She was fluid-resuscitated. An urgent esophagogastroduodenoscopy (EGD) showed actively bleeding duodenal varices (DVs), treated with hemostatic spray. A normal stomach, non-bleeding esophagitis, and grade I varices in the lower third of the esophagus were also visualized. The patient then received a prophylactic splenic artery embolization performed by interventional radiology (IR). The patient’s severe anemia was managed via a bloodless medicine protocol. The patient’s hematochezia and anemia resolved.

IMPACT/DISCUSSION: Approximately 4% of ET patients, preferentially younger women, develop abdominal vein thromboses. This may cause portal hypertension leading to varices. DV bleeding can be fatal, yet there are no well-defined management guidelines. In this case, hemospray temporization followed by splenic artery embolization was successful. If the patient were to have continued bleeding, a gastroduodenal artery embolization would be indicated. Refractory bleeds would require advanced endoscopic sclerotherapy of the DVs. Bloodless medicine options for anemic JW patients include, as in this case, intravenous (IV) epoetin alfa, IV iron, oral vitamin C, folate, and B12 supplementation, minimizing blood draws, and using neonatal vials.

CONCLUSION: Young women with ET presenting with GI bleeds must be evaluated for sequelae of PVT and/or portal hypertension. Patients with DVs also requiring lifelong anticoagulation may need more definitive variceal management including IR embolization of intra-abdominal source vessels. JW patients with severe blood loss anemia benefit from early operative interventions and bloodless alternatives.

EXERCISE CAUSING UNILATERAL LOWER EXTREMITY EDEMA: A CASE REPORT OF ILIOPSOAS BURSITIS WITH EXTERNAL VENOUS COMPRESSION

Shannon Zoulek, Cole J. Evans, Nadeem Abou-Arraj

Internal Medicine, University of Michigan, Ann Arbor, MI. (Control ID #3875272)

CASE: A 69-year-old male presented to the primary care clinic with 1-month of worsening right groin tightness and swelling. He attributed his symptoms to an intensive exercise program; however, right foot swelling developed and progressed up to his thigh. He denied fever, weight loss, dyspnea, personal or family history of a blood clot, recent travel, immobilization, or tobacco use. Examination was significant for a minimally tender, non-pulsatile, firm mass in the right groin with 3+ non-pitting edema from the foot to mid- thigh without warmth or erythema. Pedal pulses were 2+ bilaterally.

Given concern for possible DVT versus mass effect, diagnostic imaging was ordered. X-ray showed osteoarthritis of the right hip. Ultrasound demonstrated a non-vascularized mass in the right groin compressing the external iliac and common femoral veins. CT pelvis showed a 11.3 cm bilobed cystic lesion in the right iliopsoas tendon and adjacent iliacus muscle with compression of the common femoral vein and distention of the distal superficial femoral vein; severe bilateral hip osteoarthritis was also present. From these findings, we diagnosed iliopsoas bursitis, likely caused by severe osteoarthritis and overuse from repetitive exercise. He was referred to Interventional Radiology for drainage of the fluid collection. Cytology showed no evidence of malignancy or infection. Fluid aspiration resulted in marked improvement of his edema.

IMPACT/DISCUSSION: Acute, unilateral lower extremity edema is often caused by venous or lymphatic obstruction, with common etiologies being DVT, lymphedema, or tumor obstruction. Iliopsoas bursitis (IB) is a rare presentation of unilateral edema that may be overlooked but is important as it can improve with appropriate treatment. IB is most often seen in patients with hip pathology such as rheumatoid arthritis and osteoarthritis as well as overuse injuries. Imaging can help differentiate IB from other conditions. Ultrasound is most useful for ruling out venous or lymphatic disease. MRI is the standard as it can assess soft tissue and evaluate for cystic disease around the hip joint. Rapid growth and ability for compression of external structure is a known complication of severe IB as seen in our patient presenting with unilateral lower extremity edema. In patients with vascular compression, aspiration of the bursa can help alleviate symptoms. Our case highlights the importance of obtaining a thorough history and maintaining a broad differential when a patient does not have risk factors or a clinical story that aligns with more common diagnoses.

CONCLUSION: In patients who present to the primary care clinic with acute, unilateral, lower extremity edema with associated groin mass without risk factors for DVT and malignancy, iliopsoas bursitis should be considered.

Osteoarthritis, rheumatoid arthritis and overuse injuries place patients at higher risk of developing iliopsoas bursitis.

FAMILIAL MEDITERRANEAN FEVER COMPLICATED BY MASSIVE CARDIAC TAMPONADE

Haris Patail, Garima Gautam, Julie Braish, David Ozimek

Internal Medicine, UConn Health, Farmington, CT. (Control ID #3840391)

CASE: An 83-year-old female with a significant history of polymyalgia rheumatica and Familial Mediterranean Fever (FMF) presented to the emergency department with complaints of fever, nausea, and diarrhea for one week. On presentation, she further denied chest pain, dyspnea, and shortness of breath. Labs were significant for a white blood cell count (WBC) of 13700mcL, ESR of 130 mm/hr, BNP of 277 ng/L, and CRP of 433 mg/L. The patient was started on colchicine for management of a suspected FMF flare-up.

During her hospital course, her WBC increased to 27000 mcL and she developed acute hypoxic respiratory failure. Pulsus Paradoxus of 15-20 mmHg, atrial fibrillation with rapid ventricular rate (RVR), and new hypotension was noted prompting intubation, vasopressor support, and transfer to the intensive care unit. A moderate to large pericardial effusion was identified circumferential to the heart on transthoracic echocardiogram and CT imaging. The patient underwent urgent pericardiocentesis and further analysis of pericardial fluid showed a moderate hemorrhagic pericardial effusion with loculations thought to be secondary to acute pericarditis. The patient clinically improved a few days following pericardiocentesis and was successfully extubated to nasal cannula with removal of bilateral pericardial drain tubes.

IMPACT/DISCUSSION: This case illustrated FMF in an 83-year-old female complicated by massive cardiac tamponade. FMF is characterized as a condition associated with recurrent bouts of fever and inflammation including peritonitis, pleuritis, pericarditis, and arthritis however cardiac tamponade as a sequelae is considered rare. For medical treatment, colchicine is first line therapy for management of acute pericarditis, however, effusions in FMF can progress to moderate to large causing right ventricular collapse and hypotension. Given its ability to cause significant hemodynamic compromise, urgent pericardiocentesis is often indicated for definitive management.

CONCLUSION: Familial Mediterranean Fever is an auto inflammatory disorder characterized by recurrent bouts of fever and serosal inflammation. Despite its known cause of acute pericarditis, the progression to massive cardiac tamponade requiring pericardiocentesis is not commonly reported.

FATAL CASE OF STAPHYLOCOCCUS CAPITIS ENDOCARDITIS IN A PATIENT WITH TRANSCATHETER AORTIC VALVE REPLACEMENT

Rojin Esmail^1,3; Curtis Ober^4,3; Chelsea Dunn²; Damian Casadesus³

¹Internal Medicine, Ross University School of Medicine - Barbados Campus, Bridgetown, Barbados; ²Internal Medicine, Ross University School of Medicine, Miramar, FL; ³Internal Medicine, Jackson Memorial Hospital, Miami, FL; ⁴Medicine, Ross University School of Medicine, Miramar, FL. (Control ID #3875024)

CASE: Transcatheter aortic valve replacement (TAVR) has become the standard of care for high risk, inoperable patient and occasionally in intermediate risk patients with symptomatic aortic stenosis . Early or late onset of infective endocarditis (IE) after a TAVR is rare, difficult to diagnose and often fatal. Given that this procedure is relatively new, not much data has been reported on the best way to diagnose and manage this high risk population

A man in his 60s with history of end stage renal disease and TAVR presented to the hospital with a one week history of shortness of breath. Vitals showed temperature of 37.2 C, blood pressure of 80/60 mmHg, and heart rate of 70 BPM. Patient was noted to have jugular venous distention, and a grade 2/6 systolic murmur. Laboratory studies were significant for a WBC of 17,000 U/L. CT chest revealed multilobular penumonia and Transesophageal echocardiogram (TEE) showed a 1.9 cm x 0.6 cm vegetation of the tricuspid valve, severe stenosis of the prosthetic aortic valve and severe mitral regurgitation with an EF of 40-45%. The patient was diagnosed with mitral, tricuspid and TAVR-IE. Patient wasn’t considered a surgical candidate due to highly calcified aorta and he was treated with Cefazolin, Gentamicin and Rifampin. On day fifteen, he was taken to the cardiac catheterization department for structural heart evaluation and symptomatic managment with valve in valve TAVR. Post procedure, patient developed septic and cardiogenic shock. He suffered cardiac arrest and later pronounced dead.

IMPACT/DISCUSSION: To the best of our knowledge this is the first reported case of S.capitis as the cause of TAVR-IE. Incidence of TAVR- IE is rare (3 to 9 cases per 100,000) yet associated with high in-hospital mortality of 34%. The most common causative agent of endocarditis in the TAVR population is Enterococcus. Coagulase-negative Staphylococci (CoNS) is infrequent in this population with highest 30 day mortality at 31%. Chronic hemodialysis is found to be the biggest risk factor of IE in this populations and has the greatest association with CoNS.

The diagnosis of infective endocarditis after TAVR presents challenges which delays treatment and increases morbidity and mortality . A study by Magner et al, observed that TEE only detected 25% of vegetation while 31.9% of the TEEs were reported negative in presents of TAVR-IE. The higher density of the prosthetic valve prevents the passage of the ultrasound waves, and the shadow of the prosthetic valve further prevents visualization of the smaller vegetation and abscesses. TAVR-IE may present with obstructive pattern and leaflet thickening on echocardiogram, which was observed in our patient.

CONCLUSION: S.capitis is a rare and opportunistic cause of TAVR-IE with lower capability to adhere to foreign objects compared to other coagulase negative Staphylococcus.

Clinicians should consider infective endocarditis early on in the TAVR population even in presence of another infectious source.

FINDING A HEARTY DIAGNOSIS THROUGH THE THICKNESS

Nevetha Rajendran, William B. Rothwell

Internal Medicine Residency, Tulane University Health Sciences Center, New Orleans, LA. (Control ID #3876826)

CASE: A 60-year-old woman presented with atypical chest pain, vomiting and elevated cardiac troponins. She additionally complained of dysphagia, generalized weakness, and diffuse muscle pain for months. The patient displayed skin thickening and hyperpigmentation, particularly in acral regions. Her joints were stiff due to the thickened skin of her hands, ankles, and feet; they did not appear to be tender or inflamed. She denied her fingers changing color with cold temperatures. High sensitivity troponin was 352 ng/L followed by a repeat troponin of 440 ng/L. An electrocardiogram demonstrated normal sinus rhythm with a right bundle branch block and left ventricular hypertrophy. A transthoracic echocardiogram and myocardial perfusion scan were normal. An anti-nuclear antibody profile obtained was negative. Further testing revealed markedly elevated erythrocyte sedimentation rate and C-reactive protein, and a positive anti-RNA

Polymerase III antibody. A tentative diagnosis of scleroderma was made. The elevated cardiac troponins were deemed related to a diagnosis of myocarditis and less likely acute coronary syndrome (ACS). She was initiated on a prednisone taper and was advised to follow-up in clinic. During her follow-up, she endorsed overall symptomatic improvement, particularly with her dysphagia and discoloration of her hands.

IMPACT/DISCUSSION: According to the 2013 Classification Criteria for Systemic Sclerosis, skin thickening of the fingers extending proximal to the metacarpophalangeal joints is sufficient for a patient to be classified as having scleroderma. The localized form (LcSSc) has skin involvement that is confined largely to the face and extremities, while the diffuse form (DcSSc) has skin thickening extending beyond the extremities and face. DcSSc is associated with significant mortality related to cardiac, gastrointestinal, and renal involvement. The cardiac manifestations include myocarditis, conduction defects, ventricular arrhythmias, or acute heart failure. Scleroderma myocarditis is characterized by cellular infiltration and edema, which precedes myocardial fibrosis, and results in diastolic dysfunction. It progresses on an intractable course to end-stage heart failure and can manifest as sudden cardiac death. Diagnosis can be challenging because of nonspecific presentations, but when diagnosed and treated in a timely manner, can result in complete recovery of heart function.

CONCLUSION: Scleroderma is a chronic autoimmune disease that causes microvascular damage and collagen deposition in the skin and internal organs. Since the cutaneous manifestations are found in most patients, a thorough physical examination is crucial in the initial diagnosis of scleroderma. Cardiac involvement is a common complication that is frequently underdiagnosed and associated with significant mortality. In a woman with an immediate concern for ACS on presentation, the importance of a careful physical exam including the skin may provide other clues into the etiology.

FINDING THE FAULTY FIBRIL: A CASE OF RECURRENT SYNCOPE

Natasha Mehra¹; Tylan Magnusson²; Sydney Dunn-Valadez²

¹Internal Medicine, The University of Alabama at Birmingham School of Medicine, Birmingham, AL; ²Hematology and Oncology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL. (Control ID #3872730)

CASE: A 49 YOM with a history of rheumatoid arthritis presents with recurrent syncope. Over the past two months, he becomes dizzy and sees black spots every time he rises. He has fainted several times, leading to multiple clinic and ED visits. He has been diagnosed with orthostatic hypotension, which has not improved with fluid resuscitation, midodrine, or hydrocortisone. He also has diffuse joint pain, burning in his extremities, fatigue, and a 30lb weight loss over two months. His vitals on arrival are temperature of 97.2F, BP 116/72 with positive orthostatics, HR 99, PO2 100% on RA. Physical exam reveals a patient with a waxy complexion lying in bed. His labs are remarkable for a CMP with alkaline phosphatase 193, total bilirubin 1.9 (direct .9), protein 4.9, albumin 3.0; CBC with platelets 110, hemoglobin 11, INR 2.31, SPEP and UPEP without M-spike, serum and urine immunofixation with one monoclonal free lambda light chain, and a Kappa Lambda FLC ratio of .04. CT chest/abdomen/pelvis showed bilateral atelectasis, hepatomegaly, and splenomegaly. Echocardiogram shows moderate concentric left ventricular hypertrophy and abnormal diastolic dysfunction. Skin biopsy is obtained and establishes the diagnosis of small fiber neuropathy secondary to cutaneous amyloidosis. Next, bone marrow biopsy is completed to rule out an underlying plasma cell dyscrasia and reveals a B-cell clonal neoplasm. CYBOR-D is initiated for treatment. Several days later, the patient’s alpha-2-antiplasmin results low at 54.

IMPACT/DISCUSSION: Amyloidosis is a systemic disease of misfolded protein fibrils that can lead to non-specific symptoms, including fatigue, weight loss, and easy bruising. It most commonly involves the renal, gastrointestinal, and cardiac systems. However, amyloid can also wreak havoc in the nervous system via multiple mechanisms. It can cause small-fiber neuropathy. Involvement of the autonomic nerves can lead to bowel and bladder dysfunction as well as orthostatic hypotension. Additionally, amyloid deposition in the cortex can lead to dementia and spontaneous cortical and subcortical intracranial bleeding. Severe liver involvement can lead to coagulopathy from decreased production of clotting factors and factor X deficiency. Another rare cause of coagulopathy in patients with amyloidosis is alpha-2-antiplasmin deficiency. It ix the result of direct factor adsorption by the amyloid fibrils. Alpha-2-antiplasmin inhibits plasmin, which degrades fibrin and other proteins leading to breakage of a fibrin clot and restoration of blood flow. Hence, the deficiency can lead to bleeding.

CONCLUSION: Amyloidosis is a systemic disease that can present insidiously and be notoriously difficult to diagnose given potential involvement of multiple organs. Involvement of autonomic nerves can lead to orthostatic hypotension, a relatively uncommon presentation. Additionally, it can cause coagulopathy through various mechanisms, including decreased factor production, and rarely alpha-2-antiplasmin deficiency.

FINE TOUCH: REVIVING THE ART OF THE PHYSICAL EXAM IN THE WORLD OF MODERN MEDICINE

Isha Lamba, Peggy B. Leung

Internal Medicine, New York Presbyterian/ Weill Cornell, New York, NY. (Control ID #3875360)

CASE: History of Present Illness:

Mr. X is a 43 y/o man with no PMH who initially presented to his PCP’s office for weakness. All bloodwork was normal - he was reassured and asked to follow-up in 1 year.

Over the next 4 months, he presented to the ED several times complaining of full body weakness, however an MSK exam was not performed. During one of these admissions, a troponin level was incidentally found to be elevated to 5,900 ng/L. Although the patient only described mild chest discomfort, he underwent a LHC which showed no CAD. CXR, CTPE and TTE were unremarkable. The troponin elevation was attributed to type 2 NSTEMI 2/2 dehydration, and he was sent home.

Finally, he was readmitted 1 month later – this time his weakness rendered him unable to walk or perform his job as a truck driver. The patient expressed frustration that his body weakness had remained unaddressed for months and had progressed to this point.

Physical Exam:

Vitals WNL. Notable for irregular heart rhythm and 2/5 strength in b/l proximal lower extremities. No rash.

On tele, he was noted to have frequent PACs, and TTE revealed EF 49% with global hypokinesis. Troponin was 6,400 ng/L and serum CK was 13,000 U/L, raising suspicion for myositis with myocarditis. PET scan done to r/o malignancy revealed inflammation at the myocardium and vastus medialis muscles. Pathology results from vastus medialis and myocardial biopsies confirmed myocyte injury. Autoimmune workup revealed elevated levels of aldolase, myoglobin and anti-Jo 1, confirming the diagnosis of anti-synthetase syndrome. He received pulse-dose steroids and IVIG. Within 2 weeks, his muscle strength improved to 4/5. After several months, his EF recovered to 65%.

IMPACT/DISCUSSION: Idiopathic inflammatory myopathies can be insidious in onset; thus, a detailed history and exam are key. Advances in medical technology have brought many advantages such as convenience and accuracy - especially amid a pandemic where our contact with patients has been limited (1). However, this has led to the regression of clinician skills and time spent examining patients at the bedside (2). In the case of Mr. X, despite being seen in over 3 separate clinical settings, his chief complaint of body weakness was overlooked, and an MSK exam was not performed. Furthermore, the team anchored on lab findings that led to unnecessary and invasive tests such as LHC before more appropriate focused diagnostic studies. This case highlights the importance of a patient centered approach in guiding clinical decision making, as opposed to the “kitchen sink” approach. As we navigate the post-COVID world of medicine, it is important to not lose touch with our patients - and our skills.

CONCLUSION: Clinicians should perform a reasonably thorough physical exam on all patients, guided by their clinical history. For instance, a chief complaint of body weakness warrants an MSK exam.

Clinicians should place more emphasis on patient-reported history to avoid anchoring on lab findings.

FIRST IMPRESSIONS ARE NOT ALWAYS ACCURATE - COGNITIVE BIASES IN A CASE OF PRESUMED PULMONARY EMBOLISM

Shalmli Joshi, Darlene LeFrancois

Internal Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #3875723)

CASE: A 54 year old female with paraplegia from remote spinal cord injury (SCI) and ESRD on HD presented to ED for recurrent shortness of breath. That morning she had worsening breathing but no other symptoms. On arrival, BP 73/36, HR 72, RR 22, and SpO2 85% (100% on 3L NC.) She had normal respiratory effort, clear lungs, no increased JVP or edema. VBG revealed pH 7.12, pCO2 89.10, pO2 22, lactic acid 2.2. POCUS showed RV dilatation, establishing her high pretest probability for pulmonary embolism (PE). CTA was contraindicated due to allergy. Bilateral venous duplex ruled out DVT. TTE showed PASP of 54 mmHg so she was treated with tPA and heparin drip for PE and placed on BiPAP. On hospital day 4, she developed hemoptysis. Repeat TTE had higher PASP of 85 mmHg.

On transfer to floors, cardiology and pulmonology continued to recommend anticoagulation (AC) for PE due to high pretest probability. Given initial hypercapnia and worsening PASP post-tPA, primary team held AC. V/Q scan then revealed matched defects consistent with obstructive lung disease – identified as the cause of her hypercapnic respiratory failure, RV dilatation, and pHTN. She was discharged off AC with follow-up.

IMPACT/DISCUSSION: This case illustrates how in establishing a diagnosis, there is potential for cognitive bias, which contributes to diagnostic errors in up to 77% of cases per a systematic review involving 6810 physicians. In this case, providers were susceptible to base rate neglect bias - in considering a dangerous diagnosis first, the true prevalence of disease (its “base rate”) was overlooked. Studies have shown that DVT/PE risk is increased during the first 6 months post-SCI. Our patient was years out from SCI without a DVT, so base rate of PE is no longer increased.

The diagnosis of PE was also accepted by consultants without acknowledging the data against it – an example of confirmation bias. In this case, high pre-test probability was established based on RV dilatation alone, which as a single finding is not highly specific or sensitive for PE. Rather, a combination of symptoms and findings, as depicted by risk scores and studies validating their utility, can more accurately classify probability. In fact, this patient’s Well’s score translates to low or moderate likelihood of PE, not high. Risk scores in combination with clinical gestalt may have helped avoid risk overestimation, prompting a V/Q scan (LR- 0.125) prior to tPA.

Reassessing pretest probability and acknowledging data against the initial diagnosis (severe hypercapnia, worsening PASP post-tPA) halted the use of further AC. Management was appropriately redirected towards her underlying obstructive lung disease.

CONCLUSION: Studies suggest that a formal calculation of risk score can aid in a more accurate pretest probability and diagnosis of PE, and acknowledging contradictory data can help prevent further propagation of bias. Health care providers are susceptible to and should recognize cognitive bias in establishing a diagnosis.

FISH-ING FOR A DIAGNOSIS: A REPORT OF MILLER FISHER SYNDROME POST PSEUDOMONAL PNEUMONIA

Cara E. Pearson¹; Bao Sciscent¹; Kayla Fresco²; Ritesh Neupane²

¹College of Medicine, Penn State College of Medicine, Hershey, PA; ²Internal Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA. (Control ID #3877221)

CASE: A 68-year-old male with a history of COPD, lung cancer, and recently treated cavitary pseudomonal pneumonia was admitted to the hospital for new episodes of hemoptysis. Over the next several days, he developed worsening dysphagia, left sided facial numbness, orthostasis, and Bell’s phenomenon in the left eye. There were no signs of imminent airway compromise, however due to concern of rapidly worsening dysphagia and dysarthria, he was given racemic epinephrine and IV solu-medrol.

Exam revealed cranial nerve three and seven deficits, decreased sensation to light touch, proprioception, and vibration in BLEs, and absent bilateral patellar reflex. CXR, CT, and CTA did not show an acute abnormality. MRI was initially unrevealing of acute intracranial abnormality, but on later review revealed mild enhancement of cranial Nerves III and VII. CSF analysis revealed albuminocytological dissociation and Anti- GQ1b IGg was <1:100, which is within reference range. Due to the albuminocytological dissociation and the triad of ophthalmoplegia, ataxia, and areflexia, the patient was diagnosed with MFS.

Treatment with IVIG led to mild improvement in facial paresis, but the patient was still experiencing orthostatic hypotension likely secondary to dysautonomia. He was later discharged to rehab. IMPACT/DISCUSSION: Guillain-Barre Syndrome is a post-infectious demyelinating disorder characterized by a symmetrical ascending paralysis. GBS has an incidence of 1-2 per 100,000 per year worldwide. Miller Fisher syndrome (MFS) is a variant of GBS present in 5-10% of all cases that is characterized by the clinical triad of ophthalmoplegia, ataxia, and areflexia.

GBS MFS is preceded by infection, commonly after upper respiratory or gastrointestinal infection. The most commonly identified pathogens being C. jejuni, H. influenza, EBV, and Mycoplasma pneumoniae. The infectious agent identified in this patient was pseudomonas aeruginosa, which has not been reported in published literature as a preceding pathogen.

The diagnosis can be made clinically and is often underdiagnosed. Other tests that support this diagnosis include albuminocytologic dissociation and the presence of anti-GQ1b IgG in the CSF, which is present in 80-90% of cases. GQ1b is a ganglioside that is present in portions of the CN III, V, and VI. Molecular mimicry is thought to be the mechanism by which GBS and MFS manifest. A few cases have shown contrast enhancement of nerve roots on MRI. Our patient had mild enhancement of two cranial nerves. However MRI is still important in diagnostic workup to exclude acute intracranial abnormalities.

CONCLUSION: MFS is a variant of GBS characterized by ophthalmoplegia, ataxia, and areflexia. Even though the diagnosis can be made clinically, diagnostic findings such as CSF albuminocytologic dissociation, presence of anti-GQ1b, and enhancement of cranial nerves on MRI can support the diagnosis.

FLUTTER TO FAILURE: A CASE OF VIRAL-MEDIATED ACUTE MYOCARDITIS AND HEART FAILURE PRESENTING WITH ATRIAL FLUTTER

William Giesing¹; Hywel Soney¹; Ashley Chapel¹; Abul N. Khan²

¹Internal Medicine, Methodist Dallas Medical Center, Dallas, TX; ²Cardiology, Methodist Dallas Medical Center, Dallas, TX. (Control ID #3877074)

CASE: An 18-year-old male presented for evaluation of generalized body aches, dry cough, and dyspnea on exertion for nearly two to three weeks. Associated symptoms included intermittent nausea and vomiting along with diarrhea which had improved by presentation. On admission, patient was hemodynamically stable but tachycardic to 120s-130s beats per minute. Exam revealed bilateral lower lobe crackles with initial electrocardiography revealing atrial flutter with a rate of 127 beats per minute. On lab work, patient had an elevated N-terminal-pro-brain natriuretic peptide (NT-pro-BNP) of >6500 pg/ml, elevated C-reactive protein 42 mg/L, and an erythrocyte sedimentation rate of 27 mm/HR. Transthoracic echocardiogram revealed a dilated left ventricle (LV) with a reduced LV ejection fraction of 15-20%. Cardiology was consulted, patient was initiated on oral anticoagulation and planned to undergo a transesophageal echocardiogram and cardioversion. However, prior to his cardioversion, patient had spontaneously converted to sinus rhythm. During the admission, patient underwent diuresis and was initiated on guideline-directed medical therapy for heart failure with reduced ejection fraction, with close follow up after discharge. Further investigation to identify the etiology of the patient’s heart failure demonstrated elevated Coxsackie B2, B3, and B4 antibodies. On follow up, patient had maintained sinus rhythm and remained clinically improved.

IMPACT/DISCUSSION: Acute myocarditis has a prevalence of approximately 1.5 million cases per year worldwide, or about 15 cases per 100,000 people (1). Coxsackievirus makes up 20-25% of all cases of myocarditis (2). However, several cases of coxsackie-induced myocarditis are subclinical, and as such, go undiagnosed. When coxsackie-induced myocarditis does present with clinically apparent cardiac manifestations, it is often in the form of dilated cardiomyopathy, heart failure with reduced ejection fraction, and rarely brady- or tachy-arrhythmias. While the exact prevalence of myocarditis presenting as tachyarrhythmias, in particular atrial flutter, is unknown, this presentation occurs primarily in advanced cases of viral myocarditis and in cases involving younger patients (3,4). Due to the wide variety of symptoms that may manifest as a result of coxsackievirus infection, it is difficult yet crucial to consider when formulating a list of differential diagnoses.

CONCLUSION: Cases of myocarditis, such as the one reported here, can have extremely severe and life- threatening manifestations and it is important for clinicians to include myocarditis as part of the initial differential diagnosis especially in young and otherwise healthy individuals presenting with new-onset arrhythmias or heart failure.

FULMINANT LYMPHOCYTIC MYOCARDITIS WITH FULL MYOCARDIAL RECOVERY FOLLOWING VENOARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION (VA- ECMO)

Jack Jnani

Internal Medicine, Long Island Jewish Medical Center, New Hyde Park, NY. (Control ID #3875403)

CASE: We present a case of a female in her 30s with no pertinent medical history who presents with a four- day history of chest pressure, dyspnea, and fever. She was found to have elevated cardiac and inflammatory markers, as well as hemodynamic compromise consistent with cardiogenic shock. Electrocardiogram demonstrated anterior ST elevation with reciprocal changes. An angiogram showed normal coronary arteries and echocardiogram showed severe biventricular dysfunction. Patient underwent endomyocardial biopsy which showed lymphocytic myocarditis. Laboraratory testing was positive for Coxsackie A. She was initially supported with an intra-aortic balloon pump and later escalated to VA-ECMO due to electromechanical compromise. With supportive care, she was weaned off VA-ECMO and made a full myocardial recovery on follow up Echocardiogram and Cardiac MRI.

IMPACT/DISCUSSION: Myocarditis is defined as inflammation of the myocardium and can lead to myocellular necrosis. Fulminant Myocarditis should be strongly suspected in young patients who present with acute symptoms of heart failure or cardiac arrythmia.

There are four types of fulminant myocarditis that are described in the literature: 1) Fulminant lymphocytic myocarditis, primarily treated supportively, 2) Giant-cell myocarditis, treated with high-dose corticosteroids, a calcineurin inhibitor, and an antimetabolite as part of triple therapy, 3) Acute necrotizing eosinophilic myocarditis, treated with removal of the offending agent and high-dose corticosteroids, 4) Immune checkpoint inhibitor myocarditis, treated with cessation of ICI therapy and high-dose corticosteroids.

In a retrospective study of 147 patients from 1995-2011 with fulminant myocarditis treated with extracorporeal membrane oxygenation, survival to hospital discharge was 61%.

In a retrospective study done by Ammirati et al of 220 patients with biopsy-proven acute myocarditis, patients with fulminant myocarditis had significantly higher rates of death and cardiac transplantation compared to non-fulminant myocarditis at both 60 days and 7-year follow up, including those with the lymphocytic subtype. Further, in a retrospective study done by Merlo et al of 48 patients with biopsy proven lymphocytic myocarditis, 56% had persistent Left ventricular dysfunction defined as EF < 50% at 1 year follow up.

Therefore, our case is unique as our patient had severe fulminant lymphocytic myocarditis with circulatory compromise requiring VA-ECMO on initial presentation, but made a full myocardial recovery without scar on interval echocardiogram and cardiac MR.

CONCLUSION: Fulminant myocarditis (FM) is defined as sudden, severe myocardial inflammation resulting in cardiogenic shock.

VA-ECMO can be a bridge to cardiac transplantation or to allow for full recovery of cardiac function, as seen in our patient.

Viral fulminant myocarditis does not necessary entail irreversible myocyte injury, as seen in our patient.

GITELMAN SYNDROME PRESENTING AS CARDIAC ARREST

Abeselom Geletu¹; Jayna M. Gardner-Gray²; Meaghan Roche¹

¹Internal Medicine, Henry Ford Hospital, Detroit, MI; ²Internal Medicine, Henry Ford Hospital, Royal Oak, MI. (Control ID #3876917)

CASE: A 43 year-old-female with a history of cardiac arrest, seizure, and cerebral aneurysm was admitted to the medical ICU for cardiac arrest. A few hours before her presentation patient had a seizure followed by cardiac arrest. On EMS arrival, her rhythm revealed ventricular fibrillation. She was shocked and received amiodarone with a successful return of spontaneous circulation. On arrival to the ED, she was emergently intubated for respiratory distress. EKG revealed prolonged QTc to 707 ms. Labs revealed severe hypokalemia, hypomagnesemia, hypochloremia, and metabolic alkalosis. Given the second episode of cardiac arrest in a setting of profound hypokalemia in a patient with no known history of tubulopathy, eating disorder, or diuretic use, her presentation was concerning for underlying genetic renal tubular disease. Further workup revealed urine potassium of 198 mg/dL and creatinine of 27 mg/ dL with a K/Cr ratio of 7.3, suggesting renal loss of potassium. At this point, the top differential included Gitelman or Bartter syndrome. So urine calcium, chloride, and magnesium were obtained to aid in differentiating between Gitelman and Bartter phenotypes. Urine electrolytes revealed hypocalciuria with calcium (8.3 mg/dL), creatinine (34 mg/dL), and the ratio of urine Ca: Cr <0.7, which confirmed Gitelman’s phenotype. While admitted, electrolytes were repleted and put on potassium-sparing agents with stabilization of electrolytes. She later underwent successful placement of dual chamber ICD and was discharged. And she remained symptom-free.

IMPACT/DISCUSSION: Gitelman syndrome (GS) is characterized by renal potassium and magnesium wasting with concomitant metabolic alkalosis and hypocalciuria. Diagnosis is usually clinical with workup revealing electrolyte abnormalities. Its clinical features range from nonspecific symptoms to life-threatening sudden cardiac arrest and seizures, which makes its diagnosis challenging. Management of GS involves close monitoring, life-long supplementation of potassium and magnesium, and cardiac risk stratification to prevent fatal arrhythmias. Our case again demonstrates the importance of accurate diagnosis. Had this patient been accurately diagnosed with GS, she could have had close follow-up and undergone cardiac stratification before her discharge, potentially preventing a second out-of-hospital cardiac arrest. Current guidelines for Implantable Cardioverter Defibrillator (ICD) placement for managing cardiac arrhythmias do not indicate ICD placement for cases with a reversible cause of the arrhythmia. Our case suggests that ICD could be beneficial for the secondary prevention of fatal arrhythmia in patients with Gitelman syndrome.

CONCLUSION: The broad differential for electrolyte derangements and the relatively rare nature of Gitelman syndrome make its diagnosis challenging. As it can lead to fatal cardiac arrhythmias, accurate diagnosis can lead to life-saving interventions.

GONOCOCCAL SEPTIC ARTHRITIS OF THE STERNOCLAVICULAR JOINT

Nazar Akhverdyan¹; Sameer Andani¹; Mirian Garcia Rivera²; Margaret Fitzpatrick²

¹School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ²Infectious Disease, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #3875384)

CASE: A 62-year-old male with a history of ankylosing spondylitis, resolved HCV infection, polysubstance use disorder including prior intravenous drug use, and recent Streptococcus pyogenes bacteremia complicated by septic arthritis of the right knee and right sternoclavicular joint presented with tactile fevers and painful right sternoclavicular swelling for one week. Social history included unprotected insertive anal intercourse with a new male partner one month prior to onset of symptoms. Physical exam was notable for a fluctuant mass over the right sternoclavicular joint with surrounding erythema and warmth. Laboratory studies

included WBC 10.5 x 10⁹/L, platelets 745 x 10⁹/L, ESR 31 mm/hr, and CRP 85 mg/L. CT neck demonstrated a fluid collection and soft tissue thickening arising from the right sternoclavicular joint. Synovial fluid culture grew Neisseria gonorrhoeae. Pharyngeal sample was also positive for N. gonorrhoeae with negative urethral and rectal cultures. The patient was treated with intravenous ceftriaxone for six weeks with clinical and radiographic improvement.

IMPACT/DISCUSSION: Septic arthritis occurs through the spread of microorganisms into joint spaces. Most commonly, these organisms are gram positive bacteria, specifically Staphylococcus aureus. Less than 2% of cases are caused by N. gonorrhoeae. Disseminated gonococcal infection results in several clinical manifestations including polyarthralgia, skin lesions, and tenosynovitis or monoarticular septic arthritis.

Gonococcal septic arthritis most frequently effects the knees, wrists, interphalangeal joints of the hands, and ankles. Involvement of the sternoclavicular joint is a rare presentation. A PubMed search of case reports over the past 30 years with the query “Gonococcal arthritis” yielded 105 results, however only six case reports had sternoclavicular involvement. These cases were associated with pregnancy, HIV, or complement deficiency. We report a case of monoarticular gonococcal septic arthritis at an uncommon location in an immunocompetent individual without pharyngeal or genitourinary symptoms.

The patient’s history of spondyloarthropathy and recent polyarticular septic arthritis may have contributed to joint space destruction that increased the susceptibility of the sternoclavicular joint to gonococcal infection. Thus, the involvement of uncommon joints should especially be considered in patients with underlying arthropathies.

CONCLUSION: Sternoclavicular gonococcal arthritis is an uncommon presentation of septic arthritis.

Clinicians should maintain a high index of suspicion for this condition in high-risk populations with infectious symptoms and arthralgias to ensure prompt treatment.

GRANULOMATOUS PNEUMOCYSTIS JIROVECII PNEUMONIA PRESENTING WITH HYPERCALCEMIA: AN UNCOMMON MANIFESTATION OF AN AIDS-DEFINING ILLNESS Matthew J. Townsend

Internal Medicine, Duke University Medical Center, Durham, NC. (Control ID #3877211)

CASE: A 70-year-old male Veteran with HIV, ischemic cardiomyopathy (ejection fraction 30%), and remote CABG presented with several weeks of progressive fatigue, blurred vision, and dizziness. His HIV viral load was undetectable, well-controlled for years. On presentation, he was afebrile and normotensive with normal oxygen saturation; he was grossly disoriented and globally weak. Initial labs were notable for a chronic normocytic anemia, moderate thrombocytopenia, CD4 count drop to 271 (vs. 800 9 months prior), persistently undetectable HIV viral load, and calcium of 12.1 mg/dL with an albumin of 1.8 g/dL. Social history was notable for independent residence with extended family assistance for some IADLs, and no tobacco, alcohol, or other substance use. Family history was noncontributory. Home medications included oral iron, metoprolol, risedronate weekly, and a high-intensity statin. He underwent hematologic evaluation for dual cell line depression; flow from bone marrow biopsy showed no definitive atypical findings. Additional hypercalcemia workup was consistent with 1-alpha-hydroxylase activation; parathyroid hormone (PTH) was appropriately suppressed and 1,25-OH Vitamin D was elevated despite low 25-OH Vitamin D. PTH-related peptide was negative. Chest computed tomography (CT) revealed groundglass opacities and subpleural reticulations, FDG-avid on subsequent PET-CT without evidence of lymphoma or FDG-avid

mass. Beta-D-glucan and serum inflammatory markers were elevated; other fungal serologies were unrevealing. Following bronchoscopy, Pneumocystis jirovecii pneumonia (PJP) PCR was detected. Calcium was stabilized with intravenous fluids and calcitonin. He was continued on home antiretrovirals. He initiated treatment-dose sulfamethoxazole-trimethoprim but unfortunately developed failure to thrive, malnutrition, and persistent encephalopathy. Based on the patient’s previously clear goals, he transitioned to inpatient hospice; he passed away 1 month later.

IMPACT/DISCUSSION: PJP is a common acquired immune deficiency syndrome (AIDS)-defining illness and carries a substantial mortality rate. Histopathology typically demonstrates exudative alveolar infiltrates but in up to 5% of cases may manifest as granulomatous nodules. While several cases of granulomatous Pneumocystis have been reported; to our knowledge, this is the first to report symptomatic hypercalcemia as a presenting sign. As GMS stain, fungal PCR, and B-D-glucan assays have limited sensitivity and specificity, a reasonable index of suspicion for PJP must be maintained in patients with one or more risk factors. Prompt treatments of both hypercalcemia and PJP are essential to optimize outcomes.

CONCLUSION: Granulomatous nodules are an atypical and often overlooked variant of PJP. Such granulomatous inflammation can drive hypercalcemia due to 1-alpha-hydroxylase activation. The differential for hypercalcemia with multifocal groundglass opacities and immunocompromise or other risk factor(s) must include granulomatous PJP.

GROUP A STREPTOCOCCUS TOXIC SHOCK SYNDROME FROM PROBABLE SEXUAL TRANSMISSION

Andre Bshara¹; Raisa Lomanto Silva¹; Shoaib Fakhri²

¹Internal Medicine, UPMC, Pittsburgh, PA; ²PACCM, UPMC, Pittsburgh, PA. (Control ID #3872860)

CASE: A 44-year-old female presented with acute emesis, bloody diarrhea, and sore throat. She was septic, with severe acute renal injury (creatinine 3.9 mg/dL) and disseminated intravascular coagulation. Computed tomography revealed concern for aspiration pneumonia, gastritis, enteritis, and diffuse colitis without pelvic findings. She was started on broad spectrum antibiotics including meropenem, vancomycin, and clindamycin. Blood cultures grew Group A Streptococcus, diagnosing TSS. She was started on IV immunoglobulins, IV clindamycin, and continuous penicillin G.

She developed sudden bilateral vision loss and required urgent ophthalmologic evaluation; the cause was determined to be acute glaucoma secondary to capillary leak syndrome. She required intubation with mechanical ventilation for airway protection in the setting of altered mental status. She also required two vasopressors and stress-dose steroids after IV fluids failed to maintain MAP > 65mmHg. Source of GAS was not determined through a full-body skin exam, transthoracic echocardiogram, right upper quadrant ultrasound, and a pelvic exam/ultrasound. The patient’s partner reported that a prior spouse died in a similar, abrupt manner a year before. Microbiology report of the former spouse obtained posthumously showed blood cultures positive for GAS. Infectious Disease treated the partner with clindamycin due to the partner’s probable carrier status.

IMPACT/DISCUSSION: Toxic shock syndrome (TSS) is an acute illness that can be caused by group A streptococcus (GAS). GAS normally causes pharyngitis or non-necrotizing skin and soft tissue infections, but it can also present with respiratory infections, septicemia/bacteremia, and meningitis. Invasive GAS involves the invasion of a normally sterile site, such as blood or pleural space. The release of inflammatory cytokines and exotoxins mediates the tissue injury and shock of TSS. Prevalence of GAS infections in those aged 20-35 has increased, thought to be secondary to different modes of transmission, such as pregnancy-related GAS infections. Identifying the mode of transmission is crucial to avoiding the pathogen’s spread.

CONCLUSION: Our patient presented with GAS bacteremia through a presumptive oropharyngeal/sexual transmission given her partner’s history of a previously-GAS-infected spouse and unremarkable workup otherwise.

The patient also presented with acute vision loss secondary to capillary leak syndrome causing acute glaucoma. Normally, the mechanism involves ischemic optic neuropathy or necrotizing anterior scleritis.

Identifying sexual transmission may more effectively prevent this syndrome through treatment of sexual partners. Our patient fortunately had a favorable outcome despite the high mortality, though her visual prognosis remains guarded. This case is unique due to its mode of transmission, which, if identified, may be treated to avoid further spread of GAS.

HARD TO SWALLOW

Austin Rezigh¹; Alec Rezigh²

¹Medicine, The University of Texas Health Science Center at San Antonio Joe R and Teresa Lozano Long School of Medicine, San Antonio, TX; ²General Internal Medicine, Baylor College of Medicine, Houston, TX. (Control ID #3848845)

CASE: A 50 year old woman with gastroesophageal reflux disease (GERD) presented to the emergency room with acute onset dysphagia. She underwent esophagogastroduodenoscopy (EGD) which revealed food impaction and an area of stenosis in the proximal esophagus. She reported 9 months of progressive fatigue, dysphagia to solids, and 20 lbs of unintentional weight loss. She had no choking, coughing, regurgitation, fevers, night sweats, blood loss, rashes, lymphadenopathy (LAD), nausea, vomiting, diarrhea, abdominal pain, or joint pain.

Her medical history was notable for GERD, previously requiring dilations for peptic structures. Her mother had gastric cancer. She worked as a teacher. She consumed a standard American diet and did not use tobacco, alcohol, or illicit drugs. She took no medications.

Vital signs were normal. Physical exam was notable for no LAD or organomegaly, normal conjunctiva, a clear oropharynx, and a tongue that was smooth, shiny, and red without well defined papillae.

Laboratory evaluation revealed pancytopenia with macrocytic anemia and hemolysis with a normal reticulocyte count. Ferritin and iron levels were normal; the transferrin saturation (TSat) was elevated. Given the glossitis, pancytopenia with macrocytic anemia, and hemolysis without reticulocytosis, a vitamin B12 level was sent and returned severely low. Anti-intrinsic factor antibodies were positive. Intramuscular B12 therapy was initiated, resulting in resolution of hemolysis, leukopenia, and thrombocytopenia; her anemia persisted. Repeat EGD revealed a stricture in the lower esophagus and multiple cervical esophageal webs. Biopsies were negative for malignancy. Repeat iron studies were consistent with iron deficiency. Her final diagnosis was symptomatic B12 deficiency due to pernicious anemia (PA) complicated by Plummer-Vinson Syndrome (PVS). Her dysphagia, pancytopenia, and other symptoms resolved with esophageal dilation, proton pump inhibitor therapy, and vitamin administration.

IMPACT/DISCUSSION: Vitamin B12 deficiency has protean manifestations. While pancytopenia and hemolysis are not common, both are well-described. Neurogenic dysphagia from B12 deficiency was considered, but the presentation was more consistent with obstruction. With the presence of webs in the proximal esophagus, PVS was considered, despite the initial iron studies. Repeat studies confirmed iron deficiency, arguing the initial results were likely spurious in the setting of hemolysis. While concurrent vitamin deficiencies in a predisposed host are well described, as is a link between pernicious anemia and iron deficiency via hypochlorhydria, coincident PA and PVS, to our knowledge, has not been reported previously.

CONCLUSION: -If a final diagnosis does not explain key aspects of the initial presentation, evaluate for additional or alternative diagnoses

-Plummer-Vinson syndrome is the triad of iron-deficiency, dysphagia, and esophageal webs

-One vitamin deficiency should prompt concern for others

HEERFORDT-WALDENSTRöM SYNDROME, A RARE SUBACUTE VARIANT OF SARCOIDOSIS Saliman Esmati¹; Homayoon Lodeen¹; Maher Hadaya^2,1

¹Internal Medicine, Jamaica Hospital Medical Center, Jamaica, NY; ²Ross University School of Medicine, Miramar, FL. (Control ID #3877138)

CASE: A 29-year-old African American female with recent complaining of blurry vision seen by Ophthalmologist and found to have bilateral pan uveitis and was started on topical steroid therapy. She was referred to ED for worsening of her symptoms and new onset bell's palsy. Working diagnosis of systemic sarcoidosis was started. Physical examination revealed right facial palsy and submandibular swelling. Inflammatory and immunological markers including ESR, CRP, TB QuantiFERON, rheumatic factor (RF) , anticitrullinated peptid (CCP)and ANA were reported negative. Electrocardiogram showed first degree AV block. Vit D was depleted, and angitensin converting enzyem (ACE ) level and lysosome enzymes Found to be elevated. Imaging studies revealed bilateral hilar adenopathy and bronchoscopy with biopsy confirmed granulomatous inflammatory process in hilar lymph nodes. Patient symptoms continued to improve with high dose steroid therapy.

IMPACT/DISCUSSION: Patient with bilateral pan uveitis and bell’s palsy, despite being just two symptoms, together they constitute Heerfordt-Waldenström syndrome (HWS), exceedingly rare but highly indicative of sarcoidosis. There are two types of HWS. Complete HWS (cHWS) is a tetrad of fever, parotid gland enlargement, uveitis, and Bell's palsy, while incomplete HWS (iHWS) needs only two non-fever symptoms. Our patient had iHWS, although slightly less rare than cHWS. The paucity of symptoms makes it harder to recognize, as these isolated presentations could be the initial presentation of sarcoidosis.

Patients with triad of uveitis, parotid gland enlargement, or facial nerve palsy, immediately evaluate for the other two symptoms. If two are positive, this is HWS, and requires immediate sarcoidosis workup. Since it can progress rapidly and both c/i HWS will have at least two of the aforementioned symptoms, applying this guideline would capture all HWS cases, which could be the only hint of sarcoidosis, as in our case.

CONCLUSION: Finally, we saw a unique and rapid progression of sarcoidosis leading to very rare ocular manifestations of pan uveitis with papilledema. Even rarer still is the relative lack of other systemic symptoms. What this should teach is that although rare. Sarcoidosis can present almost exclusively as complicated ophthalmologic/neurosarcoidosis without any other symptoms first.

HEMOLYTIC HULLABALOO: A VASO-OCCLUSIVE CRISIS COMPLICATED BY A DELAYED HEMOLYTIC TRANSFUSION REACTION

Kevin P. Hopkins, Biplov Adhikari, Anup Agarwal

Internal Medicine, MedStar Union Memorial Hospital, Baltimore, MD. (Control ID #3874991)

CASE: A 50-year-old female patient with a known history of sickle cell disease, as well as a recent hospitalization for a vaso-occlusive crisis, presented for a one-day history of severe chest pain and dyspnea. Laboratory testing revealed anemia (Hgb 7.1, baseline 10.5), LDH elevation (LDH 1,264), and hyperbilirubinemia (TBili 3.5) suggestive of hemolysis. On admission, she was transfused two units of pRBCs (with appropriate response) and started on treatment for pulmonary emboli and acute chest syndrome, both as seen on CTA imaging. Pre-transfusion hemoglobin electrophoresis was as follows: 20.7% HgbA1, 11.4% HgbF, and 65.6% HgbS; her electrophoresis was consistent with sickle beta plus thalassemia. The patient was later started on hydroxyurea for sickle crisis prophylaxis. While initially stable following her transfusion, worsening anemia was identified beginning ten days post-transfusion; she was notably febrile (TMax 38.6 C) the night prior. Repeat Hgb electrophoresis showed: 4.0% HgbA1, 18.8% HgbF, and 77.9% HgbS; despite addition of hemoglobin A1 via transfusion and presumed depletion of her more fragile sickled cells through hemolysis, the patient was even more deficient in HgbA1 and had a higher level of HgbS than on presentation. Exchange transfusion was planned but delayed, as a repeat type and screen identified three new RBC antibodies had developed in the interim. With all findings consistent with a delayed hemolytic transfusion reaction, the patient eventually underwent exchange transfusion for a combined DHTR and vaso- occlusive crisis with successful resolution of both.

IMPACT/DISCUSSION: DHTRs are associated with alloimmunization against transfused RBC epitopes and can appear 5-15 days following the triggering transfusion. Alloimmunization rates can range from 19-47% in adult patients. During such reactions, there can be profound hyperhemolysis of both the transfused and autologous RBCs, leading to inadequate reticulocytosis and subsequent reticulocytopenia. The most frequently encountered antigens are E, C, Kell, Fya, Fyb, and Jkb, though antibodies are often undetectable. The typical patient presentation at onset is dark urine due to hemoglobinuria (94%), though low-grade fever and jaundice are also common. Diagnostic evaluation must include hemoglobin electrophoresis, which can show reduced HgbA (demonstrating destruction of donor RBCs), as also seen in our patient.

CONCLUSION: The use of extended crossmatching before transfusion, and limiting the number of transfusions in toto, can significantly aid in preventing a DHTR. Currently, there exist no validated guidelines to manage DHTR. Although there are case reports describing the use of IVIG, corticosteroids, rituximab, and eculizumab, supportive care and renal protection with IV fluids remain the mainstays of treatment. In this case, exchange transfusion was successfully used to resolve the coincident vaso-occlusive crisis and DHTR, by removing the sickled cells, epitopal RBCs, and pathologic antibodies themselves.

HEMORRHAGIC PERICARDIAL EFFUSION COMPLICATED BY CARDIAC TAMPONADE, A RARE MANIFESTATION OF ADULT-ONSET STILL’S DISEASE – THE KEY IS ACTING RIGHT AT THE RIGHT TIME

Gagan Aulakh¹; Richan Jirel¹; Christian M. Gonzalez Quinones¹; Arshdeep Singh²; Rucha Desai¹; Marian Valentin¹

¹Internal Medicine, Jersey City Medical Center, Jersey City, NJ; ²Government Medical College Amritsar, Amritsar, Punjab, India. (Control ID #3874358)

CASE: A 32-year-old male with no past medical history presented with slowly progressive pleuritic chest pain associated with palpitations for a month. Symptoms started five weeks back with sore throat, fever, and then abdominal erythematous non-pruritic painless rashes. His abdominal rash persisted for 3 weeks and then he started having intermittent fever with pleuritic chest pain. He denied joint pains (as a child as well), previous similar episodes, or a family history of autoimmune disease.

He works in the laboratory which includes handling quantiFERON test samples. He was sexually active with one partner using barrier contraceptives and denied any recreational drug abuse or travel history. At presentation, he was tachycardic to 130 bpm with normal BP, tachypneic to 24/minute, low-grade fever of 100.3F, and normal O2 saturation. Blood workup was significant for leukocytosis 13K/UL(normal range 4.5-11) with absolute neutrophilia 9.8K/UL(1.9-9.2), thrombocytosis 489K/UL(130-400) with normal LFT.

Chest X-Ray showed an enlarged cardiac silhouette then CT chest was done which revealed moderate-large pericardial effusion and echocardiography revealed pre-tamponade physiology prompting pericardiocentesis when 300 mL hemorrhagic fluid was removed and a pigtail placed. The patient was started on high-dose aspirin and colchicine.

Symptomatically he improved but remained tachycardic, febrile even on a high dose of aspirin, and had persistent leukocytosis. A repeat CT chest and Echo showed bilaterally pleural effusion and redevelopment of a large pericardial effusion respectively.

Pericardial fluid analysis was negative for tuberculosis or malignant etiology. Blood and urine cultures were negative. Given the exclusion of other etiologies, Adult-onset Still Disease(AOSD) was suspected. He had negative RF, ANA, and dsDNA antibodies with elevated other inflammatory markers such as Ferritin 1002 ng/mL (38-380), D-Dimer >7 μg/mL(0-0.5), Fibrinogen 709mg/dL (200-393), IL-6 11 pg/mL(<5), Complement C3 229 mg/dL (82-185), Haptoglobin 231 mg/dL(43-212), LDH 351U/L (120-246), ESR 68mm/hr(0-15), CRP 8.5mg/dL(0-1).

At this time we confirmed the diagnosis of AOSD by Yamaguchi Diagnostic Criteria after ruling out infective, malignant, and other rheumatologic disorders. Prednisone was started which had immediate clinical improvement and then the patient was discharged home

IMPACT/DISCUSSION: Multiple studies proved AOSD patients experience long delays in diagnosis with a median interval ranging from 1 to 4.1 months between their onset of symptoms to a definite diagnosis. Corticosteroids are the first-line management of AOSD; other options include methotrexate and other DMARDs, Anakinra, tocilizumab, and tumor necrotic factor blockers.

CONCLUSION: The diagnosis of AOSD can be challenging given that its symptomatology is similar to other conditions like infectious, neoplastic, and autoimmune causes.

Our patient was initially treated for viral pericarditis however failure of therapy arose the suspicion of AOSD.

HEPATIC SEQUESTRATION AS A MANIFESTATION OF SICKLE CELL CRISIS

Santiago Beltran¹; Raul Lopez Fanas¹; Rateb Fouad¹; Kristin A. Swedish²

¹Internal Medicine, Montefiore Wakefield Campus, Bronx, NY; ²Medicine, Division of General Internal Medicine, Montefiore Medical Center, New York, NY. (Control ID #3876214)

CASE: A 32-year-old man with history of sickle cell disease (SCD) presented with fever, abdominal pain, shortness of breath and yellowing of palms for three days. Physical exam revealed scleral icterus, palmar jaundice and marked right upper quadrant abdominal tenderness. Labs revealed a hemoglobin drop to 4.6 g/dL from baseline 7 g/dL, conjugated hyperbilirubinemia (total bilirubin 30 mg/dL), transaminitis and reticulocytosis with negative hepatitis panel and negative Coombs test. Imaging demonstrated hepatomegaly and ruled out acute cholecystitis and biliary obstruction. Supportive treatment and packed red blood cells transfusion where given. Exchange transfusion was not required since hemoglobin S (HBS) remained less than 30%. With supportive care, his liver function tests down trended and hemoglobin remained stable. He was discharged home 15 days after admission

IMPACT/DISCUSSION: SCD is an inherited point mutation in the gene HBB that encodes hemoglobin beta chains, affecting red blood cells (RBC). This mutation results in a cascade of events that leads to membrane damage, cellular dehydration, formation of sickled cells and hemolysis. Sickling and hemolysis of RBC results in vaso-occlusion with associated ischemia. Clinical manifestations include repeated episodes of severe acute pain, acute chest syndrome, splenic infarction, priapism, and acute sickle hepatic crisis. Liver involvement accounts for around 10% of patients admitted for Vaso-occlusive crisis. The spectrum of liver disease ranges from asymptomatic abnormalities in liver function tests to acute deterioration of liver function and decompensated chronic liver disease.

Acute hepatic crisis is accompanied by right upper quadrant pain, fever, leukocytosis, and variable increases in serum transaminases and bilirubin levels. An uncommon manifestation of hepatic crisis is hepatic sequestration, which is characterized by right upper quadrant pain associated with hepatomegaly, hemoglobin drop with reticulocytosis, hyperbilirubinemia and elevated liver enzymes. This is caused by sickled erythrocytes obstructing sinusoidal flow, which leads to trapping of RBCs within the liver and compression of the biliary tree. Treatment is mainly supportive, but exchange transfusion may be needed to lower HBS to <30%.

CONCLUSION: Hepatic sequestration is a serious complication of SCD that can cause significant damage to the liver. Early detection is crucial to prevent serious complication, treatment can range from supportive treatment only to exchange transfusion

HEPATITIS B: DON'T FORGET ABOUT ME

Ashley Dixon

Medicine, Weill Cornell Medicine, New York, NY. (Control ID #3876259)

CASE: 61 year old woman with stage II right invasive ductal carcinoma (dx 5/2022) on neoadjuvant doxorubicin, cyclophosphamide, and paclitaxel (LD 10/22) who is transferred from an OSH for acute liver failure concerns. She was started on doxorubicin, cyclophosphamide and paclitaxel therapy in July 2022, and at the time her AST/ALT were unremarkable.

In September she was found to have elevated transaminases on outpatient labs with AST 146 ALT 188, which at that time she mentioned she had HBV and had been “cured” 35 years prior. Two weeks later she was found to be Hep B Surface Ab+ with viral load > 200 million and was started on Tenofovir.

A month later she presented to an OSH with direct hyperbilirubinemia, hypofibrinogenemia, hypoglycemia and hyponatremia and acute kidney injury. She was transferred for management of her acute liver failure. On the day of transfer she became more lethargic, and her arterial ammonia had increased from 87 to 107. She was transferred to the ICU for frequent neurological monitoring and concerns for hepatorenal syndrome. She was started on CCVH for anuric renal failure but could not tolerate it due to worsening hemodynamics. She ultimately was transitioned to comfort care and died with family at bedside.

IMPACT/DISCUSSION: Patients on immunosuppression are at risk for hepatitis B reactivation. This is true for both chronic and resolved hepatitis B infections. Patients starting chronic immunosuppression or cytotoxic chemotherapy should be screened for Hepatitis B by testing for Hepatitis B surface antigen and Hepatitis B core antibody.

Patient who have chronic Hepatitis B who are starting immunosuppression should be treated prophylactically with Tenofovir or Entecavir due to high risk of re-activation. Patients who are found to have resolved hepatitis B receiving high risk immunosuppression including prolonged high doses of corticosteroids or B cell depleting therapy should also receive anti-viral prophylaxis. The guidelines are less clear for those with resolved hepatitis not receiving high risk immunosuppression.

Patients who develop Hepatitis B re-activation can ultimately develop acute liver failure. In the acute setting, elevated ammonia levels correlate to worsening liver failure and more severe coagulopathy in patients with no known cirrhosis, therefore arterial ammonia levels should be checked. Studies have shown that the use of CRRT for hyperammonemia is associated with lower mortality when compared to use of intermittent hemodialysis.

CONCLUSION: 1. Patients receiving high potency immunosuppression should be screened for HBV with HbcAb and HbsAg. Prevention of reactivation with prophylactic tenofovir and entecavir is essential to management.

2. Patients presenting with acute liver failure benefit from arterial ammonia levels, however checking ammonia levels in patient with known cirrhosis is not recommended.

3. Renal replacement therapy has some potential to improve outcomes in patients with hyperammonemia in acute liver failure.

HEPATITIS C CIRRHOSIS, HEPATITIS B SUPERIMPOSED INFECTION, AND THE EMERGENCE OF AN ACUTE PORTAL VEIN THROMBOSIS

Mohamed Ramzi Almajed, Parul Kochhar, Naoshin Khan, Abigail Entz

Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #3873667)

CASE: A 65-year-old man presented with generalized fatigue for one month. His history was notable for liver cirrhosis secondary to hepatitis C, treated and in sustained virologic response.

Patient was alert and oriented and exam was notable for scleral icterus, abdominal distension, and bilateral leg swelling. Workup showed new liver profile abnormalities with AST 467, ALT 470, and total bilirubin 10.9; his MELD-Na score was 26. Hepatitis C RNA was undetectable. Hepatitis B surface antigen and core antibody were positive, surface antibody was negative, and DNA level was 1,481,240. Ultrasonography with doppler and CT liver demonstrated patent vasculature. Patient was diagnosed with decompensated liver disease in the setting of active hepatitis B infection and was treated with Entecavir.

Patient initially responded to treatment and had improvement in his symptoms and laboratory abnormalities, however, five days after presentation he became confused with hepatic encephalopathy. Infectious workup was unremarkable and he did not improve after empiric antibiotics, lactulose, and rifaximin. His liver profile worsened with AST 1147, ALT 407, total bilirubin 42.3; MELD-Na score increased to 39. He was escalated to the ICU where a repeat ultrasonography with doppler demonstrated an interval absence of color flow visualization in the main, right, and left portal veins indicative of acute portal vein thrombosis (PVT). Management with intravenous heparin resulted in improvement in laboratory markers.

IMPACT/DISCUSSION: PVT involves occlusion of the portal vein by a thrombus and occurs in the setting of prothrombotic states or decompensated liver disease. Acute PVT presents with abdominal pain, fever, or gastrointestinal bleeding but is often asymptomatic. Chronic PVT results in portal hypertension which causes ascites and varices. Diagnosis is made with abdominal ultrasonography with doppler imaging, CT, or MRI. Management for patients with acute PVT involves anticoagulation to promote recanalization, although the indication for anticoagulation in chronic PVT remains unclear.

This case offers a unique presentation of acute PVT that developed within several days of a hospitalization for decompensated liver disease, as proven by the interval absence of portal venous flow on repeat imaging. Despite the workup on initial presentation being negative for PVT, reconsideration of differentials after the change in our patient’s clinical status led to the diagnosis. Active hepatitis B infection was likely the initial trigger for the patient’s cirrhosis decompensation and presentation; the subsequent coagulopathy and alteration in the portal blood flow triggered the development of an acute PVT.

CONCLUSION: Patients with cirrhosis are at risk for both prothrombotic and antithrombotic complications. Superimposed infections with hepatitis viruses and abnormal flow through the hepatic portal system increase the risk for PVT. This case demonstrates the importance of reevaluating cases to reduce anchoring bias.

HHV-6 INFECTION IN A 19-YEAR-OLD LIVER TRANSPLANT RECIPIENT — MUCH MORE THAN ROSEOLA!

Nathan DeRon¹; Leigh K. Hunter²

¹Internal Medicine, Methodist Dallas Medical Center, Dallas, TX; ²Infectious Diseases, Methodist Dallas Medical Center, Dallas, TX. (Control ID #3877140)

CASE: A 19-year-old woman with a past medical history of liver failure secondary to autoimmune hepatitis and liver transplantation complicated by multiple episodes of acute cellular rejection requiring thymoglobulin and corticosteroids presented to the emergency department with acute encephalopathy, headache, seizures, and unresponsiveness. Empirical antimicrobial therapy including antiviral and antifungal medications was initiated due to her immunosuppressed state. Magnetic resonance brain imaging revealed multifocal areas of hyperintensity in the frontal lobes, frontoparietal junction, and occipital lobes suggestive of viral encephalitis. The patient underwent electroencephalogram which showed moderate to severe generalized cerebral dysfunction. Multiple serologies and PCRs were submitted with HHV-6 PCR being newly positive with 133,000 copies/ml. After clinical stabilization and approximately six days of antimicrobial therapy, lumbar puncture was performed which revealed mild elevation of WBCs and protein but negative PCRs, cultures, and serologies. The patient was transitioned to ganciclovir and administered intravenous immunoglobulin. The patient’s symptoms improved, HHV-6 PCR copies gradually decreased, and the patient was discharged with outpatient follow-up. After approximately one month of antiviral therapy, the patient’s viral load was undetectable.

IMPACT/DISCUSSION: HHV-6 infection in immunosuppressed liver transplant recipients is complicated by higher viral burden leading to transplant organ invasion, increased fibrosis, and more severe clinical disease culminating in increased morbidity and mortality. Early diagnosis and treatment are critical since HHV-6 viremia is shown to be an independent predictor of increased risk for invasive fungal infections and late mortality in liver transplant recipients. Liver biopsy is the gold standard for diagnosing viral invasion, but given the significant risk that accompanies this intervention, multi-specialty discussion is vital. Management of HHV-6 disease typically includes ganciclovir, with alternative agents being foscarnet and cidofovir. Monitoring of HHV-6 viral load guides treatment duration.

CONCLUSION: In summary, recognition of HHV-6 disease, appropriate laboratory assessment, and early institution of therapy is important for internal medicine physicians to decrease morbidity and mortality in liver transplant recipients.

HOLD ON! BALANCING A BROAD DIFFERENTIAL IN AN UNSTEADY PATIENT WITH HIV

Kate L. Amodei¹; Grace L. Lisius¹; Casey N. McQuade²

¹Internal Medicine, UPMC, Pittsburgh, PA; ²Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #3875002)

CASE: A 58-year-old woman with HIV non-adherent with antiretroviral treatment (ART) presented with 1 month of ambulatory unsteadiness. She described feeling off-balance and holding on to objects to avoid falling. Her symptoms progressed and she could only walk several steps before needing support. She denied any falls, fevers, vertigo, vision changes, or substance use. She had not taken any medications in the past 5 years. Decades ago, she had 3 similar episodes that improved after resuming ART. She had difficulty staying connected to medical care and spent many years with CD4 count <150. On admission, her vital signs were normal without fever. Physical exam revealed slow, scanning speech, decreased short-term memory, and slow finger taps. She had a wide-based gait with en bloc turning. She had full strength bilaterally throughout upper and lower extremities. Exam revealed no upper motor neuron signs, ataxia, dysmetria, nor other focal deficits. A basic metabolic panel and complete blood count were normal. CD4 count was 110, and HIV viral load was 224,000 copies. CT head was without acute stroke or ventriculomegaly. MRI brain showed much greater than expected age-related degeneration. Lumbar puncture was performed with normal opening pressure and negative CSF cryptococcal antigen, toxoplasma antigen, HSV, CMV, Lyme, West Nile Virus, and syphilis. Given the episodic history of her neurologic presentations as well as the negative evaluation for opportunistic and primary neurologic etiologies, she was diagnosed with HIV-associated neurocognitive disorder (HAND). Her symptoms gradually improved after several weeks with resumption of ART. She was discharged home to live with her daughter.

IMPACT/DISCUSSION: Individuals with untreated HIV can experience changes in memory, concentration, attention, and motor skills. The differential for these symptoms is broad, including cerebrovascular disease, infections, malignancies, dementia syndromes, polypharmacy, primary psychiatric conditions, and substance use. Diagnostic evaluation should focus on both history and exam findings suggestive of specific diseases and risk factors for HAND like age, low CD4 count, and ART adherence. Once non-HIV related diagnoses have been ruled out, a diagnosis of HAND can be pursued. Typical symptoms include impairment in attention, concentration, working memory, psychomotor speed and precision, or depressive symptoms. Establishing the diagnosis of HAND can be difficult as it is a diagnosis of exclusion and often requires additional neurocognitive testing.

CONCLUSION: Cognitive impairment in individuals with HIV can be indicative of various disease processes. The diagnosis of HAND is one of exclusion and can only be made in individuals whose presentation cannot be explained by alternate medical diagnoses.

HOW TO REIGN IN A ZEBRA THAT PRESENTS LIKE A HORSE: A RHEUMATOLOGIC APPROACH TO ABDOMINAL PAIN

Sneha Rajendran¹; Louis Saade²; Anna K. Donovan²

¹Internal Medicine, UPMC, Pittsburgh, PA; ²Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #3872240)

CASE: A 63-year-old woman with a history of gastroesophageal reflux disease, peptic ulcer disease, and diabetes presented to the emergency department with acute on chronic abdominal pain associated with nausea, vomiting, and a 10-pound weight loss over the past year. In the outpatient setting one year prior to presentation, she had an unremarkable CT abdomen/pelvis and an EGD showing healed gastric ulcers. Family history was positive for a sister with arthritis and a brother with gastrointestinal malignancy without any additional details for either. She smoked half a pack of cigarettes per day for years. Her physical exam was notable for a soft abdomen with normal bowel sounds and tenderness to palpation in the right upper and lower quadrants.

Labs showed WBC 6.4, hemoglobin 13.4, platelets 210, normal basic metabolic panel, hepatic function panel, and lipase; UA with trace blood and ketones; and an ESR of 77 mm/hr, CRP of 1.0 mg/dL (upper limit of normal 0.8). CT abdomen/pelvis showed circumferential soft tissue infiltration about the superior mesenteric artery and non-circumferential soft tissue infiltration at the celiac axis, left adrenal, and renal veins. Rheumatology believed that polyarteritis nodosa was highest on the differential, though considered other vasculitides, IgG4 disease, infection, and malignancy. Further laboratory work up showed unremarkable ANA, RF, CA 19-9, total IgG level, and RPR; IgG4 subclass was elevated at 101.8 mg/dL.

Rheumatology recommended tissue biopsy but this was deferred given the challenging location of the abnormalities. The patient’s symptoms improved and she was discharged with an oral prednisone taper recommended by rheumatology. After hospital discharge, both imaging findings and patient’s symptoms resolved.

IMPACT/DISCUSSION: This patient presented with nonspecific abdominal symptoms with unusual findings on imaging, prompting a broad rheumatologic work up resulting in the presumptive diagnosis of IgG4 disease vs other abdominal vasculitis. Given the lack of tissue biopsy, an official diagnosis was not able to be made. Abdominal lymphoma was considered though is less likely given improvement rather than clinical deterioration after steroids. Abdominal vasculitides were also high on the differential, the most common being polyarteritis nodosa (PAN). CT angiography is usually diagnostic with characteristic beaded appearance of arteries. More rarely, ANCA-associated vasculitis, Behcet’s disease, and systemic lupus erythematosus can also result in GI vasculitis. Isolated SMA soft tissue infiltration is an atypical manifestation of IgG4, as abdominal manifestations of this disease typically involve the pancreas.

CONCLUSION: Rheumatologic conditions should be in the differential diagnosis for patients with abdominal pain.

HYDRALAZINE-INDUCED ANCA VASCULITIS: A CASE SERIES DEMONSTRATING VARIABLE PRESENTATIONS

Madeline Nottoli, Chelsea Azevedo, Divya Shastri, Ashley Scholtens, Maher Mousa, Ibrahim Qaqish, Daniel Maas

Creighton University School of Medicine Phoenix Regional Campus, Phoenix, AZ. (Control ID #3875194)

CASE: Patient one is a 69-year-old female with a history of hypertension who presented to the emergency department with azotemia, pancytopenia, hyperkalemia, and weight loss. Urinalysis showed microscopic hematuria and proteinuria and labs revealed decreased serum C3 and C4, positive ANA, anti-dsDNA, anti- Histone antibodies, and p-ANCA. Methylprednisolone (mPRED) was initiated, and her home hydralazine was discontinued. Renal biopsy was nonspecific but revealed C3 and IgA deposits and RBC casts. The patient required hemodialysis for worsening renal function. The patient was febrile, so mPRED was initially held due to concern for infection, but a negative infectious workup allowed mPRED to be resumed.

Patient two is a 70-year-old male with a history of hypertension who presented to the emergency department with azotemia, fatigue, and anorexia. The patient was found to be p-ANCA positive. His home hydralazine was discontinued. Renal biopsy showed focal crescentic glomerulonephritis with nonspecific presence of IgG, IgM, and C3 staining, which was thought to favor an infectious or autoimmune process. The patient was then found to have MSSA bacteremia with unknown source. mPRED was held, and he was started on Ancef. No source was found so the patient was started on rituximab and prednisone taper. Following a subsequent admission, the patient did require initiation of temporary hemodialysis for worsening azotemia.

Patient three is a 50-year-old male with a history of hypertension. He was seen in the nephrology clinic for a myriad of issues including proteinuria, anemia, leukopenia, intermittent fever, polyarthralgia, weight loss, dyspnea, and abdominal pain. Pertinent lab results included low C4, elevated ESR, positive ANA, and p-ANCA. His hydralazine was discontinued and the patient was started on high dose prednisone with clinical improvement and negative p-ANCA. One month later, the patient’s symptoms returned, and he was started on a one-month course of low dose prednisone, which resulted in resolution of his symptoms.

IMPACT/DISCUSSION: Hydralazine-induced ANCA-associated vasculitis (AAV) is a source of significant morbidity and mortality and may result in end-stage renal disease.¹ Diagnosis is difficult due to variable clinical presentation and non-confirmatory biopsy results, as was seen in these cases. A commonality between these patients was the presence of simultaneous infectious processes which made diagnosis more challenging. However, this may indicate that infections can trigger AAV in patients taking hydralazine, as it is autoimmune in nature. As Hydralazine is a commonly prescribed anti-hypertensive, it is important to describe varying presentations of Hydralazine-induced AAV.

CONCLUSION: ● Prompt diagnosis of hydralazine-induced AAV requires a high index of suspicion in patients taking hydralazine.

● Biopsy results should not be relied upon to make the diagnosis and initiate treatment.

● Caution should be used when prescribing high-dose hydralazine due to safety concerns.

HYPERAMMONEMIC ENCEPHALOPATHY AS A LATE COMPLICATION OF GASTRIC BYPASS SURGERY

Tyler Bendrick, Madeline Nottoli, Ashley Scholtens, Jaya Raj

Medicine, Creighton University School of Medicine Phoenix Regional Campus, Phoenix, AZ. (Control ID #3847592)

CASE: The patient is a 56-year-old male with chief complaint of generalized weakness and confusion. Past medical history included hypertension, past alcohol use disorder, and obesity, status post Roux-en-Y gastric bypass (RYGB) 19 years ago. The patient had been hospitalized multiple times at outside hospitals for abdominal pain, nausea and vomiting, and GI bleed. The patient’s wife stated that during these hospitalizations the patient exhibited confusion, memory loss, and difficulty with word finding. Prior workup included MRI of the brain, which was normal. Lab workup was remarkable for serum ammonia level of 123, AST 42 and ALT 81. Testing for viral hepatitis, autoimmune hepatitis, and hemochromatosis were negative. The patient continued to have episodes of weakness and encephalopathy, which intermittently correlated with high ammonia levels. Because of ongoing weight loss and malnutrition, he was encouraged to increase his dietary protein intake. The patient was referred to Hepatology; EUS and liver biopsy revealed mild hepatosteatosis but otherwise normal liver parenchyma.

The patient presented to this hospital with complaints of weakness, fatigue, confusion, and a ground level fall. Vitals in the ED: T 36.9, HR 75, RR 11, 110/69, 100% SpO2 on RA. Physical exam revealed a cachectic male with a soft, nontender, nondistended abdomen. Significant labs: WBC 2.8, Hgb 10.6, Hct 32.3, AST 43, ALP 354, Ammonia 81. CT head was negative. Comprehensive genetic testing for urea cycle disorders (e.g. arginase deficiency, citrullinemia, ornithine transcarbamylase (OTC) deficiency, etc.) was negative. The patient was started on a low protein diet, lactulose, and TPN, after which his mental status and ammonia levels improved and he was discharged with plans for bypass reversal.

IMPACT/DISCUSSION: Gastric bypass–related hyperammonemia (GaBHA) is a rare but increasingly recognized complication of RYGB. It is hypothesized that the high catabolic state post-RYGB, especially during physiological stress, results in an inability of the liver to metabolize proteins and a buildup of ammonia in the blood. Hyperammonemic encephalopathy can occur at varying time intervals after RYGB, ranging from early (months) to late (> 25 years). The mortality rate approaches 50%, especially when superimposed on baseline urea cycle disorders or cirrhosis. Treatment may include a low protein diet, lactulose, and/or arginine supplementation. This case emphasizes the difficulty in recognizing and treating gastric bypass related hyperammonemia with a late presentation (19 years post-op). Awareness of this rare complication facilitates early diagnosis and initiation of appropriate and treatment.

CONCLUSION: Hyperammonemic encephalopathy is a rare, life-threatening complication of gastric bypass surgery. Hyperammonemia should be included in the differential diagnosis of encephalopathy in patients without liver disease who have had gastric bypass.

HYPONATREMIA TO BURKITT LYMPHOMA: CIRRHOSIS AS AN AMPLIFYING FACTOR

Elizabeth Plakseychuk¹; Mark A. Moses¹; Monica Mehta²; Gaetan Sgro¹

¹School of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²UPMC, Pittsburgh, PA. (Control ID #3875387)

CASE: A 71-year-old man with history of hypertension, GERD, cirrhosis secondary to alcohol and colorectal cancer in remission s/p resection and chemotherapy, presented to the hospital on 3 separate occasions over the span of 1 month. On each presentation, he was experiencing nausea, increasing abdominal discomfort and distension, and varying degrees of hyponatremia with sodium (Na) ranging between 123-130 mEq/L. Workup revealed new-onset ascites with fluid studies notable for serum ascites albumin gradient (SAAG) of 2.0 g/dL and the presence of atypical cells. CT abdomen pelvis showed findings consistent with his prior surgeries as well as mesenteric enhancement. Ascites fluid cytometry was consistent with high grade Burkitt Lymphoma. Bone marrow biopsy was negative for bone marrow involvement. He was started on DA-EPOCH-R. The remainder of his course was complicated by tumor lysis syndrome, neutropenic fever, pancytopenia, and volume overload.

IMPACT/DISCUSSION: The three most common causes of ascites are cirrhosis (81%), cancer (10%), and heart failure (3%) (Runyon et al., 1992) with SAAGs > 1.1 g/dL most often associated with portal hypertension secondary to cirrhosis. Although our patient’s SAAG was above that threshold, the presence of malignant cells in his ascites fluid suggests a multifactorial etiology that might have been overlooked had his CT scan findings not prompted us to investigate ascites fluid cytology.

The most common cancer associated with mesenteric lymphadenopathy on CT is lymphoma but other causes include inflammation and infection (Lucey et al., 2005). For example, Mesenteric panniculitis is a chronic inflammatory process that can coincide with malignancy or be completely benign. One systematic review found that 38% of patients with mesenteric panniculitis had a known malignancy at the time of scan and a quarter of those patients had lymphoma (Halligan et al., 2016).

Little is known about the interaction between cirrhosis and treatment responses in Burkitt Lymphoma. One systematic review highlighted that patients with decompensated cirrhosis required more treatment modifications and experienced more treatment side effects (Jelicic et al., 2022). Although, improvements have occurred in the treatment of Burkitt Lymphoma, most lymphoma related deaths occur within the first year of diagnosis with about 55% incidence of death at 3 years for individuals ages 60-79 years old (Castillo et al., 2013).

CONCLUSION: Overlapping symptomatology presented a challenge to diagnosing Burkitt Lymphoma with mesenteric involvement in a patient with cirrhosis and new-onset ascites.

IATROGENIC OBSTRUCTIVE JAUNDICE AND CHOLANGITIS SECONDARY TO POST-ERCP HEMOBILIA

Naoshin Khan¹; Mohamed Ramzi Almajed²; Parul Kochhar¹; Abigail Entz²

¹Internal Medicine, Henry Ford Health System, Detroit, MI; ²Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #3874931)

CASE: A 67-year-old female presented acutely with abdominal pain associated with nausea and vomiting. Her history is notable for newly diagnosed liver cirrhosis of unknown etiology and diverticulitis status post colectomy.

Upon presentation, patient was alert and oriented. On examination, she was febrile with jaundice and generalized abdominal tenderness. Workup demonstrated leukocytosis of 14.3, hemoglobin at baseline of 8.7, AST 39, ALT 16, ALP 341, and total bilirubin 0.9. CT abdomen showed moderate ascites with distended gallbladder and wall thickening. Abdominal US and HIDA scan were consistent with acute cholecystitis. Given poor surgical candidacy, patient underwent ERCP that demonstrated choledocholithiasis and biliary papillary stenosis with patent cystic duct. Stent was placed in the common bile duct to maintain patency due to the presence of papillary edema. She had clinical and laboratory improvement afterwards.

Patient subsequently developed a fever with persistent RUQ pain. She had worsening hyperbilirubinemia to 4.0 and recurrence of leukocytosis to 14.0. Hemoglobin was stable around 8.0. She was started on antibiotics for cholangitis. Repeat ERCP showed that the previously placed biliary stent was occluded with a clot secondary to a post-sphincterotomy bleed. This warranted stent removal and replacement with a fully covered metal stent. Cystogram following procedure revealed a patent cystic duct. She had clinical improvement with decrease in bilirubin to 2.2 after which she was discharged.

IMPACT/DISCUSSION: ERCP is a diagnostic and therapeutic tool for the management of biliary and pancreatic diseases. It involves navigating an endoscope through the upper gastrointestinal tract and traversing the major duodenal papilla to access biliary and pancreatic ductal systems. This instrumentation is responsible for complications that include pancreatitis, cholangitis, hemorrhage, or perforation.

This case offers a rare complication of ERCP involving biliary obstruction secondary to post-ERCP bleeding with subsequent cholangitis. Bleeding after this procedure is typically associated with a decrease in hemoglobin, hemodynamic instability, or overt signs of hemobilia which our patient did not demonstrate. Localized bleeding at the common bile duct resulted in a clot that completely occluded the recently placed stent, resulting in an iatrogenic biliary obstruction. Management of this complication involves repeat ERCP for stent retrieval, bleeding control, and biliary drainage after which laboratory and clinical parameters improve.

CONCLUSION: Internists should be aware of the potential complications that occur in the immediate period after ERCP. Changes in a patient’s exam or laboratory values including cholestatic markers and complete blood count should prompt re-evaluation with imaging or repeat ERCP when indicated. This case highlights the clinical presentation and management for iatrogenic biliary obstruction secondary to biliary stent clotting after ERCP.

IBD FLARE IN THE PRESENCE OF COVID-19

Niloy Ghosh, Oscar F. Borja Montes, Abu Baker Sheikh

Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM. (Control ID #3870353)

CASE: A 59-year-old male presented to the emergency department with ~15 bowel movements per day with hematochezia for three weeks. He endorsed moderate abdominal pain, pain with defecation, decreased appetite, and positional lightheadedness. Relevant medical history included ulcerative colitis (in remission on Mesalamine therapy 1000mg QID), H. pylori c/b gastric ulcer s/p treatment, and recent COVID pneumonia. Approximately three weeks prior to his presentation, the patient noted mild cough, low-grade fevers, and generalized fatigue. He was diagnosed with COVID pneumonia at an outpatient facility but was never hospitalized. Two days afterwards, he developed bright red blood per rectum and diarrhea. A few days later he noticed bright red blood in his stool that consistently persisted for the following three weeks. Prior to this episode, the patient had been stable on his home mesalamine therapy without any flares since his initial diagnosis two years prior.

On admission, vital signs were within normal limits. Laboratory testing demonstrated a leukocytosis of 16.6, hemoglobin of 13.2, hypokalemia to 3.1, hypoalbuminemia to 3.1, ESR 50 (N: 2-37mm/hr), CRP 6.3 (N: 0-0.8 mg/dL), and fecal calprotectin 770 (N: <50mg/kg). C. Difficile, stool culture, and ova/parasite testing were all negative, and CT abdomen/pelvis was significant for proctocolitis. At this point, the patient was started on ciprofloxacin, metronidazole, and methylprednisolone. Gastroenterology was consulted and recommended resuming the patient’s home mesalamine dose, discontinuing antibiotics, continuing steroids, and trending daily CRPs. Over the next few days, the patient noted improvement in both the severity and the frequency of his diarrhea, which was accompanied by a downtrend in his CRP to 1.8. Shortly thereafter, the patient was discharged with a three-week prednisone taper and his prior home dose of mesalamine. On follow-up in the gastroenterology clinic, he noted full resolution of his symptoms.

IMPACT/DISCUSSION: COVID-19 has been reported to colonize the gastrointestinal tract in up to 31% of patients with COVID pneumonia. Viral infections have been known to trigger autoimmunity, activating immune responses to antigenic epitopes distinct from the disease itself. While the mechanism of action is unclear, it may be related to autoimmune responses via molecular mimicry or ACE-2 receptors.

CONCLUSION: There have been several reports in the literature noting IBD flares in COVID-19. While our patient likely was at a slightly higher risk of a COVID-19 associated IBD flare due to the lability and pro- inflammatory nature of an IBD colon, his symptoms were likely precipitated by not taking his home 5-ASA medication. Our case helps showcase one potential impact of the COVID-19 virus on the gastrointestinal system and a possible treatment algorithm moving forward. Further studies are required at this time to investigate the association between COVID-19 and IBD.

I CAN’T DO MY HAIR OR GET UP FROM MY CHAIR: A RARE PRESENTATION OF PRIMARY HYPERALDOSTERONISM

Claire Garpestad¹; Yasmin S. Meah²

¹Internal Medicine - Pediatrics, The Mount Sinai Hospital, New York, NY; ²Medicine, Medical Education, Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3873975)

CASE: A 65-year-old woman with lupus in remission, hypertension, type 2 diabetes and hyperlipidemia presented to the emergency department with 5 days of myalgias and weakness. She described achiness in her thighs and arms and inability to rise from her seat or lift her arms. She denied dry mouth, rash, temperature intolerance, or substance use. Her medications were valsartan, hydrochlorothiazide, amlodipine, metformin and atorvastatin; she was not on corticosteroids. On exam, the patient was normotensive. She appeared uncomfortable and had significantly reduced strength of proximal upper and lower extremities. Labs were notable for potassium of 2.0 and creatinine of 1.15 above her baseline 0.7. CPK was 6,059. AST and ALT were elevated to 259 and 160. ESR/CRP were also high at 44.3/44. Glucose and TSH were normal. Spot urine potassium was elevated at 50mEq/L. This patient was admitted for severe hypokalemia and secondary rhabdomyolysis due to hydrochlorothiazide use. Despite stopping the diuretic and several days of ample electrolyte repletion, potassium failed to rise substantially. Subsequent work-up revealed elevated plasma aldosterone concentration of 26.3ng/dL, plasma renin activity of 0.167ng/mL/hr, with an elevated aldosterone to renin ratio of 157. Abdominal CT and adrenal venous sampling confirmed a 9mm right-sided aldosterone- producing adenoma. She is now on spironolactone awaiting right adrenalectomy.

IMPACT/DISCUSSION: Primary aldosteronism is characterized by resistant hypertension and hypokalemia. Its prevalence had been underestimated at less than 1% of those with resistant hypertension while more recent studies have shown a prevalence of up to 20%.1 Hypokalemia as the presenting symptom is rare, affecting only 9-37% of individuals with this condition.2,3 Rarer still is rhabdomyolysis as a consequence of this hypokalemia, typically seen when potassium drops below 2.5.2,4 Hydrochlorothiazide- induced hypokalemia occurs in up to 50% of patients in a dose-dependent manner.5 Effects of hydrochlorothiazide last 6 to 12 hours; resistant hypokalemia after discontinuation should raise concern for alternative causes.6 The first-step in diagnosis of primary aldosteronism is measurement of plasma aldosterone and renin levels. If elevated, abdominal CT and adrenal venous sampling distinguish an unilateral aldosterone-producing adenoma (30-40% of cases) from bilateral adrenal hyperplasia (60-70%).3,7,8 Adrenalectomy is recommended for hormonally active unilateral adenomas, while mineralocorticoid receptor antagonists are the mainstay of treatment for bilateral hyperplasia. Despite such definitive treatment options, patients often face delays in diagnosis and management.9,10.

CONCLUSION: Hypokalemia is often associated with muscle weakness but potassium levels under 2.5 can induce rhabdomyolysis.

Screening for primary aldosteronism should be considered in patients with hypokalemia and hypertension. Adrenalectomy is recommended for functional adrenal adenomas regardless of size.

IDENTIFYING AND TREATING VARICELLA ZOSTER VIRUS ENCEPHALITIS AND ITS ASSOCIATED COMPLICATIONS IN IMMUNOCOMPROMISED PATIENTS

Priyal Sakhuja, Janika C. Kemppainen, Patricia Ng

Internal Medicine, Stony Brook University Renaissance School of Medicine, Stony Brook, NY. (Control ID #3875467)

CASE: Mr. X is a 72-year-old male with a history of ulcerative pancolitis (on chronic steroids and immunotherapy), DM Type 2, and bladder cancer who was admitted for diffuse body pain, altered mental status, and fever. Blood cultures were positive for MRSA, and he was started on IV vancomycin and meropenem. Despite antibiotic therapy, the patient continued to be altered and febrile, and thus a lumbar puncture was performed. CSF PCR was positive for varicella zoster virus (VZV) although Mr. X did not present with any rash or skin lesions on exam. He was initiated on IV valacyclovir and underwent MRI spine which demonstrated transverse myelitis from T3-T9. Given MRI findings, the patient was also started on high dose steroids. However, he continued to present with altered mental status along with flaccid quadriplegia and absent deep tendon reflexes. Subsequent CT head showed an acute subarachnoid hemorrhage around the brainstem. Ultimately, Mr. X’s clinical course did not improve, and his family decided to pursue comfort care.

IMPACT/DISCUSSION: This case highlights the importance of identifying VZV and its associated complications in immunocompromised patients, particularly in those who do not present with typical skin lesions. VZV is one of the most common neurological infectious diseases and the second most common virus resulting in encephalitis or meningitis (Skripuletz, 2018). Patients with encephalitis usually present with altered mental status varying from subtle focal deficits to complete unresponsiveness. In the case of immunosuppressed hosts, diffuse varicella encephalitis presents with more severe symptoms due to impaired cellular immunity and often is not preceded by typical skin lesions, which poses a challenge to identify it quickly and accurately (Lee, 2016). A rare complication of VZV encephalitis is transverse myelitis, which results in loss of sensory and motor function below the level of injury. Viral infections such as herpes and polio cause 25-45% of myelitis but are rarely seen as complications in immunocompromised patients with VZV (Cebollada, 2017). It can also be difficult to diagnose in patients with underlying neurological unresponsiveness from diffuse VZV encephalitis as shown by our patient case. Subarachnoid hemorrhage is another less common complication of VZV infection. VZV travels along the intracranial nerves to arterial walls and penetrates to a greater extent in immunocompromised patients (Wu, 2021). A literature review of cerebrovascular complications of VZV infection noted that incidence of ischemic stroke was 73.53%, while intracerebral hemorrhage and venous sinus thrombosis were relatively rare (Wu, 2021).

CONCLUSION: In immunocompromised patients with persistent fever and altered mental status, clinicians should consider neurologic infections such as VZV encephalitis.

Rare complications of VZV encephalitis include transverse myelitis and subarachnoid hemorrhage, which is treated with IV antiviral therapy, steroids and supportive care.

IDIOPATHIC GRANULOMATOUS MASTITIS: RECOGNIZING AND TREATING NON- LACTATIONAL MASTITIS IN THE BREAST

Christina Dilaveri

General Internal Medicine, Mayo Foundation for Medical Education and Research, Rochester, MN. (Control ID #3862410)

CASE: A 37-year-old G1P1 presented for evaluation of persistent left breast mass, pain, and skin changes.

She had her child at age 31 and did breastfeed for one year; medications include desogestrel/estradiol. She has no family history of breast cancer. Breast exam demonstrated a mass in the left breast at 3:00 adjacent to the nipple-areolar complex measuring 2 cm and erythema, warmth, induration and localized skin thickening. Mammogram noted a density in the lateral subareolar left breast and ultrasound saw an ill-defined hypoechoic region at 4:00, 3 cm from the nipple measuring 3 cm. Biopsy was done and pathology was consistent with acute, chronic and granulomatous inflammation, including non-caseating granulomas. Gram, GMS and AFB stains were negative. A diagnosis of idiopathic granulomatous mastitis (IGM) was made. She

was placed on a two-week course of doxycycline with no improvement. Because of progressive skin changes, oral steroids were started. Prednisone 40 mg daily was started with a plan to taper quickly. At follow up the patient had noted some improvement, but symptoms had plateaued. Prednisone was increased back to 30 mg daily and the steroids were tapered more slowly. On serial follow up the mass and pain resolved and the skin changes were improved.

IMPACT/DISCUSSION: IGM is a rare disorder of the breast that can present like an abscess or breast cancer. It most often presents in parous women within 5 years of pregnancy/breastfeeding. Symptoms include mass, pain, local signs of inflammation and fistula. Imaging and biopsy are needed to rule out breast cancer and obtain fluid for cultures. Biopsy can help establish the diagnosis with pathology showing non-caseating granulomas. There is no consensus on treatment. For mild, unifocal lesions, observation may be appropriate as up to 50% of cases self-resolve over 6-18 months. Some cases are associated with Corynebacterium species and so if antibiotics are used those that target Corynebacterium should be used and longer courses are often needed. Steroids have been studied since the 1980’s and oral, topical and intralesional steroids have all been evaluated. If oral steroids are used, does of 30-40 mg of prednisone and 3-6 months duration is often needed with a slow gradual taper needed to prevent rebound inflammation. Surgery is reserved for those cases that do not respond to maximal medical therapy given high risk of recurrence and of scar/deformity to the breast.

CONCLUSION: IGM is a rare inflammatory condition in the breast that occurs in parous women outside of breast feeding and can mimic abscess or breast cancer. This diagnosis should be considered in patients presenting with apparent breast infections within 5 years of breastfeeding that do not respond to typical antibiotic therapy or have recurrent episodes of mastitis. Imaging and biopsy help rule out infection and cancer and can help with establishing the diagnosis. Treatment remains controversial as there are no guidelines but should be based on disease severity.

IMITATION GAME: A CASE OF CHOLESTATIC LIVER INJURY DUE TO TREPONEMA PALLIDUM INFECTION

John Horton, Shahid Jaffer. Hospital Medicine, University of Minnesota Medical School Twin Cities, Minneapolis, MN. (Control ID #3876332)

CASE: A 42 year-old man with a history of major depressive disorder and methamphetamine use disorder presented to his clinic with fatigue and a rash for 2 weeks. On exam, there were widespread brown maculopapular lesions present on his trunk and extremities which spared the palms and soles. He denied any recent use of acetaminophen or use of new medications. He reported sobriety from all substances for 4 months. Prior to this, he did endorse frequent use of methamphetamine and alcohol. He endorsed multiple sexual partners in the context of prior substance use and with inconsistent use of barrier protection. He denied any new sexual partners for the past 4 months. Medications included Lamotrigine and Zyprexa.

Lab work was notable for ALT 1213 U/L, AST 616 U/L, ALP 1520 U/L, and T. Bilirubin of 0.7 mg/dL. A broad work-up for cholestatic liver injury was initiated. Lab work for viral hepatitis and autoimmune serologies were negative. Doppler ultrasound was negative for biliary obstruction or portal vein thrombus. MRCP showed findings of intrahepatic cholangitis without biliary obstruction.

STI screening returned with positive Treponema antibodies and an RPR titer of 1:16. Lumbar puncture was performed to rule out neurosyphilis and the patient was started on IV Penicillin G 24 million U/day. Liver biopsy was performed due to concern for syphlitic hepatitis, with results showing findings of cholangitis and a low grade hepatitis pattern. Though spirochetes were not seen on liver biopsy, his cholestatic liver injury was attributed to treponema pallidum infection due to significant improvement of liver injury upon completion of a 10 day course of IV Penicillin.

IMPACT/DISCUSSION: Historically nicknamed “the great imitator,” syphilis can be challenging to diagnose at times due to its ability to cause multisystem disease. Currently, rates of syphilis are rising across the United States. Maintaining a low threshold for testing is important, particularly in patients with risk factors for sexually transmitted infections.

Cholestatic liver injury from syphilis is rare, occurring in 0.2-9.7% of all infected patients. Typically seen in the first or second stages of disease, lab work classicaly shows a markedly elevated alkaline phosphatase with normal/mild elevations in aminotransferases and bilirubin levels. Liver biopsy is recommended to confirm the diagnosis, though spirochetes are not commonly detected on staining. Penicillin is the treatment of choice, but the optimal duration of treatment remains unclear.

CONCLUSION: Cholestatic liver injury is a rare complication of syphilis typically seen in primary or secondary disease and characterized by marked elevation in alkaline phostphase levels. Liver biopsy can help confirm the diagnosis, and penicillin is the treatment of choice.

Rates of syphilis are rising in the United States, and the threshold for testing should be low, particularly in those populations with increased risk factors for sexually transmitted infections.

IMMUNE CHECKPOINT INHIBITOR INDUCED HYPOPHYSITIS: WHY HYPONATREMIA MATTERS

Eda Algur³; Tiffany Dharia¹; Amy S. Clark²

¹Internal Medicine, Massachusetts General Hospital, Boston, MA; ²University of Pennsylvania Department of Medicine, Philadelphia, PA; ³University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #3870765)

CASE: A 50-year-old male with history of metastatic colon adenocarcinoma on ipilimumab/nivolumab, immune-mediated (drug induced) hypothyroidism on levothyroxine was found to have asymptomatic hyponatremia (Na 128 mmol/L, ref range 136-144 mmol/L) at a routine visit and advised to limit water intake. One week later, he noted nausea, headache, difficulty concentrating, blurry vision, and polydipsia.

Repeat outpatient labs revealed worsening hyponatremia (Na 120 mmol/L), and he was sent to the emergency department. Urine studies notable for K 22.7 mmol/L, Osm 319 mOsm/kg, Na 34 mEq/L. Serum studies notable for Osm 251 mOsm/kg, Na 120 mmol/L. On examination, he was euvolemic with no focal neurologic deficits.

After admission, fluid restriction (1L/day), salt tablets 2g twice daily, and furosemide 20mg daily slowly increased Na over 4 days to 138 mmol/L at discharge. Workup revealed mildly prominent pituitary gland on brain MRI, adrenal insufficiency (ACTH 2.5 pg/mL, AM cortisol <0.02 mcg/dL) and hypogonadism (LH 0.93 mIU/mL, prolactin <0.25 ng/mL) consistent with hypophysitis. Endocrinology was consulted and the patient was started on IV hydrocortisone (HC) 50mg every 8 hours, tapered to every 12 hours, and discharged on PO HC 30mg daily. Levothyroxine was decreased from previous dose of 175mcg to 150mcg daily given TSH <0.01 uIU/mL. Ipilimumab/nivolumab therapy resumed as an outpatient.

IMPACT/DISCUSSION: Immune checkpoint inhibitor-induced hypophysitis is rare and underdiagnosed as clinical manifestations vary in timing and severity. The highest incidence was observed in combination therapy with a CTLA-4 inhibitor (ipilimumab) and PD-1 (nivolumab) or PD-L1 inhibitor at 6.4%. [1] Hypophysitis should be considered for patients on checkpoint inhibitor therapy with symptoms of adrenal insufficiency, hypothyroidism, and hypogonadism along with headache and vision changes and may present with isolated lab abnormalities. Continuation of checkpoint inhibitor therapy is usually recommended as adrenal axis hormone rebound is not expected and can be corrected with medications.

[1] Barroso-Sousa R, Barry WT, Garrido-Castro AC, Hodi FS, Min L, Krop IE, Tolaney SM. Incidence of Endocrine Dysfunction Following the Use of Different Immune Checkpoint Inhibitor Regimens: A Systematic Review and Meta-analysis. JAMA Oncol. 2018 Feb 1;4(2):173-182.

CONCLUSION: Immune checkpoint inhibitor induced hypophysitis is a rare condition that should be considered in patients on or have received immunotherapy including CTLA-4 inhibitor/PD-1 inhibitor combination therapy who present with headache, vision changes, and endocrine laboratory abnormalities. Lab workup of hypothalamic-pituitary-endocrine axis hormones prior to starting any steroids should be initiated along with brain MRI. Treatment consists of corticosteroid therapy and hormone replacement therapy; discontinuation of checkpoint inhibitor therapy is rarely recommended.

IMMUNOMODULATORS GONE AWRY, A UNIQUE CASE OF PEMBROLIZUMAB INDUCED MYOCARDITIS

Anand Bhagat¹; Mouna Penmetsa²; Ashwin Mahesh¹; Alina Cheema²

¹Internal Medicine, University of Connecticut School of Medicine, Farmington, CT; ²Internal Medicine, UConn Health, Farmington, CT. (Control ID #3874867)

CASE: A 65-year-old male with a history of metastatic non-small cell lung cancer (NSCLC) and hypothyroidism presented to the emergency department (ED) with lightheadedness and syncope, requiring intubation for airway protection. He was noted to be on admission hypotensive with an electrocardiogram (EKG) showing third-degree AV heart block with a rate of 33 bpm. The patient received multiple doses of atropine followed by initiation of dopamine and epinephrine infusion. Cardiology was consulted and a temporary transvenous pacemaker was placed. Following placement, however, the patient’s troponin continued to trend with repeat EKGs revealing no ST segment changes consistent with NSTEMI. An echocardiogram obtained showed normal systolic function with an ejection fraction of 53%. Hypothyroidism was ruled out as thyroid stimulating hormone mildly (TSH) was elevated at 4.45 with free T4 elevated at 3.24. Lyme titers were negative. The patient continued to require intermittent pacing despite having a rate set as low as 50 bpm. Hematology-oncology was consulted as the patient was recently reinitiated on chemotherapy and immunotherapy with carboplatin and paclitaxel followed by pembrolizumab two weeks prior to presentation due to recurrence of NSCLC. Given suspected pembrolizumab-induced myocarditis, the patient started to receive stress dose steroids with an improvement in heart rate. Given complications during his hospitalization course, including new embolic strokes, the patient was transitioned to comfort measures only.

IMPACT/DISCUSSION: Immune checkpoint inhibitors (ICI) have become the mainstream therapy for many malignancies including NSCLC. Pembrolizumab, an ICI, is a monoclonal antibody that targets programmed cell death receptor 1 (PD1) which results in an amplified antitumor response. Due to the nonspecific effect on the immune system, ICIs can cause immune-related adverse events (irAE), however, fewer than 1% of cases have been reported of cardiotoxicity including myocarditis. Immune-mediated myocarditis has a highly variable presentation ranging from elevated troponin to conduction abnormalities. Diagnosis can be difficult often requiring Endomyocardial biopsy, which is the gold standard. Current guidelines recommend discontinuation of ICI and administration of high-dose prednisone followed by a taper. In our case, we suspect pembrolizumab-induced myocarditis resulting in complete heart block due to the patient's improvement with high-dose prednisone.

CONCLUSION: While autoimmune myocarditis is considered a rare irAE, as ICIs become more widely used, it is likely this irAE will become more common. ICI toxicity can occur at any time, even after patients have been tolerating treatment for months. Internists should increasingly consider autoimmune myocarditis on the differential because prompt diagnosis, withdrawal of ICI, and initiation of immunosuppressive therapy will help prevent long-standing complications.

IMPROVEMENT IN DIAGNOSTIC APPROACH, USING POINT OF CARE ULTRASOUND FOR AN EARLY DIAGNOSIS OF CONGESTIVE HEART FAILURE

Sameer Khan¹; Waldo J. Santiago Colberg²; Jordan Nickols²; Nathan Douthit^3,4

¹Internal Medicine Residency Program, East Alabama Medical Center, Opelika, AL; ²Internal Medicine, East Alabama Medical Center, Opelika, AL; ³Internal Medicine Residency, East Alabama Medical Center, Opelika, AL; ⁴Edward Via College of Osteopathic Medicine - Auburn Campus, Auburn, AL. (Control ID #3876785)

CASE: A 56-year-old female presented to the Emergency Department with dyspnea and was found to be in acute hypoxemic and hypercapnic respiratory failure. She was intubated and admitted for further workup and management. History was gathered from her son, who reports that three days prior to admission, the patient had increased dyspnea and orthopnea. The patient’s medical history was significant for hypertension, for which she is noncompliant on medication. On admission, patient’s vitals were significant for a BP of 137/69 mmHg and an O2 saturation of 100% on assist-control with a FiO2/PEEP of 80%/10 and Tidal Volume/RR of 480/22. Physical exam was significant for coarse breath sounds bilaterally on lung exam and 3+ pitting edema on the bilateral lower extremities. Labs were notable for a BNP of 793 pg/mL (normal 100-200 pg/mL). Chest X-Ray on admission showed extensive bilateral pulmonary opacities. Bedside POCUS reveals a dilated left atrium, dilated left ventricle, and severely reduced ejection fraction. A formal echo was ordered for further evaluation of the patient’s heart function, however, after performing a POCUS exam, aggressive diuresis therapy was initated from the first day of admission. Two days after admission, the formal echo was read and revealed a mildly dilated left atrium, moderately dilated left ventricle, and an ejection fraction of 20-25%. Diuresis was continued, patient was weaned to minimal ventilator settings, and subsequently extubated on day five of admission. Euvolemia was achieved with approximately 26L of output and a total net fluid balance of –17L. Cardiology initiated guideline directed medical therapy for the treatment of heart failure with reduced ejection fraction and the patient was stable for discharge on the tenth day of admission.

IMPACT/DISCUSSION: POCUS has been a rising trend within the medical community. Multiple studies have evaluated the diagnostic accuracy of POCUS. In one study by Lichtenstein et al., lung ultrasound identified pleural effusions and consolidations along with the extent of injury with higher specificity and sensitivity than auscultation or Chest x-ray. A study by Pivetta et al. found that ultrasound was more accurate in differentiating decompensated heart failure from noncardiogenic causes of dyspnea. In the case of this patient, POCUS allowed earlier treatment of the patient's acute condition with earlier therapy for acute heart failure. It is important to note however that POCUS comes with its own limitations, such as operator dependent accuracy. POCUS curriculums in residency programs reduce this limitation through standardized learning. Through the use of POCUS, cardiopulmonary disease can be diagnosed and managed in a more time efficient and accurate manner.

CONCLUSION: ● POCUS can be a valuable asset when performing a physical exam and has the ability to affect patient care.

● It is important to recognize that point of care ultrasound is operator dependent, and is only as useful as the skill of the one performing the exam

INFECTIOUS MONONUCLEOSIS AND THE DANGERS OF A FALSE NEGATIVE

Benjamin Ravichander¹; Lillian Sangha¹; John D. Goldman²; Irina Mishagina¹

¹Internal Medicine, UPMC Central PA, Harrisburg, PA; ²Infectious Disease, UPMC Central PA, Harrisburg, PA. (Control ID #3868849)

CASE: A 19-year-old male with no significant past medical history presents to the clinic with complaints of a two-day history of sore throat, fever, and posterior cervical lymphadenopathy. At that time, a rapid streptococcal antigen and heterophile antibody test were ordered and resulted as negative. He was sent home with instructions for supportive management. One week later, he was playing football, and after suffering a tackle, had excruciating left-sided abdominal pain. He quickly became hypotensive, and due to these unstable vital signs, he was taken to the hospital. Imaging revealed he suffered a splenic laceration, and he was promptly treated with a proximal splenic artery embolization. He was discharged home but presented to the emergency department again within a few days due to persistent fevers and near-syncope. He was found to be septic with an elevated white blood cell count, fever, and tachycardia. His repeat heterophile antibody and rapid streptococcal antigen tests were both positive, and his blood cultures were found to grow Group C streptococcus. Intravenous antibiotics were initiated, and he completed a two-week course after an echocardiogram confirmed the lack of valvular vegetations.

IMPACT/DISCUSSION: Infectious mononucleosis (IM) is a common disease with high prevalence in the United States caused by the Ebstein-Barr virus (EBV). IM presents with fever, fatigue, sore throat, and tender lymphadenopathy. Due to these nonspecific symptoms that overlap with other conditions, a rapid test to confirm a diagnosis is ideal. The heterophile antibody test is a rapid test that uses blood agglutination of heterophile antibodies in lieu of the gold-standard of serum testing for EBV-specific antibodies. The heterophile antibody test is clinically useful due to the rapid availability of a result in under 20 minutes. However, despite its high specificity (>90%), the sensitivity of the test is much weaker (70-90%). This results in a false negative rate that depends on the patient’s age and the disease's clinical timeline in relation to when the sample was collected. Antibodies are present at peak levels between two and six weeks of the disease, and those collected earlier, as in the case above, can increase the likelihood of a false negative result. There is a known risk of splenic rupture which occurs in 0.1-0.5% of patients with IM. In teenagers and younger adults who engage in physical activity, the risk of splenic rupture is higher.

CONCLUSION: Careful consideration should be taken to provide guidance to patients who present with symptoms concerning for IM but have negative confirmatory testing due to testing too early in the disease process. This could potentially avoid severe downstream complications and hospitalizations.

INHALED AEROSOLIZED PROSTACYCLIN AS ADJUNCT THERAPY IN IN ACUTE PULMONARY HYPERTENSION FROM MASSIVE PULMONARY EMBOLISM

Shwe Synn¹; Abhishek Sharma¹; Marjan Islam^2,1

¹Internal Medicine, Montefiore Medical Center, Bronx, NY; ²Pulmonary and Critical Care Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #3875391)

CASE: A 65-year-old man experienced a sudden cardiac arrest, where point-of-care ultrasound identified a severely dilated and hypokinetic right ventricle (RV) and acute deep vein thrombosis in the right lower extremity. A presumptive diagnosis of massive pulmonary embolism and obstructive shock was made. A post-arrest computed tomography of the head revealed an age indeterminate infarct, contraindicating thrombolytic therapy. Upon arrival to the ICU, the patient required 100% FiO2 on mechanical ventilator, and norepinephrine at 50 mcg/min to maintain a mean arterial pressure of 65mmHg. Intravenous heparin therapy was initiated. To reduce pulmonary vascular resistance, the patient received inhaled aerosolized epoprostenol. Over the course of 48 hours, the patient’s vasopressor requirements were slowly weaned off. By ICU Day 4, the patient’s shock state had resolved, and he was successfully taken off mechanical ventilation. Repeat Echocardiogram on ICU Day 5 revealed a normal RV size and systolic function.

IMPACT/DISCUSSION: Prostacyclin is a known systemic and pulmonary vasodilator. Intravenous prostacyclin causes systemic hypotension. When given by inhalation however, reductions in pulmonary artery pressures can occur without significant concomitant falls in systemic pressures. In acute pulmonary hypertension, a reduction in pulmonary artery pressures may reduce RV afterload and improve left ventricular diastolic filling, limiting the impact of interventricular interdependence and alleviating obstructive shock. Consequently, in the case presented, therapeutic interventions such as inhaled aerosolized prostacyclin can reduce pulmonary artery pressures and improve RV function. While RV function may improve following the acute embolism with or without inhaled prostacyclin therapy, given the critically ill state of our patient, reducing RV afterload may have allowed hemodynamics to stabilize to allow time for recovery from the massive PE. Indeed, randomized clinical trials are needed to determine if inhaled pulmonary vasodilators can accelerate resolution of obstructive shock and/or objectively improve RV function following massive PE. Our case demonstrates a remarkable resolution of obstructive shock by employing inhaled pulmonary vasodilators, when use of thrombolytics was contraindicated.

CONCLUSION: Intravenous thrombolytics are recommended in patients with PE with sustained hypotension. In patients where thrombolytics are contraindicated, inhaled pulmonary vasodilators may reduce RV afterload without affecting mean arterial pressure, and allow for improved hemodynamics by mitigating obstructive shock. Further studies are warranted to assess whether inhaled pulmonary vasodilators afford a faster resolution of shock and/or confer a mortality benefit.

INSECT BITE AS A POSSIBLE INCITING FACTOR FOR TTP

Sally Tayel, Bryan Rubio, Muhammad Afzal Khan

Internal medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #3838907)

CASE: A 52-year-old male with history of asthma and depression presented with acute onset of nausea, chills, and myalgias a day after an insect bite. On initial presentation, he was febrile (100.4 F) and examination showed diffuse petechiae with areas of ecchymosis. A bite mark was seen on the medial aspect of the right arm, with central area of redness surrounded by pallor. Laboratory findings showed normocytic anemia (hemoglobin 11.0 g/dl), thrombocytopenia (count 9000 cells/mcL), elevated total bilirubin (4.8 mg/dL), haptoglobin level <10 mg/dL and acute renal insufficiency (creatinine 1.19 mg/dL). Initial working diagnosis was Babesiosis; however, the peripheral blood smear showed no parasites but revealed schistocytes. Lyme and Ehrlichia serologies were negative. Coomb’s test was negative. Thrombotic microangiopathy persisted, and the patient was started on high dose IV steroids and plasma exchange. ADAMTS13 assay was < 5%, later confirming a diagnosis of TTP. Hospital course was complicated by relapse after discontinuing plasmapheresis, so indwelling central venous catheter was placed, and he was discharged on day 22 to complete outpatient plasma exchange and rituximab.

IMPACT/DISCUSSION: TTP was first described by Moschcowitz in 1924 as a primary thrombotic micro- angiopathic disorder with mortality rate of almost 100%. It is thought to be caused by autoantibodies targeting ADAMTS13 resulting in microthrombi formation and end-organ damage commonly of CNS and kidneys. TTP is usually characterized by a pentad of clinical findings: microangiopathic hemolytic anemia, thrombocytopenia, fever, neurological symptoms, renal insufficiency. A variety of unusual reactions have been reported following Hymenoptera stings including TTP; however, there have been no known cases reported after other insect bites. The underlying cause of TTP after insect bite remains speculative, with different hypotheses, such as endothelial damage or allergen sensitization promoting platelet aggregation. Despite recent advances in diagnosis and treatment, TTP presents a serious challenge to health care providers. Our patient presented with thrombotic microangiopathy and PLASMIC score of >5 raising concern for acquired TTP given his age. In the absence of underlying malignancy, immunosuppression, infections or toxins; the insect bite was suspected to be the trigger. Although the insect was never identified, the patient believed it was a spider. This patient required long-term plasmapheresis and rituximab to prevent further relapse.

CONCLUSION: This case highlights the possibility of TTP when a patient presents with severe thrombocytopenia and hemolytic anemia following an insect bite and stresses the importance of early identification of TTP. It also emphasizes the new guidelines of TTP management, recommending initiation of rituximab with first acute event to shorten duration of treatment and prevent relapse.

INSOMNIA RELIEF, WITH A SIDE OF JAUNDICE

Gianna Aliberti, Katherine Wrenn

Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #3874784)

CASE: A 59-year-old female with depression and insomnia presented to her PCP with 2 weeks of nausea. She denied vomiting or abdominal pain but noted fatigue, anorexia, and darkened urine. Physical exam was notable for jaundice without abdominal tenderness or organomegaly. Labs revealed ALT 2777, AST 1522, alkaline phosphatase 296, and total bilirubin 11.5. Other labs were unremarkable and extensive hepatology evaluation revealed only a low titer positive anti-smooth muscle antibody with low suspicion for autoimmune hepatitis. She ultimately recalled recently trying an insomnia supplement that contained stephania, which has been shown to have potential implications in liver injury. Her liver enzymes improved with supportive care, and she was discharged without need for biopsy. She was seen for follow up with symptom resolution.

IMPACT/DISCUSSION: There are many medications, supplements, and herbs commonly implicated in drug-induced liver injury (DILI) and herb-induced liver injury (HILI). Although not as common in the literature as DILI, HILI should be suspected as part of the differential for acute liver injury given the wide availability and lack of regulation of supplements and herbs. HILI most often presents as an acute liver injury with marked elevations in ALT, AST, and bilirubin. Patients are typically jaundiced but may range from asymptomatic to fulminant liver failure. To diagnose HILI, exposure of the supplement/herb should precede the onset of symptoms and underlying liver disease should be excluded. Stephania, the likely culprit, is a Chinese plant used for anti-inflammatory properties. One study in rodents showed possible liver/kidney injury, and case reports have implemented it in liver toxicity.

Initial evaluation of acute hepatitis should include a thorough history and physical exam. Important aspects of the history hepatotoxin exposure, risks for viral hepatitis, and disorders related to underlying liver disease. Abdominal exam should assess for size and consistency of the liver and spleen, ascites, and tenderness, as well as for jaundice, stigmata of liver disease, and altered mental status. Initial labs should include ALT, AST, alkaline phosphatase, bilirubin, albumin, prothrombin time, and INR, as well as complete blood count, chemistry, and thyroid studies. When acute liver failure (lab derangements plus encephalopathy) is excluded, the degree of elevation in ALT and AST can be helpful in narrowing a differential. More specific testing should include toxin screen, acetaminophen levels, acute viral serologies (HAV, HBV, HCV), autoimmune studies (ANA, ASMA, ALKMA, IgG), and transabdominal ultrasound with doppler. If all is negative or liver function does not improve, liver biopsy may be warranted.

CONCLUSION: - DILI/HILI should be considered in a patient with acute elevation in LFTs, particularly in those without underlying liver disease

- A thorough review of over-the-counter medications, herbs, and supplements should always be included in the acute hepatitis workup

INSULINOMA – A RARE DISEASE HIDING IN PLAIN SIGHT

Rabia Khan, G. W. Garriss, Joanna Miragaya

GME- Internal Medicine, Wellstar Kennestone Hospital, Marietta, GA. (Control ID #3877374)

CASE: An 80-year-old male, with no significant past medical history, presented with an episode of syncope. He reported he was having lunch with friends when he became lightheaded for about 30 seconds. He denied shortness of breath, chest pain, palpitations, loss of consciousness, or any history of head trauma. He denied any history of diabetes or seizures. On further questioning, his wife reported that he had several episodes of hypoglycemia associated with light headiness, confusion, and weakness over the last three months. He has been checking his fasting blood glucose at home and these had ranged from the 40s to the 70s. He also reported that his symptoms would improve after ingestion of “high-sugar" drinks, so he did not seek help.

The differential diagnosis included poor dietary habits, post-prandial hypoglycemia, adrenal insufficiency, and an insulinoma. Given the patient’s age and lack of other history, MEN or Von Hippel-Lindau syndrome were felt to be less likely.

Lab workup was notable for HbgA1C of 5.8%, glucose of 47mg/dL, elevated insulin levels (21.6 mIU/L) and an inappropriately high normal C-peptide ( 2.97 ng/mL). Workup for adrenal insufficiency was normal.

On review of a past CT of the abdomen/pelvis, a pancreatic tail mass was noted; this had not been further evaluated and this raised the suspicion of a neuroendocrine tumor (NET) or insulinoma. MRI abdomen confirmed a solid enhancing mass in the pancreatic tail, consistent with a functional NET (insulinoma); there was no evidence of adenopathy/metastatic disease. He was evaluated by oncology. The decision was made to surgically resect the tumor. He had no hypoglycemic events post robotic enucleation of pancreatic tail mass and partial pancreatectomy. Pathology confirmed a well-differentiated NET.

IMPACT/DISCUSSION: Insulinomas are rare pancreatic endocrine tumors. The reported incidence of insulinomas is 1–4 million/year. They can occur at any age and have a slight female predominance. Typically, they present as small (<2 cm in diameter), solitary benign masses. Most are sporadic, but, 10% are multiple and occur as part of multiple endocrine neoplasia syndrome type I (MEN–I). Because of nonspecific symptoms, insulinoma may be misdiagnosed or confused with other disorders. After biochemical confirmation of hyperinsulinism, preoperative localization of the tumor in the pancreas may be difficult. Surgical removal, which is often curative, continues to be the treatment of choice.

CONCLUSION: Insulinomas are usually benign but can cause hypoglycemia which can be life-threatening. Biochemical diagnosis is easy, but preoperative localization may prove difficult. Fortunately, most insulinomas can be identified intraoperatively by experienced surgeons. Surgical resection remains the treatment of choice with an extremely high success rate. The laparoscopic approach is increasingly performed and blind pancreatic resection is not recommended. Finally, medical options are reserved for unresectable or metastatic tumors.

INTESTINAL OBSTRUCTION IN MIDDLE AGED MAN FOUND TO BE MECKEL’S DIVERTICULUM

Gnanashree Dharmarpandi¹; Dhyanesh Patel¹; Muhammad Ali Anees²; Waqas Rasheed¹; Tarek Naguib^3,1

¹Internal Medicine, Texas Tech University System, Lubbock, TX; ²Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, Texas, USA, Amarillo, TX; ³Internal Medicine, Texas Tech University Health Sciences Center - Amarillo, Amarillo, TX. (Control ID #3877187)

CASE: Intestinal obstruction can be functional or mechanical. Mechanical causes are either intraluminal or extraluminal with adhesions being the most common cause followed by hernia, malignancies, infections, or inflammation. Meckel's diverticulum (MD) is a congenital anomaly caused by failure of vitelline duct obliteration. It is a common pediatric problem, usually asymptomatic, but it can lead to intestinal obstruction, hemorrhage, or perforation.

A 53 years old male with a history of alcohol abuse disorder, cirrhosis, and lung cancer presented with severe, constant, generalized, stabbing abdominal pain associated with nausea and vomiting. He also reported constipation but was able to pass flatus on the day of admission. Physical exam was positive for tense, tender and distended abdomen with very infrequent bowel sounds as well as jaundice and clubbing. Initial work-up showed anemia, thrombocytopenia, hyperbilirubinemia, and hypoalbuminemia. CT abdomen showed distended small bowel with transition point at right upper quadrant. The patient was managed with supportive care including nothing per oral, nasogastric (NG) suctioning, intravenous (IV) fluids, and analgesics. On the 2nd day of admission, he had total 3 L NG output, reported worsening of abdominal pain not responding to analgesics, had rebound abdominal tenderness, became hypotensive, and encephalopathic. He was started on more IV fluids, vasopressors, antibiotics, and emergent exploratory laparotomy was performed which showed Meckel's diverticulum with significant adhesions around it causing intestinal obstruction. There was a patchy small bowel and distal omental ischemia. He also had foul smelling ascites without any perforation which was assumed to be likely from translocation of bacteria from the gut. The patient remained hemodynamically unstable on 3 vasopressors, developed multi-organ failure, and comfort care was chosen considering his significant comorbidities.

IMPACT/DISCUSSION: MD is an uncommon GI tract anomaly, commonly exhibited in young patients and is rarer and discovered incidentally in adults. In adults, this often presents with complications such as intestinal obstruction, inflammation, bleeding, and torsion. These complicated are caused by the diverticulum’s attachment to the umbilicus, abdominal wall or other viscera by fibrous band. CT scans are the choice of test to identify MD, but do not always reveal a diverticulum in the absence of concurrent complication. A significant portion of cases are identified during workup for an acute abdomen or SBO during exploratory laparotomy, as in our case.

CONCLUSION: The rarity of presentation leads to poor preoperative diagnosis in complicated MD patients. Although benefits of prophylactic removal of incidental MD is not well understood, early diagnosis and resection in a complicated MD has a better prognosis. Hence small bowel obstruction secondary to Meckel’s diverticulum should be a consideration in adults with acute abdomen.

IN THE LYME LIGHT: A YOUNG MAN WITH ERYTHEMA MIGRANS, LIGHTHEADEDNESS, AND AV BLOCK

Lillian Hallmark¹; Susan B. Glick²

¹Medical College, Rush University Rush Medical College, Chicago, IL; ²Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #3875879)

CASE: An 18-year-old man presented with lightheadedness and near syncope. Six weeks prior, he noticed two erythematous lesions with bulls-eye appearance. He also experienced fatigue, diaphoresis, abdominal pain, and emesis. The patient lives in a Chicago suburb and had not traveled outside of the Chicago area prior to illness onset. He did not recall a tick bite.

He improved and visited a local State Park.

2-3 weeks later the patient noted more erythematous and nonpruritic lesions involving the face, arms and back along with arthralgias of the knee and thumb.

5 days prior to admission he began to experience lightheadedness, palpitations, and near syncope, both when sitting and when standing.

At an urgent care facility, an EKG revealed 3rd degree AV block and he was referred to the local ED. There, an EKG revealed sinus bradycardia with 1st degree AV block, and he was discharged home on doxycycline.

He sought care with a primary care physician the following day after remaining lightheaded. EKG revealed 3rd degree AV block with junctional bradycardia. He was diagnosed with probable Lyme carditis, transferred to the ED, and admitted to the CCU.

There was no prior medical history. He was taking doxycycline and was allergic to amoxicillin. He smoked 1-2 cigarettes and marijuana daily and drank 3-4 beers per week. Family history was noncontributory.

On physical examination he was well-appearing. BP 118/56, HR 40, RR 20, Temp 98.8. There was bradycardia and erythematous annular lesions over the right posterior shoulder, right medial thigh, and bilateral shins. The remainder of the physical examination was normal.

The patient was treated with IV ceftriaxone and his conduction abnormalities resolved. Lyme IgM and IgG returned positive.

IMPACT/DISCUSSION: Carditis is one of the manifestations of early disseminated Lyme disease and presents within 2 months of primary infection. Due to improved recognition of Lyme disease and initiation of antibiotic therapy, Lyme carditis is now relatively rare, affecting 1% of patients with Lyme disease. Affected patients may be asymptomatic or experience palpitations, chest pain, dyspnea, lightheadedness, syncope, or sudden cardiac death.

Lyme carditis presents most commonly as AV block, which can quickly swing from complete AV block to 1st degree AV block and back again, as it did in this patient. Lyme carditis may also result in pericarditis, myocarditis, or cardiomyopathy.

The diagnosis is made based on the clinical presentation in junction with positive Lyme serology. Treatment includes IV antibiotics and telemetry. Permanent pacing is rarely needed as complete AV block ^{typically resolves within 7 days.}

CONCLUSION: AV block is a common presentation of Lyme carditis with high-degree AV block accounting for 2/3 of cases. Because the degree of AV block can vary rapidly, it is important to recognize Lyme carditis as a possible cause of AV block so that affected patients can be treated appropriately with antibiotics, telemetry, and/or a temporary pacemaker.

INVASIVE PNEUMOCOCCAL DISEASE AND ITS RARE COMPLICATION: AUSTRIAN SYNDROME

Jill Guillette, Parker Lachowsky, Vishnu Ilineni

Internal Medicine, Texas Health Resources, Arlington, TX. (Control ID #3876497)

CASE: A 64-year-old male presented with a one-day history of fever, cough, and confusion. He had no medical problems and was not on any medications. On exam, he was somnolent but arousable to verbal stimuli. He was not oriented to person, location, or time. Cardiac auscultation was negative for murmur. Blood cultures were positive for Streptococcus pneumoniae. His cerebrospinal fluid (CSF) cultures also grew S. pneumoniae. Transthoracic echocardiogram (TTE) was negative for any valvular abnormality. Chest x-ray showed right sided infiltrates.

Prior to positive cultures, he was treated with empiric vancomycin, ceftriaxone, and ampicillin due to high suspicion of bacterial meningitis. After culture results confirmed S. pneumoniae, he was diagnosed with bacteremia and meningitis and transitioned to IV ceftriaxone. Patient responded well and was discharged home after completing 2 weeks of IV antibiotics.

Two weeks later, he returned to the hospital with shortness of breath and lower extremity edema. Examination revealed a new diastolic murmur. His blood cultures were negative. TTE showed severe aortic regurgitation. A follow-up transesophageal echocardiogram (TEE) revealed vegetation on the aortic valve.

He had open aortic valve replacement and repair of aortic root abscess. After surgery, he clinically improved.

IMPACT/DISCUSSION: Austrian syndrome is a rare complication of invasive pneumococcal disease. It is a triad of meningitis, pneumonia, and endocarditis. It has an incidence of 0.9-7.8 cases per 10 million people each year. It has a mortality rate of 32% which increases to 60% if not diagnosed early.

Clinicians should have a high degree of suspicion for Austrian syndrome in patients with invasive pneumococcal infection. Early detection and aggressive treatment are vital in treating this life-threatening condition. Currently, we depend on positive blood cultures and presence of vegetation on echocardiogram to detect endocarditis. This completes the diagnostic triad of Austrian syndrome.

As revealed by our case, an aortic valve vegetation was likely missed on the initial TTE. As a result, he was treated with only 2 weeks of antibiotics for bacteremia and meningitis, rather than the 4-6 weeks needed for endocarditis. On literature review, we found that sensitivities of TTE in detecting valvular vegetations and abscesses is only 63% and 28% respectively. The sensitivities can be significantly increased to 100% and 87% in detecting vegetations and abscesses by TEE.

Although our patient recovered after open aortic valve replacement, his case demonstrates the importance of early diagnosis of Austrian syndrome and appropriate treatment to decrease morbidity and mortality.

CONCLUSION: In patients with invasive pneumococcal infections, clinicians should have high suspicion for Austrian syndrome. TEE should be preferred over TTE due to its significantly better sensitivity in diagnosing endocarditis. Early diagnosis and aggressive treatment are crucial in this life-threatening condition.

ISOLATED ELEVATED TOTAL BILIRUBIN FROM NAPROXEN OVERDOSE; A CLINICAL VIGNETTE

Tobin Mathew^2,1; Olivia Heutlinger^2,1; Dylann Fujimoto^2,1; Rebecca Yamarik¹; Samuel Baz¹; Vishnu Bharani²; Christopher R. Grant³

¹Internal Medicine, VA Long Beach Healthcare System, Long Beach, CA; ²Internal Medicine, University of California Irvine, Irvine, CA; ³Internal Medicine, UC Irvine Douglas Hospital, Orange, CA. (Control ID #3874794)

CASE: A 63-year-old male with a medical history of polysubstance use disorder (methamphetamine, fentanyl, alcohol, marijuana) presented with left sided abdominal pain and nausea after attempted suicide (SA) by ingestion of sixteen 500 mg naproxen tablets. Naproxen ingestion per body weight was 92.4 mg/kg.

Laboratory evaluation was notable for elevated total bilirubin to 5.7 mg/dL from 0.6 mg/dL two months prior, with direct bilirubin 0.1 mg/dL. Liver enzymes, hemolysis labs, thyroid labs, and peripheral smear were unremarkable. Physical exam was notable for the lack of jaundice. The patient was not taking outpatient medications or supplements. The patient had a mild normocytic anemia with normal iron panel, folate, and vitamin B12 level. A right upper quadrant ultrasound showed cholelithiasis without evidence of hepatobiliary abnormality or hepatosplenomegaly. The patient received intravenous fluids and his abdominal pain resolved overnight. The elevation of total bilirubin is thought to be due to the naproxen metabolite

O-desmethylnaproxen (ODMN), which has been shown to interfere with some time-endpoint diazo-based bilirubin assays, including the Jendrassic and Grof method used in the hospital evaluating this case. The next day the patient's total bilirubin was normal at 0.9 mg/dL. He was then transferred to the inpatient psychiatric unit for further treatment.

IMPACT/DISCUSSION: The workup for our patient was unrevealing for typical causes of hyperbilirubinemia including hemolysis, biliary stasis, and hepatobiliary structural/functional abnormalities. Additionally, there was no known underlying biliary abnormality with recent normal bilirubin and no jaundice along with rapid normalization. The JG method for bilirubin assay measurement can lead to elevated measured total bilirubin in cases of supratherapeutic serum naproxen levels. Assay interference has only been shown to occur at supratherapeutic serum naproxen levels with ODMN and does not occur within the therapeutic range. Some bilirubin assays (e.g., Roche Hitachi917 assay) are not affected by ODMN levels due to use of a different diazotizing reagent that does not interfere. Toxic ingestion is the third leading cause of death in successful SA and the incidence rate of this method of attempt is increasing. Non-steroidal anti- inflammatory drugs (NSAIDs) are readily available over-the-counter and are a common drug of choice for SA. Our patient had no clear organic cause for hyperbilirubinemia, and likely had a false measurement ODMN interference.

CONCLUSION: In cases of supratherapeutic naproxen levels, its metabolite, ODMN, may interfere with some diazo-based total bilirubin assay methods resulting in an isolated elevated total bilirubin with no other apparent organic cause. This elevation in total bilirubin is transient and should return to baseline as naproxen and ODMN levels decrease. As the incidence of toxic ingestion of medications including naproxen increases, clinicians should be aware of this interference pattern.

ISOLATED UPPER MOTOR NEURON DEFICITS; A RARE SUBTYPE OF AMYOTROPHIC LATERAL SCLEROSIS

Patrick Farahvashi²; Melissa A. Rusli¹

¹Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; ²Nova Southeastern University, Fort Lauderdale, FL. (Control ID #3875738)

CASE: 31 yo Caucasian male presented with gradually worsening neuromuscular symptoms over the past year: 9+ months of torticollis-like tics followed by 6+ months of worsening bilateral lower extremity weakness and stiffness. He reported minimal weight loss and admitted to difficulties with standing and walking for prolonged amounts of time, requiring use of ambulatory devices to avoid falling. He used to skateboard as a teenager, but denied any head trauma. He obtained a medical marijuana card for these symptoms (ingests by edibles). PMH of ADHD (previously on on treatment), former cigarette smoker. Family history was negative for neuromuscular disease.

On exam, he displayed a stiff wide-based flat-footed gait with positive Romberg sign and abnormal tandem walk. Motor exam: 4 out of 5 strength of hip flexors, knees and ankles, normal 5 out of 5 strength of upper extremities. Reflexes were brisk 3+ bilaterally throughout all reflex points of upper and lower extremities. Negative for any sensory loss, cranial nerve deficits, or dysdiadochokinesia.

Thorough metabolic labwork were normal. He was referred to neurology who recommended an MRI of the cervical, thoracic, and lumbar spine, as well as an EMG of his legs for presumed Primary Lateral Sclerosis. He was started on cyclobenzaprine 5 mg to assist with his tics.

IMPACT/DISCUSSION: Amyotrophic lateral sclerosis (ALS) is a well-known sporadic etiology of motor dysfunction affecting upper and lower motor neurons, which presents with weight loss and rapid deterioration in condition. However, there are several variants, such as Primary Lateral Sclerosis (PLS), which warrant awareness and discussion given their impact on prognosis and treatment. PLS is a progressive isolated UMN disorder which presents with gait abnormalities and hyperreflexia. Onset typically occurs in more men between ages of 40-60 yo. Patients tend not to develop LMN deficits, but those who do later on are then diagnosed with “UMN-onset ALS”. PLS is reported to have a better prognosis than both classic ALS and UMN-onset ALS. Patients tend to live longer and exhibit slower disease progression. This case presentation involves upper motor neuron (UMN) deficits only given his hyperreflexia and positive Romberg. The slower progression and minimal weight loss also make ALS less likely. His presentation initially stumped our clinical team, however, with further awareness of PLS, we were able to counsel and reassure our patient with more clarity regarding this rare presentation.

CONCLUSION: Primary Lateral Sclerosis is a rare subtype of the more recognized syndrome of Amyotrophic lateral sclerosis. PLS differs by featuring only upper motor neuron deficits, has a slower progression, minimal weight loss, and fortunately carries a better long-term prognosis. While there are no current treatments, increased awareness amongst clinicians can lead to more accurate diagnosis and counseling for patients.

IS THIS RASH HERPES ZOSTER OR ZOSTERIFORM CUTANEOUS METASTATIC BREAST CANCER?

Cullen Hudson³; Astha Saini^1,2; Zachary Buxo²; Anupama Devara^1,2

¹Internal Medicine, Detroit Medical Center, Detroit, MI; ²Wayne State University School of Medicine, Detroit, MI; ³School of Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #3875378)

CASE: A 42-year-old woman diagnosed with locally advanced, triple negative invasive ductal carcinoma of the left breast at the age of 39 achieved remission with chemotherapy, lumpectomy/lymph node dissection and radiation therapy. Two years after initial diagnosis, the triple negative invasive breast carcinoma reoccurred. PET/CT revealed multiple enlarged hypermetabolic left retropectoral and axillary lymph nodes consistent with metastatic disease, chemotherapy was immediately started. Eight months later, she presented to the hospital for intractable left upper extremity pain and a 2 week history of a zosteriform rash.

Physical examination revealed grouped tender vesicles over the left medical upper back wrapping around the left chest wall onto the breast and upper medial left arm. Dermatology described these lesions as a classic presentation of herpes zoster. Oral acyclovir was started for suspected herpes zoster. Despite 5 days of treatment, the vesicles coalesced into nodules with surrounding erythema. Infectious Disease recommended IV acyclovir due to the atypical presentation and concern that the intravenous antiviral was needed because the patient was immunocompromised. She did not exhibit any improvement in the rash after 3 days of IV acyclovir and a punch biopsy was obtained revealing metastatic triple negative invasive ductal carcinoma, consistent with the patient’s primary cancer.

IMPACT/DISCUSSION: Our patient’s rash resembled the manifestation of herpes zoster. Punch biopsy was performed because there was no improvement after treatment with acyclovir. Biopsy results confirmed cutaneous metastasis of triple-negative invasive ductal carcinoma. Only 3.6% of the total reported cutaneous metastases of breast carcinoma have zosteriform phenotype. The rare incidence of zosteriform cutaneous metastasis can cause significant delay in the diagnosis of cutaneous metastases of breast cancer. Triple- negative breast cancer has been shown to be a highly metastasizing, heterogeneous disease that accounts for 10-15% of total breast cancer cases. Cutaneous metastasis has poor prognosis and high relapse rate within five years after treatment.

CONCLUSION: 1. Treatment for a herpetic rash should be revised if a patient does not show improvement following an intervention following 4-5 days in an immunocompromised host, broaden the differential diagnosis

2. Physicians should remain vigilant of zosteriform manifestations of metastasis in patients with breast cancer.

IT'S THE MOST WONDERFUL TIME OF THE YEAR...FOR CARBON MONOXIDE POISONING Aakash R. Goyal¹; Navjot Rai¹; Karen Avgush²

¹Internal medicine, Crozer-Chester Medical Center, Upland, PA; ²Internal Medicine, Crozer-Chester Medical Center, Upland, PA. (Control ID #3876657)

CASE: Patient is an elderly female with a complicated past medical history who presented to the emergency department for evaluation after a fall at home with an old heating system. Prior to the fall, she reported dizziness and headache but denied other concerning symptoms. She did not hit her head nor lose consciousness during the event. Her vital signs and physical exam, including a neurologic examination, were generally unremarkable. The EKG was nonischemic. Laboratory studies were significant for an elevated lactate and troponin as well as a carboxyhemoglobin of 15%. CT of the head and chest x-ray were negative for acute abnormalities. It was determined that the patient’s

presentation was likely secondary to carbon monoxide poisoning. After expert consultation, the patient was deemed not to be a candidate for hyperbaric oxygen therapy and was treated with high-flow oxygen. Carboxyhemoglobin levels trended down to normal range prior to discharge with concomitant resolution of the elevated lactate and troponins with the noted intervention.

IMPACT/DISCUSSION: Falls are the leading cause of injury-related visits to hospitals in the United States and the primary etiology of accidental deaths in persons over the age of 65 years. Evaluation of a patient who has fallen includes a focused history and physical examination as well as testing to identify the underlying cause thereof.

Risk factors for falls in the elderly include advanced age, medications, cognitive impairment, sensory deficits, and accidental poisoning. The presenting features of carbon monoxide poisoning include general malaise, dizziness, headache, flu-like symptoms, or symptoms mimicking gastroenteritis. Severe carbon monoxide poisoning can present with neurologic symptoms like seizures, syncope, and coma; metabolic abnormalities such as lactic acidosis; and cardiovascular issues like myocardial ischemia, ventricular tachycardia, and pulmonary edema. In patients with symptoms severe carbon monoxide toxicity, treatment with hyperbaric oxygen is suggested.

CONCLUSION: Carbon monoxide poisoning represents a preventable and reversible cause of morbidity and mortality once identified. The elderly have been shown to be at particular risk and concerns are raised about potential unrecognized cases of carbon monoxide poisoning in this population. These concerns arise from difficulties in the identification of those who may be victims. In general, carbon monoxide has no helpful, unique clinical presentation and is known to emulate common illnesses as well as exacerbate established ones. Furthermore, as a gas, it is undetectable by the human senses and can be present in most households, particularly in the colder months. Thus, this condition should be considered in the differential of a wide variety of presentations, especially during months when it is more likely to be encountered.

ITRACONAZOLE-INDUCED THROMBOCYTOPENIA: A RARE ASSOCIATION

Abhinav Vyas¹; Dania Kaur²; John w. Scarborough²

¹Internal Medicine, North Alabama Medical Center, Florence, AL; ²Department of Internal Medicine, North Alabama Medical Center, Florence, AL. (Control ID #3876776)

CASE: A 77-year-old gentleman with multiple comorbidities, including recently diagnosed microscopic polyangiitis vasculitis with a pulmonary-renal syndrome, presented with dyspnea and low oxygen saturation at home. The patient was recently discharged three days back with appropriate therapy for microscopic polyangiitis. On arrival, he was afebrile, heart rate of 137 bpm, respiratory rate of 26/min, and blood pressure of 130/90 mmHg with a saturation of 91% on 6 L nasal cannula oxygen. Labs demonstrated leukocytosis, hemoglobin of 9.5 g/dL, hematocrit of 28.2, and platelet of 128,000. Chemistry showed normal electrolyte levels with Blood urea nitrogen of 60 mg/dL and creatinine of 2.5 mg/dL. A repeat chest x-ray on this admission showed a marked increase in the interstitial alveolar infiltrates in bilateral lungs.

Electrocardiogram demonstrated atrial fibrillation with a rapid ventricular response. He was started on a diltiazem drip and admitted to the intensive care unit for further management and care. However, throughout the hospital stay, the platelet count kept declining. Two days later, it was 59,000. The patient's last platelet count before admission was 249,000. Peripheral blood smear demonstrated thrombocytopenia with normal morphology of the platelets. The patient was recently discharged on itraconazole 200 mg twice daily for disseminated histoplasmosis. After discontinuing itraconazole, the platelet count started normalizing within the next 4-5 days. During the next few days, the patient developed vasculitis-induced diffuse alveolar hemorrhage and worsening renal failure. He was subsequently intubated for worsening respiratory failure and started on high-dose intravenous steroids with minimal improvement. Hence, it was decided that it was in the patient's best interest to provide comfort care with palliative care consultation.

IMPACT/DISCUSSION: Itraconazole is an imidazole derivative antifungal agent widely used for opportunistic systemic fungal infections. There have been very few reported cases of itraconazole-induced thrombocytopenia in the literature. Our patient developed thrombocytopenia within 2 to 3 days of starting itraconazole which is not typically consistent with immune thrombocytopenia. Literature mentions selective bone marrow suppression by itraconazole, causing thrombocytopenia. Signal transducers and activators of transcription (STAT) proteins are hypothesized as one of the targets of itraconazole. Down-regulation of STAT proteins by itraconazole has been hypothesized as a cause of thrombocytopenia in patients. Naranjo Adverse Drug Reaction Probability Scale score was 5, indicating itraconazole as the likely cause of thrombocytopenia.

CONCLUSION: We recommend that physicians monitor patients for signs and symptoms of thrombocytopenia, including petechiae and ecchymosis, after initiating treatment with itraconazole. If patients develop signs and symptoms of thrombocytopenia, consider stopping itraconazole and switching to a different class of antifungals.

JOHNSON AND JOHNSON VACCINE INDUCED PANCYTOPENIA

Sujan Niraula¹; amit barua¹; Anjan Katel²; Madan R. Aryal³

¹Internal medicine, Nuvance Health, Vassar Brother Medical Center, Poughkeepsie, NY; ²Department of Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal, Kirtipur, Kathmandu, Nepal; ³Hematology and Oncology, Enloe Medical Center, Chico, CA. (Control ID #3875912)

CASE: 55-year-old man presented with new onset petechiae and mild gum bleeding. He denied any fever, joint pain, alcohol use and recent travel. Subsequent work up revealed pancytopenia (Leukocyte count

3000/microL, Hemoglobin 11 g/dL, Platelet 63,000/microL). Further work up including creatinine, LDH, haptoglobin, total protein, liver function tests, TSH, Iron studies, B12, folate, copper, PT/INR, PTT, fibrinogen, FDP and D dimers were within normal limit. Peripheral smear did not show any schistocytes, blasts or dysplastic cells. Serum protein electrophoresis with immunofixation was normal. Infective disease work up for viral infection including HIV, hepatitis and EBV were negative. Autoimmune work up including cryoglobulin, complement levels, ANA, ds-DNA, anti-smith Antibody, anti RNP, rheumatoid factor, Anti- CCP, C-ANCA and P-ANCA antibodies were negative. Peripheral blood flow cytometry was negative. CT chest abdomen pelvis was negative for any mass or lymph node with no evidence of liver disease or splenomegaly. No new medication was started recently. However, he had COVID-19 vaccine 2 weeks before. Review of complete blood count showed no abnormalities prior to receiving COVID-19 vaccine. Bone marrow biopsy confirmed a normal consumptive process consistent with reaction to medication or vaccine use and no evidence of any dysplasia. With patient’s consent, information was reported to the Vaccine Adverse Event Reporting System. He was started on a prednisone 1mg/kg with improvement of counts (WBC:5100/microL, Hemoglobin 13.2 g/DL, Platelet counts 130,000/microL) but as soon as dose was tapered to less than 40 mg/day, petechiae and pancytopenia worsened. Hence, he was transitioned to mycophenolate mofetil (MMF) and remains on MMF 500 mg twice daily which allowed the tapering and eventual discontinuation of prednisone. He continues to be on MMF and attempts to taper MMF has so far been unsuccessful.

IMPACT/DISCUSSION: Although cases of immune thrombocytopenic purpura has been reported with J&J vaccine³, pancytopenia has not been reported before. Given the temporal association with vaccination with no other causes identified and improvement of pancytopenia with immunosuppressive therapy, our case strongly suggests this rare association of pancytopenia with the vaccine. Previously Shastri et al reported pancytopenia after third dose of Pfizer vaccine with bone marrow suppression. Patient had presented with fever and fatigue requiring hospitalization which resolved with steroid use.⁴ It is postulated that COVID-19 vaccine triggers immune mediated response via anti-SARS-COV2 spike protein or SARS-COV2 recognizing T cells which can result in immune mediated cytopenias.⁵ More observation data will likely help us understand the rare side effects associated with vaccine.

CONCLUSION: Though its very rare, our case highlights the importance of considering COVID-19 vaccination as a rare cause of pancytopenia in the appropriate setting.

JUST CLAMP IT - DEMYSTIFYING DDAVP IN SEVERE HYPONATREMIA

Valerie Gobao¹; Hoda Kaldas²

¹Internal Medicine, UPMC, Pittsburgh, PA; ²Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #3874603)

CASE: A 61-year-old man with alcohol use disorder, poor nutrition, and chronic hyponatremia (baseline

125mEq/L) on sodium tablets presented with new falls and right sided weakness after four days of vomiting and diarrhea. He was not able to tolerate his sodium tablets. He continued to drink 7-10 beers a day. Vitals were stable. On exam, he was stuporous but responsive to noxious stimuli. Labs were notable for sodium of 98 mEq/L and potassium of 3.6 mEq/L. Serum osmolality was 210 mOsm/kg, urine osmolality was 385 mOsm/kg, and urine sodium was 31 mEq/L consistent with SIADH. Uric acid and AM cortisol were normal. Non-contrast CT head, CTA of the head and neck, and spot EEG were unremarkable. He was admitted to the ICU and started on continuous infusion of 3% hypertonic saline and 2mcg of Desmopressin (DDAVP) every 6 hours. Potassium was repleted carefully. Over the next 8 days, his sodium corrected at a rate no faster than 4 to 6 mEq/per 24 hours. An 800cc fluid restriction was added when the patient was able to swallow. The patient’s mental status and sodium improved to baseline.

IMPACT/DISCUSSION: Chronic severe hyponatremia is defined as serum sodium less than 120 mEq/L. It is important to correct sodium at a rate no more than 4-6mEq every 24 hours to prevent Osmotic Demyelination Syndrome (ODS) which results from brain cell death due to rapid intracellular fluid shifts. Identifying high risk patients is critical. Patients are at highest risk for ODS when serum sodium is less than 105meQ/L, or with features such as chronic alcohol use, poor nutrition, and hypokalemia. Rapid sodium correction with water diuresis occurs most often in SIADH, volume depletion, and adrenal insufficiency.

When patients are at high risk for rapid sodium correction and ODS, a proactive approach using DDAVP with hypertonic saline is a safe strategy to prevent overcorrection. DDAVP, known as” the clamp”, prevents rapid water diuresis and allows sodium to correct in a more controlled way. General internists may not be familiar with this approach. DDAVP is dosed at 1-2mcg every 6 to 8 hours until the sodium is greater than 125 mEq/L. It is given with continuous hypertonic saline starting at 0.25mL/kg/hour. This approach may be safer than hypertonic saline alone. This case is the perfect high-risk scenario to use the DDAVP clamp. The patient

had multiple risk factors for rapid sodium correction and ODS including volume depletion, initial sodium of 98 meQ/L, SIADH, chronic alcohol use, and poor nutrition. With this approach, his sodium corrected safely, avoiding neurologic damage.

CONCLUSION: Patients are at highest risk for ODS with sodium less than 105meQ/L, chronic alcohol use, poor nutrition, and hypokalemia. Rapid sodium correction is most common in the setting of SIADH, volume depletion, and adrenal insufficiency. In severe hyponatremia with high risk for ODS and rapid correction, the general internist can use the DDAVP clamp with hypertonic saline to start treatment while waiting for specialist assistance.

LATE PRESENTATION OF PSEUDOANEURYSM SECONDARY TO OCCULT HYPODERMIC NEEDLE

Alexander Levstik¹; Makeda Dawkins¹; Kira Murphy³; Ekramul Gofur²; Liana Tatarian⁴

¹Internal Medicine, Westchester Medical Center, Valhalla, NY; ²Radiology, Westchester Medical Center, Valhalla, NY; ³Surgery, Westchester Medical Center, Valhalla, NY; ⁴Internal Medicine, Westchester Medical Center Health Network, Valhalla, NY. (Control ID #3874781)

CASE: A 71-year-old man was transferred from an inpatient psychiatric unit for evaluation of bilateral lower extremity weakness. Past medical history included schizoaffective disorder, intravenous drug use, chronic kidney disease, cervical stenosis, and solid left upper extremity swelling previously attributed to hematoma complicated by cellulitis. Following unrevealing evaluation, including computed tomography myelogram and lumbar puncture, the patient had spontaneous return of lower extremity function, with initial presentation attributed to a functional movement disorder. Although his most acute concern resolved, the solid upper extremity mass first noted 2 months prior became pulsatile with a bruit. Given his extensive psychiatric history and active delusions, obtaining a reliable history was challenging. He denied trauma, pain, or upper extremity weakness, however his reporting was inconsistent, “that was where they injected acid,” and “they drew blood, and this is what happened". Ultrasound (US) doppler showed an anechoic space with a characteristic “yin yang sign” of swirling blood, consistent with pseudoaneurysm. X-ray (XR) revealed a retained 3.5cm hypodermic needle. The patient was emergently taken for surgical repair. Following recovery, the patient was discharged back to his inpatient psychiatric unit.

IMPACT/DISCUSSION: Pseudoaneurysms are known complications of trauma, including fractures and percutaneous interventions. The majority of pseudoaneurysms are asymptomatic. Intravenous drug users (IVDU) are at elevated risk of pseudoaneurysm formation due to repeated self-injection. IVDU are also at higher risk of complications, and may unknowingly inject near or through asymptomatic pseudoaneurysms resulting in rupture. Due to the proximity of the brachial artery to the median nerve, there is a risk of compressive neuropathy with brachial pseudoaneurysms. Careful neurovascular examination of the distal extremity should be part of a complete physical examination. Investigation of superficial pseudoaneurysms should include both US doppler, and XR, which has better utility than US to to rule out fracture and detect foreign bodies. Patients with altered mentation should be treated with particular care, given their reduced ability to report significant risk factors such as retained foreign bodies, increasing the importance of objective findings.

CONCLUSION: This case of an asymptomatic late brachial pseudoaneurysm in a vulnerable patient highlights the importance of thorough and serial physical examination, despite well described and previously treated findings. Investigations of superficial pulsatile masses should include US and XR.

LEFT VENTRICLE AIR EMBOLUS AND ACUTE CORONARY SYNDROME

Bibek Saha¹; Alex Danielson¹; Sara Inglis¹; Victoria Kalinoski-Dubose¹; Panithaya Chareonthaitawee²

¹Internal Medicine, Mayo Clinic, Rochester, MN; ²Cardiovascular Medicine, Mayo Clinic, Rochester, MN. (Control ID #3874107)

CASE: An 82-year-old male with a history significant for unresectable urothelial carcinoma with possible metastasis to the lungs and liver, COPD, complete heart block status post pacemaker presented to the hospital after an outpatient CT-guided pulmonary nodule biopsy was complicated by an air embolism (AE) in the left ventricle (LV). During the event, he was repositioned to avoid further embolization, given supplemental oxygen, and remained asymptomatic with a normal neurologic exam. Repeat imaging showed no residual air in the LV. On presentation at the hospital, the patient reported hematuria and chronic right-sided flank/back pain which had been present for 6 weeks without changes in severity. He denied fever, chills, cough, sore throat, confusion, visual changes, numbness, focal weakness, slurring, chest pain, nausea, emesis, and dyspnea.

On exam, he was afebrile (36.6°C), hypertensive (148/56mmHg), with a normal heart (74bpm) and respiratory rate (17breaths/min), with an oxygen saturation of 94%. He was in no acute distress, with normal mentation, and was not diaphoretic. Cardiopulmonary exam was overall normal.

Labs showed creatine at 1.65mg/dL (baseline: 1.6-1.7mg/dL). Troponin 5^th generation was 2010ng/L at baseline, 2 hours was 2045ng/L and 6 hours was 2182ng/L with a positive delta. EKG showed sinus rhythm but was difficult to interpret in the setting of the pacemaker. TTE showed an ejection fraction of 38% with regional wall motion abnormalities and no evidence of an intracardiac shunt. Previous TTE performed 12 years ago was normal.

Hyperbaric oxygen therapy was deferred given hemodynamic stability and no neurological symptoms, and the risk of barotrauma in the setting of COPD. Given the TTE findings and the large elevation in troponin in the absence of explicit evidence of myocarditis, acute kidney injury, and demand ischemia, the patient was thought to be having a Type 1 NSTEMI from AE migration into the coronary circulation. Due to his overall prognosis, the patient declined coronary angiogram. The patient passed away within one month of discharge.

IMPACT/DISCUSSION: AE is rare, but common causes include central venous catheter insertion/removal, trauma, barotrauma, and otolaryngology and neurosurgical procedures. Here we reported an uncommon case of LV AE complicating CT-guided lung biopsy and subsequent acute coronary syndrome (ACS). While the phenomenon of LV AE complicating CT-guided lung biopsy is rare by itself, to our knowledge, cases involving the development of subsequent ACS, such as ours, are even rarer. Indeed, in the cases where there are additional complications, they are typically stroke or cardiac arrest. However, we were unable to rule out obstructive CAD as the cause of the ACS.

CONCLUSION: 1. A rare complication of CT-guided lung biopsy is LV AE with possible migration into the coronary circulation causing ACS

2. If there are concerns for ACS after a recent CT-guided lung biopsy, AE should be in the differential preventing delayed management

LEMIERRE’S SYNDROME INVOLVING ACTINOMYCES ODONTOLYTICUS FROM INJECTION DRUG USE

Roohali Sukhavasi¹; Nina Gao³; Christopher Smith¹; Sarah A. Schmalzle^2,1

¹Infectious Disease, University of Maryland School of Medicine, Baltimore, MD; ²Center of Infectious Disease Ambulatory Practice, Institute of Human Virology, Baltimore, MD; ³Clinical Microbiology, University of Maryland School of Medicine, Baltimore, MD. (Control ID #3868771)

CASE: A 46 year-old man who injects drugs presented with right neck and groin swelling and pain following opioid injection. CT angiography revealed a thrombosed and inflamed internal jugular vein occlusion adjacent to a 4.7cm abscess. The abscess was incised and drained with penrose drain placement and twice- daily clindamycin irrigation. Cultures from the abscess grew primarily oral flora including Actinomyces odontolyticus, and blood cultures remained sterile. The patient symptomatically improved following linezolid and ceftriaxone initiation. Imaging on post-operative day 2 did not show reaccumulation of the abscess, presence of cerebral or pulmonary septic emboli, or extension of the thrombosis cranially or caudally; anticoagulation was not initiated. The patient eloped on post-operative day 4 with drain in place and returned 3 days later with worsening swelling and drainage. Oral linezolid was resumed, and he was discharged with a 2-week prescription, with final antibiotic duration to be determined at the scheduled follow-up, which he did not attend. He returned 3 weeks later for multi-limb swelling, but with resolution of the right neck abscess after completing his 2-week prescription.

IMPACT/DISCUSSION: Lemierre’s syndrome is a rare condition of septic thrombophlebitis occurring in the internal jugular vein that classically follows Fusobacterium necrophorum pharyngitis, which can be complicated by spread along the carotid sheath resulting in proximal and distal septic emboli. We present the first reported case of Lemierre’s syndrome involving the oral flora Actinomyces odontolyticus. This is a novel presentation of the oral bacterium A. odontolyticus cultured from an injection-drug-use associated abscess with adjacent septic thrombophlebitis. Actinomycosis typically begins as a para-pharyngeal or tonsillar infection that can progress to bacteremia in vulnerable populations with severe presentations of systemic soft-tissue abscesses. Instead of oropharyngeal outward extension or hematogenous spread, this case involved contiguous proximal spread from a neck abscess associated with injection drug use with licked needles. Notably, the patient’s thrombophlebitis resolved after an approximate 2-week course of linezolid, significantly shorter than the historical actinomycosis treatment standard of 6-12 months. Additionally, the patient presented atypically for Lemierre’s syndrome without septic emboli, presence of Fusobacterium sp., or bacteremia. In the last decade, a significant increase of Actinomyces spp. identification as the causative agent in extra-oropharyngeal infection has occurred, likely due to recent increased availability of MALDI- TOF mass spectrometry, which can identify difficult-to-culture bacteria.

CONCLUSION: As Actinomyces spp. are more readily identified in clinical specimens, further study of treatment duration will be needed. Additionally, recognition that pathogens other than Fusobacterium can result in internal jugular thrombosis is clinically notable.

LIFE-THREATENING WITHDRAWAL OF INTRATHECAL BACLOFEN PUMP

Brittany Toffey, Peggy B. Leung

Internal Medicine, Weill Cornell Medicine, New York, NY. (Control ID #3875970)

CASE: Patient is a 23-year-old man with cerebral palsy (Ax0 at baseline), with intrathecal baclofen pump (ITB) and epilepsy hospitalized for months with right-sided hip osteomyelitis s/p debridement now presenting with worsening tachycardia and hypertension in the hospital. He had 2 more days of meropenem for MDR pseudomonas and had finished his abx course of linezolid 2 days prior for MRSA in his wound. Patient started to become diaphoretic, tachycardic to 170’s (baseline 110’s), and hypertensive to 200’s/100’s (b/l 120/80). Given hemodynamic instability, full infectious work-up was resent, and linezolid was restarted. Pulm/crit and neuro were consulted. Neuro recommended IV benzos for agitation and felt sxs were unlikely to be from seizure. The next morning, the medicine team found the patient to have more prominent myoclonic movements in his bilateral upper and lower extremities. His baclofen pump was interrogated, found to be empty, and emergently refilled by the PMR team. His symptoms resolved quickly, and the patient returned to his baseline.

IMPACT/DISCUSSION: The patient’s worsening tachycardia and diaphoresis prompted a full infectious work-up, including further imaging of his osteomyelitis. His broad antibiotics were restarted empirically. Although infection should be on the differential, it is important to consider other etiologies and not anchor on a leading diagnosis based on past presentations. With hemodynamic instability especially tachycardia and hypertension, medication withdrawal and pump malfunction should be highly considered as the underlying etiology.

Intrathecal baclofen pumps help patients achieve better control of spasticity. Baclofen is a high-affinity GABA-B agonist. GABA is essential for modulating maintenance of thalamocortical rhythms, sensory and fine motor control, and epileptogenic neuronal discharges. Pump malfunction or failure to refill the pump may lead to life-threatening withdrawal. It occurs over 1-3 days and may become fulminant. Withdrawal presents like benzo/ETOH withdrawal with tachycardia, hypertension, diaphoresis, and myoclonus.

High dose benzos are lifesaving until baclofen pump can be restored. This patient had a prn valium ordered for agitation, which was a life-saving measure until it was determined that his baclofen pump was empty. It is imperative to educate patients, families, and healthcare professionals about symptoms of withdrawal and the necessity of having the pump refilled on time. Electronic medical records can be helpful in alerting physicians when the baclofen pump needs to be refilled to prevent reservoir depletion, especially when a patient is hospitalized during this refill due date.

CONCLUSION: 1.) Review full medication list and interrogate medical pumps in patients with episodes of hemodynamic instability of unclear etiology

2.) Inthrecal baclofen pump withdrawal can present with hypertension, tachycardia, diaphoresis, myoclonus; it should be treated with IV benzos until the pump can be refilled.

LISINOPRIL INDUCED UVULAR ANGIOEDEMA

Lydia Busey, Joshua Makepeace

Internal Medicine, UVA Health, Charlottesville, VA. (Control ID

#3873594)

CASE: A 75-year-old male with coronary artery disease and hypertension managed with lisinopril presented to the emergency department with chest pain; however, upon evaluation, he endorsed several hours of trouble swallowing, dysphonia, and intermittent upper airway obstruction. He denied shortness of breath, wheezing, rash, or GI symptoms. He reported similar events in the past which resolved spontaneously. Further history was remarkable for a biological son who also experienced similar symptoms in the setting of lisinopril therapy. Vital signs were within normal limits. On examination, uvular swelling and erythema were noted without edema of the remainder of the oropharynx, tongue, or lips. The patient was given methylprednisolone, epinephrine, diphenhydramine, and famotidine and admitted to the cardiac ICU for close monitoring. Labs were notable for a normal white blood cell count, eosinophil count, CRP, C4, and tryptase. The patient’s symptoms resolved within 36 hours of admission. Given the patient’s lack of systemic symptoms, unrevealing workup, time course, and history of lisinopril use, bradykinin-mediated angioedema due to ACE-inhibitor (ACEi) use was thought to be the most likely diagnosis.

IMPACT/DISCUSSION: Angioedema is a potentially life-threatening condition characterized by subcutaneous or submucosal edema that commonly affects the face, hands, feet, and genitalia. The incidence of angioedema in patients taking ACEi is low and can occur at any time during the treatment course. However; given the large number of patients taking ACEi, they have become the most common cause of angioedema. The present case adds to a small body of literature describing isolated uvular angioedema (Quincke’s disease), a rare form of angioedema isolated to the uvula. Given the potential for airway compromise, the initial history and physical exam is essential to differentiate between this and other etiologies of uvular swelling including infection, trauma, inhalational exposure, and hereditary angioedema, each of which may have a different approach to management. For ACEi-induced angioedema, management focuses on close monitoring for potential airway compromise and avoidance of causative medications. ACEi, angiotensin receptor-neprolysin inhibitors, and DPP4 inhibitors may all increase bradykinin levels, and consequently must be avoided in any patient who presents with suspected bradykinin-mediated angioedema.

CONCLUSION: - ACEi are the most common cause of angioedema, a life-threatening condition characterized by subcutaneous and submucosal edema that can lead to airway compromise.

- ACEi-induced angioedema can occur at any time during treatment, and does not need to be associated with initiation or escalation of therapy.

- Isolated uvular swelling is a rare cause of ACEi-induced angioedema, and must be differentiated from other etiologies for which management differs.

LISTEN TO YOUR HEART: A RARE CASE OF NON-NEUROGENIC ORTHOSTATIC HYPOTENSION

Matt Slief, Alonso I. Heudebert, Robert M. Centor

Internal Medicine, The University of Alabama at Birmingham, Birmingham, AL. (Control ID #3875398)

CASE: A 69 year old male with history of peripheral neuropathy due to alcohol use disorder (in remission), orthostatic hypotension (OH) presumed due to autonomic neuropathy, and deep vein thrombosis status post remote inferior vena cava (IVC) filter placement was evaluated for worsening severe lightheadedness upon standing of at least three year’s duration. The patient was profoundly orthostatic on initial examination: supine (127/79; heart rate (HR) 71), seated (119/79; HR 91), and standing (88/62; HR 94). His orthostasis proved refractory to a 2L normal saline volume challenge, compression stockings, and midodrine. His testing resulted negative for diabetes, adrenal insufficiency, and amyloidosis. Given his significant increase in heart rate upon standing, we searched for alternative non-neurogenic causes of OH, including IVC filter occlusion. Abdominal computed tomography with venous phase confirmed chronic IVC filter occlusion with numerous collaterals. Following IVC filter removal, the patient’s orthostatic intolerance resolved. His repeat vital signs confirmed significant improvement: supine (156/88; HR 74), seated (136/88; HR 80), and standing (128/77; HR 92).

IMPACT/DISCUSSION: The two pathophysiologic subtypes of OH are neurogenic and non-neurogenic. Neurogenic OH is caused by central or peripheral damage to the baro-reflex pathway leading to impaired compensatory peripheral and splanchnic vasoconstriction upon standing. Non-neurogenic OH is commonly caused by volume depletion or vasodilatory medications.

In contrast to neurogenic OH, non-neurogenic OH is characterized by a marked increase in HR. In terms of quantifying the expected HR response, a consensus expert panel endorsed a △HR > 15 beats per minute as supporting non-neurogenic OH. Further, a study comparing individuals with neurogenic OH to those with non-neurogenic OH found a △HR/△Systolic Blood Pressure (SBP) ratio above 0.492 discriminated between these etiologies with high sensitivity (91.3%) and specificity (88.4%). Our patient’s vital signs met both measures for non-neurogenic OH (△HR 23 and △HR/△SBP 0.59, respectively). Because our patient’s vital signs favored non-neurogenic OH and his orthostasis remained refractory to volume repletion, we postulated our patient’s primary driver for OH was insufficient venous return resulting from his IVC filter occlusion. Indeed, this represents a rare, novel complication of IVC filters. In addition to filter thrombosis, late IVC filter complications include filter migration and IVC perforation. Given these risks, it is imperative to limit IVC filter placement to cases of acute pulmonary embolus or deep vein thrombosis with concurrent absolute contraindication to anticoagulation. Furthermore, a clear retrieval plan should be documented at the time of placement.

CONCLUSION: Non-neurogenic OH may be distinguished from neurogenic OH by a robust compensatory increase in heart rate or utilizing the △HR/△SBP ratio

We present OH as a rare complication of IVC filters

LOW LEVELS MATTER – HYPOPHOSPHATASIA

Priya Velumani¹; Barath Rangaswamy²; Rahul Atodaria¹; Hema Kondakindi¹; Patrice Lamey¹

¹Internal Medicine, texas tech university of health sciences, Odessa, TX; ²internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX. (Control ID #3876440)

CASE: A 19 -year-old patient with a history of depression presented to the Endocrine office for evaluation of abnormal labs. Pt had dizziness and a fall recently which prompted his PCP to do lab work which revealed high calcium and low alkaline phosphatase. He was referred to Endocrine clinic for further work up. Apart from nonspecific bone pains in lower extremities, patient did not have any other symptoms. No history of fractures, kidney stones. Vitals and physical examination were essentially normal. No skeletal deformities or bony tenderness. ALP (Alkaline Phosphatase) was low at 25 IU/L and calcium was high 10.4 mg/dl. Repeat labs revealed ALP 20 IU/L with liver fraction 47%, bone fraction 53% and Calcium 10.6 mg/dl, PTH 12 pg/L, Phosphorous 3.8 mg/dl, 25 OH vitamin D 39.9 ng/ml. Thyroid function tests were normal. Pyridoxal 5’ Phosphate ( PLP) was high at 490 nmol/L. DEXA showed low Z score at left hip -2.0. ALPL genetic testing revealed pathogenic variants in ALPL gene (c881A>C; p. Asp294Ala), autosomal recessive, most likely a carrier. With persistently low serum ALP activity, high PLP, and the genetic mutation in the ALPL gene, we diagnosed the patient with HPP ( Hypophosphatasia)

IMPACT/DISCUSSION: HPP is a rare and unique inherited disorder of bone and mineral metabolism, caused by mutations in the ALPL gene, encoding the tissue-nonspecific isoenzyme of ALP (TNSALP) causing decreased ALP activity. Pauci symptomatic HPP presents with little or no clinical expression. Diagnostic clues are low serum ALP and increased levels of ALP substrates including PLP. Genetic testing for ALPL pathogenic variants is essential to confirm the diagnosis. Until now there is no curative treatment for HPP. Symptomatic treatment involves a multidisciplinary team including endocrinologists, dentists , orthopedists, medical geneticist etc. A very recent 5-year study on adults and adolescents with pediatric-onset HPP concluded that enzyme replacement therapy using Asfotase alfa is associated with normalization of circulating TNSALP substrate levels and improved functional abilities.

CONCLUSION: There is a perceived low importance and awareness among clinicians associated with the low serum ALP in contrast to high levels for a work up towards diagnosis. Adult HPP is often diagnosed after middle age. It is often underdiagnosed or misdiagnosed for years. We report a case of HPP diagnosed in early adulthood by pursuing incidental abnormal ALP. This case demonstrated how important it is to have a curious approach to abnormal commonly tested biochemical lab work in primary care practice. Increased awareness of this rare disease and early diagnosis can help decrease morbidity associated with this.

LUNG METASTASIS 30 YEARS AFTER INITIAL DIAGNOSIS OF OSTEOSARCOMA

Ali Hamza Khair¹; Jaanki Khandelwal⁶; Roman Karkee³; Muhammad Waqar Sharif³; Joud Enabi⁴; Aimen Asim Dar²; Kelash Bajaj⁵

¹Internal Medicine, Texas Tech University Health Sciences Center, Odessa, TX, US, Odessa, TX; ²Research, Texas Tech University Health Sciences Center Permian Basin Campus, Odessa, TX; ³Internal Medicine, Texas Tech University Health Sciences Center, Permian Basin, Odessa, TX; ⁴Internal Medicine, Texas Tech University Health Sciences Center Odessa Library, Odessa, TX; ⁵Oncology, West Texas Oncology, Odessa, TX; ⁶Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX. (Control ID #3875162)

CASE: A 53-year-old male with history of left below knee amputation secondary to osteosarcoma at the age of 23 presented with complaints of new onset cough. He had just returned from a trip to Boston where he developed allergy-like symptoms. He was seen at an urgent care clinic and was treated symptomatically with minimal improvement. He then saw his PCP and received montelukast and promethazine, but symptoms persisted. In the office, he reported exertional dyspnea, as well as orthopnea. On physical exam, he had decreased breath sounds and egophony noted over the right lung. Baseline labs were unremarkable. X-ray of the chest revealed complete white out of the right lung with slight tracheal deviation towards the left. CT scan confirmed the presence of massive right sided pleural effusion, with right middle lobe mass and atelectasis of the ipsilateral lung. CT-guided biopsy of the mass revealed high grade sarcoma with cartilaginous differentiation, suggestive of recurrence of osteosarcoma. Abdominopelvic CT did not identify any extra pulmonary metastases. Genetic testing for Li-Fraumeni syndrome was negative. Chemotherapy with MAP regimen (methotrexate, cisplatin and doxorubicin) was initiated. Following chemotherapy, patient is now in remission.

IMPACT/DISCUSSION: Despite therapeutic advances, 30%-50% of osteosarcoma patients with no metastasis at time of diagnosis will develop recurrence. Recurrence is most common within 2-3 years of treatment and the lung serves as the most common site of metastasis. The most common mode of metastasis of osteosarcoma is micrometastasis in the lungs. Late relapse is defined as local or metastatic recurrence ≥5 years after initial treatment. Rates of late relapse vary by osteosarcoma grade. Incidence rate of late relapse in low-grade osteosarcoma is about 5.5%-30%. Late relapse of high-grade osteosarcoma only occurs in

0.6%-2.9%.

Very late relapse, defined as recurrence ≥10 years after initial treatment is extremely rare and incidence rate is reported to be as low as 0%-0.4%. During our literature review, we encountered only 17 cases of very late relapse. Of those, only 4 patients developed relapse >20 years after initial treatment, and all cases presented with pulmonary metastasis as the site of relapse. The longest relapse free interval ever reported was published in a recent case report in 2020, which was 38 years after the initial diagnosis. Prior to that, the longest reported relapse free interval was 27 years. This case therefore describes the second longest disease-free interval of osteosarcoma in the literature and serves as an important reminder to clinicians to maintain very late relapse in the differential for any patient presenting with unexplained pulmonary symptoms, regardless of time elapsed since their initial osteosarcoma diagnosis.

CONCLUSION: Pulmonary metastasis is the most common site of osteosarcoma recurrence. It may be easily missed, as the frequently encountered complaint of refractory cough may be the only initial symptom.

LUPUS VERSUS SYPHILIS: WHO IS THE REAL “GREAT IMITATOR”?

Nicole Curtis, Cindy Traboulsi, Michael Simonson

Department of Medicine, UPMC Presbyterian-Shadyside, Pittsburgh, PA. (Control ID #3873907)

CASE: A 36-year-old woman with systemic lupus erythematous (SLE) and lupus nephritis presented with subacute myalgias, headache, and painless non-pruritic rash. Her home medications were hydroxychloroquine, prednisone, and mycophenolate mofetil. She did not smoke or use drugs. She reported one new sexual partner one month prior to admission. On exam, she had normal vital signs. A diffuse maculopapular rash was seen on the torso and extremities, involving the bilateral palms and soles, but sparing the face. No genital lesions were seen. Labs showed a creatinine of 3.9mg/dL (baseline 3), WBC 5.2cells/uL, CRP 1.9mg/dL, and normal C3 and C4. Flu/RSV/Covid were negative. Anti-chromatin and ds-DNA were normal. HIV, coxsackie antibody, and blood cultures were negative. Syphilis IgG/IgM was positive and RPR was reactive (titer 1:8). She was diagnosed with secondary syphilis and was treated with intramuscular benzathine penicillin G. Six hours after treatment, she experienced subjective fevers, nausea, myalgias, and headache which resolved with supportive care. She was discharged with plans to repeat a RPR in 6 months.

IMPACT/DISCUSSION: Here, a patient with SLE presented with diffuse rash and myalgias and was diagnosed with secondary syphilis. Both lupus flares and syphilis can present with constitutional symptoms (fever, headache, myalgias, rash, malaise), alopecia, neurologic symptoms, positive RPR, and nephritic or nephrotic syndrome. It is also possible to have both conditions during the same presentation.

In patients with SLE, identification and treatment of disease flares is important to decrease the risk of significant end-organ damage. The SLE Disease Activity Index (SLEDAI) and associated Flare Index (SFI) can be used to classify lupus flares, consisting of 24 variables across nine organ systems. In this case, myalgias, low-grade fever, rash, AKI, and elevated CRP supported a lupus flare. However, improvement of renal function with fluids, normal ds-DNA, and normal C3/C4 made a lupus flare less likely and required broadening of the differential.

Syphilis is a known cause of palmoplantar rash. Both treponemal and non-treponemal testing is required to confirm the diagnosis of syphilis in SLE patients as 30% can have positive lupus-anticoagulant causing a false positive RPR. In this case, both tests were performed and the diagnosis of secondary syphilis was confirmed.

The Jarisch-Herxheimer reaction can occur when treating syphilis and includes fevers, chills, flushing, headache, myalgias, and worsening of skin lesions. This reaction is caused by the release of Treponema pallidum lipoproteins after antibiotic treatment, thereby stimulating inflammatory cytokines, including tumor necrosis alpha and various interleukins. It is important to be aware of the signs and symptoms to provide proper supportive therapy.

CONCLUSION: This case highlights similarities between lupus and syphilis as well as emphasizes the importance of a broad differential when patients present with vague symptoms.

LYME PERICARDITIS: A POTENTIALLY UNDERRECOGNIZED CAUSE OF PERICARDITIS IN LYME ENDEMIC AREAS

Alyse Reichheld²; Genesis Perez-Melara¹; Benjamin Mecsas-Faxon²; Jonathan Crocker²; Laura Desrochers²

¹Harvard Medical School, Boston, MA; ²Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #3873471)

CASE: A 52-year-old man with hypertension presented with 3 months fatigue; drenching night sweats, chills that began 2 months ago, and 1 month pleuritic chest pain and dyspnea. He denied headache, rash, arthralgias, recent respiratory illness, cough or neurologic symptoms. He worked as a librarian in Boston, MA and had no recent travel. He took only lisinopril, and family history was positive for rheumatoid arthritis. Exam showed JVP 10 cm, bibasilar crackles, and right upper quadrant tenderness without organomegaly. Blood work showed leukocytosis, mild transaminitis, and C-reactive protein above assay. ECG showed low voltage sinus tachycardia with nonspecific T-wave abnormalities. CT chest revealed mediastinal lymphadenopathy and splenic hypodensities. Transthoracic echocardiography showed pericardial thickening, moderate pericardial effusion without tamponade, and normal valves. Colchicine and ibuprofen were given for presumed idiopathic pericarditis with initial improvement. Pericardial fluid was not sampled. Fever to 102F briefly returned for two days, and the night sweats improved over twelve days of hospitalization. Extensive workup for infectious, inflammatory, autoimmune, and malignant etiologies of pericarditis revealed only a positive test for IgG/IgM to B. burgdorferi. Lyme specific treatment was withheld pending Lyme Western blot results. He was discharged with plan for chest PET-CT following discharge. Lyme Western blot showed 9/10 IgG bands and 3/3 IgM bands, and a predominant IgM>IgG A. phagocytophilum pattern was seen, suggesting tick borne illness with acute coinfection of Lyme and Anaplasma, with Lyme pericarditis. Doxycycline was administered for 3 weeks. Repeat echocardiogram showed trace pericardial effusion. All symptoms and lab abnormalities resolved.

IMPACT/DISCUSSION: Lyme disease is the most common vector-borne disease in the United States. Carditis develops in 1.5-10% of U.S. infections, most frequently manifesting with conduction abnormalities.

Lyme pericarditis is even rarer, occurring in 2-5% of Lyme carditis cases (i.e., 0.04% to 0.5% of all cases). Other uncommon cardiac manifestations include coronary aneurysms, congestive heart failure, endocarditis, myocarditis, and valvular disease. Borrelia spp. may have a tropism for cardiac tissue resulting in direct invasion of the myocardium by the spirochete and an exaggerated macrophagic and lymphocytic response.

CONCLUSION: Lyme infection should be considered in the differential diagnosis of pericarditis in Lyme endemic regions when the etiology of pericarditis is unclear, even in the absence of other cardiac conduction abnormalities or in patients without known exposure or other classic Lyme symptoms.

LYMPHOMA PRESENTING AS ACQUIRED ANGIOEDMA

Murali K. Duggirala

Internal Medicine, Mayo Clinic, Rochester, MN. (Control ID #3867639)

CASE: Patient is a 45-year-old man with no significant past health history, presented with a history of episodic scrotal and feet edema. These typically start as a swelling on the top of feet and gradually extend to involve the entire foot and have been occurring spontaneously every other month for the last 2.5 years, each lasting a day or two. He also complained of episodes of vague attacks of upper epigastric and retrosternal discomfort. He denies any rash, urticaria, swollen lips, tongue, or a sensation of throat closing. He has visited with primary care physicians, emergency rooms and received Epinephrine, Benadryl, Prednisone without any improvement. He took no medications and had no family history of angioedema.

Initial evaluation showed a white count of 10.5 (3.4-9.6x10⁹), lymphocyte count 5.21 (0.95 - 3.07x10⁹), serum protein electrophoresis showed small abnormality in gamma fraction. Lymphoma/leukemia phenotyping showed CD5 positive B cell Lymphoproliferative disorder. Complement 4 level was undetectable <3 (14-40mg/dL), C1 esterase inhibitor (C1INH) antigen was low 4 (19-37 mg/dL), C1 INH function was also low at 30%; C1q level was low at 7 (12-22mg/dL). He was diagnosed to have acquired angioedema, likely from an underlying lymphoma. Bone marrow biopsy showed low grade B cell lymphoma involving approximately 20% of marrow cellularity. Treatment with Rituximab was initiated and after 3-months of treatment; a repeat bone marrow biopsy was normal and patient also remains symptom free. He was prescribed Icatiband for treatment of acute angioedema attacks.

IMPACT/DISCUSSION: Hereditary angioedema (HAE) and acquired angioedema (AAE) present as recurrent episodes of swelling of lips, tongue, airways, limbs, genitals or gastrointestinal tract. HAE (autosomal dominant) typically presents in childhood and has positive family history, whereas AAE often presents in later years. Our patient was 45 years old with no family history, who presented with episodes of angioedema. The abdominal pain episodes are likely a manifestation of mucosal edema of gastrointestinal tract. HAE/AAE do not respond to Epinephrine, Antihistamines or Prednisone during acute episodes, as noted in our patient. AAE can have an underlying MGUS or lymphoma. In our patient, a mild lymphocytosis was tipoff for an underlying lymphoproliferative disease. Absent C4 level, and low C1 INH and low C1q suggested the diagnosis of AAE and bone marrow biopsy confirmed lymphoma.

CONCLUSION: ● Patients AAE do not have family history and tend to present in later years.

● C4 and C1 esterase inhibitor levels and function are decreased in both HAE and AAE. C1q level is decreased in AAE and normal in HAE.

● Patients (HAE or AAE) do not respond to Epinephrine, Antihistamines or Prednisone during acute treatment. Acute episodes are treated with IV purified or recombinant C1 esterase inhibitor (Berinert or Ruconest), Sq kallikrein inhibitor ecallantide (Kalbotor), bradykinin B2 receptor antagonist Icatibant (Firazyr).

MALAKOPLAKIA OF THE SMALL INTESTINE: A CANCER MIMICKER

Nazar Akhverdyan¹; Marina Mutter²

¹School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ²Medicine, University of Colorado, Denver, CO. (Control ID #3875352)

CASE: A 74-year-old Laotian female with a history of hypertension, type 2 diabetes mellitus (A1C 6.0%), and Hurthle cell carcinoma status post thyroidectomy in 2008 with presumed pulmonary recurrence on surveillance presented with several months of unintentional weight loss and a painful right lower quadrant mass. Exam was notable for an indurated mass with surrounding warmth and erythema. Laboratory studies included WBC 16.2 x 10⁹/L with 92% neutrophils. MRI pelvis demonstrated an 8.7 x 7.3 x 8.3 cm right lower quadrant mass abutting the right iliopsoas musculature and a superficial fluid collection with a cutaneous fistula. Due to initial concern for malignancy, a biopsy was obtained at an outside hospital that demonstrated confluent sheets of histiocytes (von Hanseman cells) with eosinophilic cytoplasm and intracytoplasmic basophilic inclusions (Michaelis-Gutmann bodies), consistent with malakoplakia. She was transferred to our hospital for a second pathologic opinion as well as surgical and ID consultations; the diagnosis of malakoplakia was confirmed by a review of the pathologic specimens. Subsequent cultures of the abscess grew Escherichia coli, Proteus mirabilis, Bacteroides fragilis, and Candida glabrata. The patient was treated with an extended course of amoxicillin-clavulanate and fluconazole with clinical improvement. On exploratory laparotomy one month later, the mass invaded the terminal ileum and was resected with en- bloc ileocecectomy, right oophorectomy, and right ureteral stent placement.

IMPACT/DISCUSSION: Malakoplakia is a rare chronic granulomatous disease caused by defects in macrophage bactericidal function that leads to impaired digestion of phagocytized microorganisms. It frequently presents in immunocompromised patients with HIV/AIDS, organ transplantation, malignancy, poorly controlled diabetes, and autoimmune disorders. This condition preferentially effects the urinary and gastrointestinal tracts with clinical manifestations ranging from irritative urinary symptoms to cutaneous lesions. We report a case of malakoplakia presenting as an abdominal mass with extensive pelvic and intestinal involvement complicated by a polymicrobial abscess and cutaneous fistula.

The nonspecific presentation of malakoplakia poses a diagnostic challenge. This patient’s radiographic findings and unintentional weight loss were initially concerning for malignancy. Thus, lack of familiarity with this condition can delay diagnosis and treatment. Pathognomonic histopathologic features include von Hansemann cells and Michaelis-Gutmann bodies. Treatment involves antibiotics and surgical excision. This example also illustrates the multidisciplinary management of malakoplakia, in this case necessitating close collaboration between pathology, infectious disease, general surgery, urology, and gynecologic oncology.

CONCLUSION: Clinicians should consider malakoplakia in patients with an abdominal mass concerning for a neoplastic process, especially in those who are immunocompromised.

MANAGEMENT OF CARNITINE PALMITOYLTRANSFERASE 1A DEFICIENCY: INPATIENT MANAGEMENT OF KNOWN CPT1 DEFICIENCY WITH ACTIVE COVID-19 INFECTION Sadman Zaman, Neil Gerts, Jeong Hwan Kim, Liana Nikoghosyan, Jasprit Takher

Internal Medicine, Los Robles Regional Medical Center, Thousand Oaks, CA. (Control ID #3873375)

CASE: Background: Carnitine Palmitoyltransferase 1A Deficiency (CPT1D) is a rare metabolic disorder that causes the body to lose its ability to oxidize long-chain fatty acids during periods of fasting. During periods of stress such as viral illnesses, CPT1D can be exacerbated with symptoms including hypoglycemia, transaminitis, hyperammonemia, elevated carnitine, and hepatic failure, all leading to increased risk of death. Here we report one of the first documented cases of SARS-CoV-2 in a patient with CPT1D.

Case Report: A 25-year-old female with a history of CPT1D presented with a chief complaint of cough for the past two weeks which was not responsive to over-the-counter cough suppressants. The patient denied any other symptoms. Significant labs on admission were Aspartate transaminase 188, Alanine transaminase 138, alkaline phosphatase 118, and glucose of 141. The patient also had an elevated ammonia level of 137, and found to be COVID-19 positive. Her chest x-ray was negative for any acute pathology. She was diagnosed with CPT1D at a young age when she developed right upper quadrant swelling. Since her diagnosis, she has been followed by a geneticist, and has been on medium-chain triglyceride (MCT) oil. Given that CPT1D can be worsened during viral illnesses, the patient’s geneticist recommended to begin Dextrose 10% (D10W) with normal saline at 100 cc/hr to prevent hypoglycemia. Blood glucose was checked every four hours, she was given 25 mg of MCT oil while inpatient, a hypoglycemia protocol was put in place, and oral intake was encouraged.

Throughout her hospital course, the patient was continued on D10W, but was noted to experience episodes where her blood sugar would decrease to the low 100s. The original ammonia level of 137 and the transaminitis both downtrend. After receiving the MCT oil, the patient’s blood glucose and ammonia level normalized and she was determined to be stable for discharge.

IMPACT/DISCUSSION: Only about fifty known cases of CPT1D have been documented. The disease is transmitted in an autosomal recessive pattern of inheritance. Symptoms are often exacerbated by periods of fasting or by a concurrent infection, which was COVID-19 in this case. Based on our research, this is the first confirmed case of treatment of CPT1D in a patient with active COVID-19 infection. In fact, due to the rarity of this disease, this presentation is one of few cases of documented admissions of a patient with CPT1D. Patients with CPT1D have an increased mortality risk and risk of acute decompensation during viral infections and patients can present with worsening hypoglycemia, liver function tests, and ammonia levels. As a result, it is recommended to provide patients with supplemental glucose and MCT oil.

CONCLUSION: CPT deficiency can be exacerbated by bacterial or viral infections. With increased cases of COVID-19 it is important for clinicians to be aware of CPT1 treatment, and management in the setting of COVID-19.

MANAGEMENT OF ECTOPIC VARICES DUE TO SPLENIC VEIN THROMBOSIS IN THE SETTING OF ALCOHOL USE

Jasdeep Bathla^1,2; Anirudh R. Damughatla^1,2; Mohammad Chaudhry^1,2; Jared Goldberg^1,2

¹Internal Medicine, Detroit Medical Center, Detroit, MI; ²Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #3875491)

CASE: A 34-year-old male with history of alcohol use disorder, delirium tremens, chronic atrophic pancreatitis, and pancreatic pseudocyst presented for hematemesis that lasted an hour. He required 4 units of packed red blood cell transfusion before esophagogastroduodenoscopy (EGD). EGD showed edematous gastric mucosa with moderate blood, gastric varices, and a large, bulging duodenal varix that had all thrombosed. A CT abdomen showed a chronic splenic vein thrombosis, a partial, non-occluding chronic thrombus involving the superior mesenteric vein, and hepatic congestion. Liver ultrasound showed patent portal vein with many varices in the porta hepatis and patent hepatic veins without hepatofugal blood flow or cirrhosis. Of note, there was also portal vein thrombosis with redemonstration of large pancreaticoduodenal varix leading to the left renal vein. He was started on low-dose carvedilol twice daily and proton-pump inhibitor, but no anticoagulation given high bleed risk. Due to staffing issues, he was referred for outpatient portal venography, percutaneous liver biopsy, and possible portal vein stenting or balloon-occluded retrograde transvenous obliteration for large portosystemic varices.

A week later, he was acutely intoxicated and presented again for hematemesis. After hemodynamic stabilization, he underwent portal venography with visualization of the varices, uncomplicated coil embolization of duodenal varix, and portal venous pressure was measured at 24 mmHg with new evidence of hepatofugal flow. Random liver biopsy showed extensive fibrosis with nodule formation consistent with cirrhosis. He was given the HiB, Prevnar, meningococcal, and group B vaccines with planned outpatient evaluation of possible splenectomy or transjugular intrahepatic portosystemic shunt (TIPS).

IMPACT/DISCUSSION: Duodenal varices represent a subset of the portosystemic collateral pathway known as ectopic varices due to their atypical location away from the gastroesophageal junction. Like normal varices, they can be caused by portal hypertension such as from cirrhosis and, less commonly, from extrahepatic portal hypertension in the form of splanchnic venous occlusion. In our patient, there was most likely a component of both etiologies, given cirrhotic findings on biopsy and previously identified splenic and portal vein thrombosis. Management is complex as EGD banding confers a high morbidity and mortality rate with ectopic varices. Portal vein thrombosis had previously been a contraindication to TIPS, however, improvements in technological guidance have removed this barrier. Ultimately, given splenic vein occlusion, splenectomy is considered a curative measure.

CONCLUSION: Albeit a rare presentation of hematemesis, ectopic varices are a challenge due to their atypical locations and complex management requiring a multidisciplinary approach. Treatment revolves around hemodynamic stabilization, hemostasis of bleeding, and addressing underlying etiologies of variceal development.

MANDIBULAR OSTEOMYELITIS IN A PATIENT WITH SICKLE CELL DISEASE

Asma Bahrami¹; Alec Rezigh²

¹Internal Medicine, Baylor College of Medicine, Houston, TX; ²General Internal Medicine, Baylor College of Medicine, Houston, TX. (Control ID #3869010)

CASE: A 19-year-old man with sickle cell disease presented with left jaw swelling. Two weeks prior to admission, he developed bilateral jaw pain and trismus. Formal dentistry evaluation revealed no abnormalities. He was referred to oral surgery and diagnosed with bilateral masticator myositis. Conservative therapy was ineffective. On the day of presentation, he awoke with new left jaw swelling and worsening pain. He had no fever, chills, dyspnea, or tooth pain. He had a normal temperature, blood pressure, and respiratory rate. His heart rate was 105 beats per minute. Examination revealed significant left facial swelling with tenderness to palpation along the left mandible without palpable fluctuance.

Labs were notable for leukocytosis and acute on chronic hemolytic anemia. He developed a fever after admission. Blood cultures were drawn and empiric antibiotics initiated. Intravenous fluids and transfusion support were given. Computed tomography of the neck with contrast demonstrated inflammation of the soft tissue overlying the left mandible suggestive of subperiosteal abscesses and concurrent bone infarction or osteomyelitis. The teeth and periapical areas were normal. Interventional radiology was consulted and drained the fluid collection. The wound and blood cultures grew streptococcus intermedius. He improved with antibiotic therapy.

IMPACT/DISCUSSION: Sickle cell disease can have several bony complications, including vaso-occlusive pain or crisis, bone infarction, osteomyelitis, osteopenia, osteoporosis, and hyperplasia. Vaso-occlusive crisis occurs along a spectrum and is associated with ischemia and infarction due to disruption of the vasculature. Ischemia is more common in long bones and vertebral bodies, but can occur in facial bones. Osteomyelitis is an inflammatory and infectious disease of the bone. Predisposing factors include disruption to the blood supply. Persistent ischemia can cause osteonecrosis and increases the risk of infection. When evaluating facial or jaw swelling, it is important to first exclude odontogenic disease. Evaluation for infarction and/or osteomyelitis can then be pursued. Bacteria can invade via direct extension or hematogenous spread, but many infarcts remain sterile. It is difficult to distinguish sickle cell related infarction from infection given overlapping symptoms (fever, erythema, edema) and nonspecific imaging and laboratory signs of inflammation.

In this case, the patient was experiencing vaso-occlusive pain and ischemia in his jaw in the setting of an acute exacerbation of his sickle cell disease. This predisposed the patient to secondary infection, ultimately leading to osteomyelitis with concurrent sepsis and bacteremia. It is important to recognize the potential complications of sickle cell disease and to start treatment early.

CONCLUSION: Vaso-occlusive disease and ischemia can occur in essentially any bone. Early recognition and treatment of vaso-occlusive disease can prevent infarction and subsequent infection.

MASSIVE LEFT VENTRICULAR PSEUDOANEURYSM FORMATION FIVE MONTHS AFTER LEFT HEART CATHETERIZATION: THE CONUNDRUM OF COMPLEX AND CHRONIC TOTAL CORONARY OCCLUSIONS

Hannah Milad¹; Hussein Gaith²; Jonathan Zimmerman²

¹School of Medicine, Wayne State University School of Medicine, Detroit, MI; ²Beaumont Hospital Dearborn, Dearborn, MI. (Control ID #3875239)

CASE: A 42-year-old man presented with severe chest pain and shortness of breath; in addition to distant heart sounds, bilateral lung crackles, troponin I of 0.72 ng/mL, new ST depressions in leads V2 and V3, and massive cardiomegaly on chest x-ray, he was diaphoretic, tachycardic, and hypoxic with skin mottling. Five months prior, the patient presented with atypical chest pressure accompanied by a small increase in troponin I (1.05 ng/mL); he subsequently underwent angioplasty and stent placement to a 100% occluded left circumflex (LCX) artery. After an initial improvement in symptoms, he reported a gradual progression of shortness of breath until his current presentation. Within hours, he developed respiratory failure, was intubated, and underwent a second left heart catheterization; his coronary arteries and previously-placed stents were patent, however, an intra-procedural echocardiogram demonstrated a massive left anterolateral wall pseudoaneurysm - three times the size of the left ventricular lumen - and an ejection fraction <10%.

IMPACT/DISCUSSION: Ventricular pseudoaneurysms are a known complication of acute myocardial infarctions. However, we speculate our patient’s pseudoaneurysm formed as an iatrogenic complication of his initial catheterization: the gradual formation of a myocardial hematoma led to myocardial necrosis and, eventually, a contained free wall rupture. Several features of our patient's original LCX thrombus hinted towards risky intervention including the site location, length of occlusion, presence of calcifications, and evidence of both acute and chronic processes at play.

CONCLUSION: Our case is emblematic of cardiology’s nascent understanding of how to identify risky cardiac catheterizations – in particular, those complicated by “chronic total occlusions" (CTOs) - and when to implement appropriate follow-up strategies. Having reviewed the literature, we now understand our patient’s return of symptoms weeks after his initial angioplasty and stent placement merited follow-up imaging and/or labs, which may have allowed for earlier discovery and treatment of his pseudoaneurysm.

MAYHEM BY METRONIDAZOLE: AN UNEXPECTED CAUSE OF ENCEPHALOPATHY AND CNS LESIONS ON MRI

Matthew N. Metzinger¹; Ann E. Perrin²

¹Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ²Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #3876935)

CASE: A 61-year-old male with type 2 diabetes mellitus, chronic osteomyelitis, peripheral vascular disease and nonischemic cardiomyopathy develops new-onset encephalopathy and decreased upper extremity motor strength on hospital day 52. He initially presented with neck pain and was septic with a cervical epidural abscess secondary to an infected right diabetic foot wound. He underwent cervical decompression, abscess drainage and right below the knee amputation. He received daptomycin and metronidazole but had recurrence of his upper extremity weakness on day 28, necessitating return to the OR for repeat decompression of the cervical abscess. He then was placed on vancomycin, ceftriaxone and metronidazole and had improvement in his upper extremity strength. Surveillance imaging on day 42 showed resolution of the cervical abscess and his antimicrobial regimen was transitioned to trimethoprim-sulfamethoxazole and metronidazole. On day 52, the patient developed encephalopathy, upper extremity weakness and hypophonia. Due to concern for recurrence of his cervical abscess, despite no fever or leukocytosis, repeat MRI of the brain and spinal cord showed high-grade spinal canal stenosis at C4-C5. He went back to the OR with neurosurgery and had scar tissue and a small ventral epidural phlegmon removed, the cultures of which were negative. It was thought his dysarthria and encephalopathy were due to the prolonged course of metronidazole, with the scar tissue and phlegmon leading to the upper extremity weakness. Metronidazole was stopped and while his encephalopathy resolved, his upper extremity weakness only minimally improved.

IMPACT/DISCUSSION: Metronidazole is a commonly prescribed antibiotic with activity against anaerobic bacteria and parasites. While it is generally well-tolerated, its side effect profile most commonly includes nausea, vaginitis, headache and the disulfiram-like reaction if taken with alcohol. Neurologic adverse effects from metronidazole are less well-known and their incidence is more common after prolonged exposure to and/or being treated with higher doses of metronidazole and in patients with concomitant liver or renal disease. Symptoms of metronidazole-induced CNS toxicity include dysarthria, gait instability, limb discoordination, encephalopathy and polyneuropathy. On T2/FLAIR MRI, patients commonly have symmetrical hyperintense lesions in the dentate nuclei, corpus callosum and the brainstem. Discontinuation of metronidazole leads to improvement in the MRI findings and most symptoms in patients with metronidazole-induced neurotoxicity, although peripheral neuropathy often persists.

CONCLUSION: In patients receiving metronidazole, metronidazole-induced neurotoxicity should be on the differential when evaluating acute-onset cerebellar dysfunction, encephalopathy, polyneuropathy or dysarthria. As the mechanism of this neurotoxicity is unclear, treatment remains discontinuation of metronidazole with near complete symptom and imaging improvement seen in most patients.

MEDICAL DECISION MAKING REGARDING UTILIZING DUAL ANTIPLATELET THERAPY IN PATIENTS WITH IMMUNE THROMBOCYTOPENIA

Sanath S. Shetty¹; Rohan Umrani²; Ritu Doijad³

¹Internal Medicine, Jefferson Health - New Jersey, Voorhees, NJ; ²Internal Medicine, Rowan University School of Osteopathic Medicine, Stratford, NJ; ³Henry J Austin Health Center Inc, Trenton, NJ. (Control ID #3877024)

CASE: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor antagonist is indicated for acute coronary syndrome, percutaneous intervention, and secondary stroke prevention. Despite its proven benefit in vascular diseases, research is limited in its use in patients with thrombocytopenia. We are presenting a clinically challenging case where patient requiring DAPT therapy is severely thrombocytopenic.

A 52 year old female with a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus was admitted for an non-ST-elevation myocardial infarction (NSTEMI) requiring a stent to the ostial right coronary artery (RCA). Dual antiplatelet therapy was initiated with ticagrelor and aspirin. Prior to initiating this therapy, she had mild thrombocytopenia with platelets of 136,000 per microliter. Within 2 months of DAPT therapy, she developed progressive thrombocytopenia. She was readmitted 5 months later for chest pain and found to have another NSTEMI due to in-stent restenosis with neointimal hyperplasia. She was referred for left heart catheterization receiving another drug eluting stent to Ostial RCA given intimal hyperplasia and recommended to continue dual antiplatelet therapy for an additional year. At this time, her platelets were noted to be 58,000 per microliter. Given her severity of thrombocytopenia after starting DAPT, she was referred to a hematologist. 1 year following initial coronary stent placement, she was found to have platelet levels of 8,000 per microliter. Her thrombocytopenia workup at that time was negative. Peripheral smear did not show evidence of clumping suggestive of pseudothrombocytopenia. Findings were consistent with immune thrombocytopenia.

IMPACT/DISCUSSION: A multidisciplinary decision was made between cardiologist and hematologist to stop ticagrelor due to bleeding risk and continue with aspirin monotherapy. Stopping ticagrelor required thorough discussion of risks and benefits with patient as she was 6 months from her last coronary stenting procedure. She was also initiated on dexamethasone 40 mg PO for 4 days. Upon completing steroid therapy and stopping ticagrelor, her repeat platelet level increased to 103,000 per microliter. Her ticagrelor was discontinued indefinitely, but she is kept under close supervision of hematology and cardiology.

CONCLUSION: DAPT is reasonable in patients with immune thrombocytopenia whose platelets are greater than 50,000 per microliter without evidence of bleeding. Although new literature suggests optimal DAPT therapy can be as short as 6 months, patients with thrombocytopenia who require DAPT therapy should have close surveillance as they may develop in-stent restenosis. More research is needed to understand the risk profile of this niche group, who need anti-platelet therapy to maintain stent patent while not developing spontaneous bleeding with low platelet count. A case-based, multi-disciplinary approach will be beneficial in pursuing DAPT versus monotherapy in patients with severe thrombocytopenia.

METFORMIN ASSOCIATED LACTIC ACIDOSIS AND EUGLYCEMIC DIABETIC KETOACIDOSIS: CO-OCCURRENCE OF RARE DIABETES COMPLICATIONS

Vinay Ayyappan, Uttara Gadde, Andrew Jarrah, Joyce Kim. Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA. (Control ID #3876662)

CASE: This is a case of a 57-year-old woman with a past medical history of type 2 diabetes mellitus, chronic pancreatitis, hypertension, alcohol use disorder, and major depression who presented initially to an outside hospital with altered mental status. In the days prior to her presentation, she reported significantly decreased appetite in the setting of her depression. She reported adherence to her medication regimen which included amlodipine, atorvastatin, rifaximin, famotidine, metformin, and liraglutide. She denied any toxin ingestion. Initial vital signs were notable for a temperature of 87.6 F. A basic metabolic panel was remarkable for an anion gap of 56, glucose of 152, and creatinine of 12.15 (prior baseline of 2). A venous blood gas was remarkable for pH 6.6 with pCO2 of 21, HCO3 16, beta-hydroxybutyrate 8.51, lactic acid 22; and a urinalysis was significant for ketonuria. A toxicological workup was negative. She was intubated in the setting of severe acidemia and altered mental status and transferred to our facility for initiation of continuous renal replacement therapy (CRRT) due to her acute renal failure. She was started on an insulin drip for presumed euglycemic DKA. She demonstrated rapid renal recovery and dialysis was subsequently discontinued and she was successfully extubated. On discharge, she was instructed to discontinue her metformin and liraglutide with close follow up with endocrinology.

IMPACT/DISCUSSION: This is a unique case of euglycemic diabetic ketoacidosis (DKA) and metformin induced lactic acidosis occurring in a woman with type 2 diabetes. The etiology of her lactic acidosis is thought to be multifactorial, with both euglycemic DKA and metformin toxicity contributing. Euglycemic DKA can be triggered by inhibition of hepatic gluconeogenesis in the setting of starvation-induced ketoacidosis, similar to our patient. The patient had progressive pre-renal injury due to decreased oral intake in the weeks prior to her presentation which likely caused contributed to metformin associated lactic acidosis (MALA). This is particularly likely in the setting of renal failure due to impaired drug clearance. The impact of this case is critically important, since metformin is the first line pharmacological therapy for type 2 diabetes. In patients with kidney injury, dose adjustments should be promptly considered to avoid downstream effects of toxicity. In patients with increased risk of variable oral intake (our patient presented with several of these risk factors including alcohol use disorder and depression) and concurrent use of metformin, more frequent monitoring of renal function may be warranted.

CONCLUSION: Euglycemic DKA is a rare manifestation of DKA which may be triggered by starvation- induced ketoacidosis. Metformin-associated lactic acidosis is more likely to occur in the setting of acute renal injury, thus renal function should be monitored and doses should be titrated to account for decreased renal clearance.

METFORMIN BOWEL CONFOUNDS TREATMENT ASSESSMENT IN AGGRESSIVE LYMPHOMA: A CASE REPORT.

LAKSHMI BHAVANI POTLURI^1,2; Nithin Thummala³; Paramveer Singh³

¹INTERNAL MEDICINE, Wayne State University School of Medicine, Detroit, MI; ²INTERNAL MEDICINE, Detroit Medical Center, Detroit, MI; ³Barbara Ann Karmanos Cancer Institute, Detroit, MI. (Control ID #3876513)

CASE: A 58-year-old man with a known diagnosis of type 2 Diabetes Mellitus on oral hypoglycemic agents and recently diagnosed diffuse large B cell lymphoma of the terminal ileum was started on chemo- immunotherapy. Mid-treatment imaging, using 18F-FDG positron emission tomography (PET)-computed tomography (CT), showed hypermetabolic FDG avid right lower quadrant mass, with SUV higher than the liver. After completing therapy, PET/CT reported marked heterogeneity of terminal ileum and widespread radiotracer activity in the colon. No other FDG avid sites were appreciated on PET/CT scans. Due to FDG avidity, a diagnosis of refractory DLBCL was considered with plans to begin the next line of therapy. Upon discussing with the radiologist, the pattern of widespread FDG activity in the colon is more consistent with the recent metformin use.

IMPACT/DISCUSSION: Metformin's anti-diabetic action is through suppression of hepatic gluconeogenesis and improved peripheral sensitivity to insulin. It can also enhance the uptake of 18F-labeled fluorodeoxyglucose (FDG), a non-metabolizable glucose derivative used during 18F-FDG PET/CT. This effect is significant in our case, as it affected imaging interpretation. Cessation of metformin use for several days is required to normalize 18F-FDG uptake in the intestine, suggesting that the enhanced uptake is not a direct effect of the drug in the circulation but rather a prolonged secondary effect.

CONCLUSION: Knowledge and documentation of medical conditions and current medications are essential to avoid misinterpretation of imaging results. Withdrawal of metformin 48-72 hours before PET image acquisition is recommended to avoid potential confounding of detection and assessment of treatment response.

MILIARY PNEUMONIA: HOW AN AUTOMATED CBC DIFFERENTIAL CAN GIVE CLUES

Jonathan Pham¹; Taylor Ngo²

¹Infectious Diseases, University of Utah Health, Salt Lake City, UT; ²California Northstate University College of Medicine, Elk Grove, CA. (Control ID #3877330)

CASE: A 23 year-old male with no significant medical history, presented to the emergency room with loss of appetite and weight loss for approximately 1 month; fevers, chills, night sweats, malaise, submandibular swelling, and productive cough for 5 days. At the time of his presentation, he was found to be febrile and in septic shock.

He was born in Mexico and immigrated to the US approximately 1.5 years prior. The patient was admitted to the intensive care unit. He was newly diagnosed with HIV/AIDS, with a viral load of 62,901 copies/mL and a CD4 count of 7 cells/uL (10.1%). He continued to be in septic shock and eventually required intubation due to further respiratory failure.

The patient had a bronchoscopy with bronchoalveolar lavage, which revealed a positive Aspergillus galactomannan antigen index with optical density 7.1; fungal culture grew Histoplasma capsulatum. The patient had a bone marrow biopsy with Grocott’s methenamine silver stain and Periodic acid-Schiff stain, along with a peripheral blood smear with Wright-Giemsa stain, which showed macrophages with intracellular yeast. The size was consistent with Histoplasma capsulatum rather than Cryptococcus neoformans.

The patient was started on liposomal Amphotericin B and Flucytosine. The Flucytosine was added on while more information was collected to differentiate the morphological appearance of Histoplasma vs Cryptococcus in the bone marrow biopsy and bronchoalveolar lavage fluid. Unfortunately, the patient developed cardiac arrest on hospital day 3 and passed away.

IMPACT/DISCUSSION: The patient presented with a syndrome of miliary pneumonia and septic shock in the setting of newly diagnosed HIV/AIDS, for which the HIV was likely to have been present for years. The GMS stain on his BAL fluid and bone marrow biopsy, as well as the images from the automated CBC differential revealed 2-4 um intracellular budding yeast. These features were consistent with Histoplasma (approximately 2-4 um) rather than Cryptococcus (approximately 4-10 um).

This case also reveals other important learning points. There are several fungi that are known to cross-react with the Aspergillus galactomannan antigen test, which primarily include Histoplasma, Blastomyces, Fusarium, and Talaromyces. This occurs because these fungi also possess galactomannan antigens that are similar to the Aspergillus galactomannan antigen. Another learning point is that disseminated histoplasmosis can cause shock from both septic shock and adrenal insufficiency. Infections that have a predisposition for involving the adrenal glands include histoplasmosis, TB, and nocardiosis. Last but not least, miliary pneumonia can be due to other infectious etiologies besides TB, including histoplasmosis, coccidioidomycosis, and cryptococcosis.

CONCLUSION: Patients with HIV/AIDS are at risk of reactivation of a latent Histoplasma infection, and are also predisposed to developing disseminated histoplasmosis

MIND THE GAP? - PSEUDO ACIDOSIS IN HYPERTRIGLYCERIDEMIA

Barath Rangaswamy²; Rahul Atodaria¹; Kejal Shah¹; Dan Le¹; Triet Le³

¹Internal Medicine, Texas tech university of health sciences - Permian basin, Odessa, TX; ²internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ³School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX. (Control ID #3877254)

CASE: 39-year-old female with medical history of severe hypertriglyceridemia, type 2 diabetes, chronic pancreatitis presented with severe epigastric abdominal pain and nausea. She was afebrile, normotensive, and other vital signs within normal limits. Her mental status and physical exam were normal, no eruptive xanthomas. Initial blood work revealed mild leukocytosis, blood glucose 171 mg/dl and mildly elevated lipase 98 U/L. Basic Metabolic Panel (BMP) showed normal renal parameters and electrolytes, but measured bicarbonate (tCO2) was low at 10 mmol/L with elevated anion gap of 26 mEq/L. She had a mildly elevated lactate level and beta-hydroxy butyrate level was normal at 0.19 mmol/l. Triglycerides level was 2314 mg/dl. Patient denied history of alcohol abuse or family history of elevated triglycerides. She quit taking statins and fibrates few months ago. Treatment was initiated with IV fluids, Insulin drip for hypertriglyceridemia, atorvastatin and fenofibrate. On follow-up BMP, tCO2 remained low at 9 mmol/L with elevated anion gap of 23 mEq/L. However, on the arterial blood gas (ABG), bicarbonate was normal at 25.5 mEq/L. pH 7.35, PaCO2 45.2mmHg, PaO2 66 mmHg. The discrepant bicarbonate level was suspected due to lab interferent, the very high triglycerides. Patient received insulin drip for more than 72 hours after which the triglycerides improved to 664 mmol/L. The tCO2 improved to 25 mmol/L and anion gap improved to 10 mEq/L. Patient was finally transitioned to subcutaneous insulin and showed significant recovery.

IMPACT/DISCUSSION: Discordance between the calculated bicarbonate from the ABG and the measured bicarbonate reported in the BMP can occur and consequently allows for incorrect diagnosis and inappropriate treatment. Pseudo hypo-bicarbonatemia, a discrepancy between HCO3 and tCO2 that occurred secondary to laboratory interference in the setting of hypertriglyceridemia such as our patient, has been previously described. In institutions which use enzymatic spectrometric methods for electrolyte measurement, large particles such as chylomicrons and very low-density lipoproteins absorbs light and create scattering interference during analysis. Leading to falsely low tCO2 values. In contrast, the HCO3 value in ABG is calculated form pH and partial pressure of Co2 which are not subjected to this interference. We suggest physicians employ clinical judgement when unexpectedly low serum bicarbonate occurs especially in the absence of clinical deterioration and confirm the low tCO2 measured by arterial or venous blood gas measurement to avoid potential mistreatments. Laboratories can consider issuing a warning comment while reporting bicarbonate results in the setting of triglycerides >1000 mg/ml to prompt clinicians if clinically indicated.

CONCLUSION: It is essential to recognize that hypertriglyceridemia affects laboratory techniques causing unexpectedly low serum bicarbonate that can potentially lead to a misdiagnosis. Hence, it needs to be verified with an ABG.

MINERAL MINING - A CONFOUNDING CASE OF WERNICKE'S ENCEPHALOPATHY

Carlos Silva¹; Rajesh Gulati²; Mark Noah¹

¹Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; ²School of Medicine, University of California Riverside, Riverside, CA. (Control ID #3854919)

CASE: A 26-year-old previously healthy female presented with several months of worsening bilateral lower extremity weakness. She endorsed having multiple shots of hard liquor daily for several years and reported a loss of appetite for the past month following a friend’s death. Her last drink was three days before admission. On admission, vital signs were stable except for mild tachycardia. The patient was completely disoriented and unable to ambulate due to unsteadiness. She had an abnormal finger-to-nose test, stocking-glove pattern neuropathy, and bilateral vertical nystagmus. She also had leukopenia, normocytic anemia, and low serum thiamine, folate, and copper. Per neurology recommendations, she was empirically treated for Wernicke’s encephalopathy using IV thiamine 500 mg TID for 2 days, followed by 200 mg daily for 5 days. MRI brain was negative for mamillary body or thalamic changes. Further encephalopathy workup was negative, including lumbar puncture, Vitamin B12, methylmalonic acid, HIV, RPR, serum ethanol, and urine drug screen. After completing her parenteral thiamine therapy, she was discharged with oral thiamine and folate supplementation for alcohol use disorder and gabapentin for neuropathy. She was instructed to purchase over- the-counter copper supplements for her copper deficiency. The patient made a full recovery other than she did not remember being hospitalized during a follow-up phone visit.

IMPACT/DISCUSSION: This patient’s neurological status was initially attributed to Wernicke’s encephalopathy given her disorientation, vertical nystagmus, and cerebellar signs such as a positive finger-to- nose test. However, she incidentally had low serum copper. Although rare, it occurs in people with malnutrition, such as this patient who endorsed significantly decreased eating for the past month prior to admission, and it can be treated with supplements or cocoa. Copper deficiency is not typically associated with alcohol use based on current literature. However, it can lead to anemia, leukopenia, and neuropathy, all of which were present in this patient. Although a stocking-glove pattern neuropathy and macrocytic anemia are not unexpected in patients with alcohol use, this patient had normocytic anemia, leukopenia, and no mamillary body or thalamic changes in her brain MRI, which suggests that her neurologic symptoms were not solely from Wernicke’s encephalopathy.

CONCLUSION: Wernicke's encephalopathy is usually considered in the differential diagnosis of patients with neurologic abnormalities in the setting of heavy alcohol use. However, copper deficiency should also be assessed, especially in patients with poor food intake. Properly managing patients with such a complex clinical picture is essential to improve their neurologic status, avoid irreversible complications such as Korsakoff psychosis, and treat reversible vitamin and mineral deficiencies.

MIRM'S THE WORD, HAVE YOU HEARD? MYCOPLASMA PNEUMONIAE-INDUCED RASH AND MUCOSITIS (MIRM) AS A CAUSE FOR SEVERE MUCOSITIS IN A YOUNG ADULT

Shane Fiust-Klink, Eric Palecek

Medicine, Medical University of South Carolina, Charleston, SC. (Control ID #3876803)

CASE: A 24 year-old sexually active healthy male presented with one week of severe mucositis and fever. After developing multiple painful oral ulcers, he was seen in urgent care; rapid strep test was negative, and he was prescribed amoxicillin. One day later, he developed fever to 102F, lip swelling, and worsening ulcerations with odynophagia progressing over the next week and leading to ED presentation. He denied dyspnea, cough, headache, dysuria, rash, eye pain or drainage. His exam was notable for fever to 100.3F with otherwise normal vitals. Exam showed diffuse oral erosions with hemorrhagic crust involving vermillion lips, palate, and buccal mucosa with tongue sparing. He had no skin rash and his sclera were anicteric without injection. Initial differential diagnosis included Steven-Johnson Syndrome (SJS), primary HSV, coxsackie virus infection, Behcet syndrome, acute HIV, and mycoplasma pneumoniae-induced rash and mucositis (MIRM). Labs were notable for CRP of 4.9 mg/dl, ESR of 33 mm/hr, normal CBC and CMP, and negative testing for HIV, RPR, monospot, and respiratory virus PCR panel. He was empirically started on acyclovir and steroids, and dermatology was consulted. Further labs showed positive urine chlamydia NAAT, EBV serologies suggestive of past infection, ANA 1:80 with negative reflex ENA panel, and negative testing for coxsackie antibody titers, CMV PCR, and HSV PCR. Mycoplasma IgG and IgM antibodies were reactive consistent with a diagnosis of MIRM. Within 72 hours, he began to improve and was discharged on a prednisone taper and doxycycline for both mycoplasma and chlamydia.

IMPACT/DISCUSSION: Severe mucositis and fever in a healthy young adult has a narrow differential diagnosis. For our patient, most possibilities were excluded by diagnostic testing or a lack of consistent clinical findings. SJS was a concerning possibility, though his oral ulcers preceding amoxicillin administration by 24 hours made this less likely. MIRM is a cause of mucositis which primarily affects children, however, it can be seen in young adults. Clinical manifestations of MIRM include severe mucositis with crusting of the lips and buccal mucosa, and variable, sparse, cutaneous lesions. Onset of mucositis is typically preceded by a viral prodrome, not clearly present in our patient. Labs generally show elevated CRP & ESR, and diagnosis can be confirmed by positive Mycoplasma PCR and immunoglobulin levels.

Management involves inpatient evaluation, dermatologic evaluation, and supportive treatment. Adjunctive therapies include systemic steroids and antibiotics targeting M. pneumoniae.

CONCLUSION: MIRM, generally viewed as a pediatric condition, should be included in the differential for severe mucositis and fever in the immunocompetent young adult.

Testing for MIRM includes lab evaluation for M pneumonia PCR, IgG, IgM, and IgA, and treatment includes supportive care with adjunctive use of steroids and antibiotic therapy targeting M. pneumoniae.

MIXING IT UP: A CASE OF A PARANEOPLASTIC FACTOR VIII INHIBITOR IN A PATIENT WITH LUNG ADENOCARCINOMA

Matthew J. Pisarcik, Jordan Infield, Ammon M. Fager

Internal Medicine, Duke University, Durham, NC. (Control ID #3872600)

CASE: A 71-year-old female with a past medical history of HIV on antiretroviral therapy, compensated cirrhosis due to chronic hepatitis C, and a 50-pack year smoking history presented to the emergency department for evaluation of syncope following two weeks of progressive oropharyngeal mucosal bleeding. Review of systems was notable for several months of diffuse, spontaneous ecchymoses. Her physical exam was remarkable for active mucosal hemorrhage, multiple large ecchymoses on her face and extremities, and melena on digital rectal exam. Her initial stabilization required massive transfusion for acute blood loss anemia. Laboratory studies demonstrated marked elevation of the aPTT which did not correct on mixing studies, a Factor VIII activity level of 4%, and a high-titer Factor VIII inhibitor. Additionally, her PT was mildly elevated but corrected on mixing studies, and her Factor VII activity was mildly reduced at 25%. Further testing revealed a new lung adenocarcinoma and her coagulopathy was primarily attributed to a paraneoplastic acquired hemophilia A. She was treated effectively with a prolonged steroid taper, Rituximab, FEIBA®, and the bispecific antibody Emicizumab.

IMPACT/DISCUSSION: The differential diagnosis for coagulopathy is broad in patients with comorbid malignancy and cirrhosis, and includes disseminated intravascular coagulation, thrombocytopenia, and coagulation factor deficiencies due to hepatic dysfunction or vitamin K deficiency. Although less common, acquired factor inhibitors should remain an important consideration for all internists evaluating a patient with bleeding. Conditions associated with the development of coagulation factor inhibitors span specialties and include malignancy, rheumatologic disease, pregnancy, and HIV. However, roughly 50% of cases are idiopathic. Early recognition of factor inhibitors is paramount since 70% of patients present with severe bleeding, where delays in diagnosis often result in significantly increased morbidity and mortality.

This case of a patient with multiple acquired coagulopathies in the setting of lung adenocarcinoma and cirrhosis highlights the challenge of diagnosing disorders of hemostasis in patients with multiple comorbidities. Furthermore, it serves as a reminder that several processes contributing to a coagulopathic state may be present simultaneously. Thus, it is critical for clinicians to maintain a comprehensive differential and avoid anchoring to a single diagnosis. This approach helps ensure no treatment modalities are overlooked, which is especially important given management strategies can vary widely between coagulopathies.

CONCLUSION: - Coagulation factor inhibitors are important diagnostic considerations in patients with bleeding

- Multiple coagulopathic processes requiring varying diagnostic and treatment approaches may be present simultaneously

MOLLARET’S MENINGITIS: AN ANTIMICROBIAL DILEMMA

Mandvi Pandey, Tanmayee Polamraju, Sanjay Pujar, Teja Sree Vallapu Reddy, Enrique J. Rincon

Internal Medicine, Texas Health Resources, Arlington, TX. (Control ID #3875490)

CASE: A female in her 40’s with a past medical history significant for recurrent meningitis presented to the emergency department with a chief complaint of sudden onset severe headache of 15-hour duration. It was associated with fatigue and myalgia which commenced two days prior to the headache. The patient also complained of nausea, vomiting, neck stiffness, and lower back pain. The headache was diffuse and of severe intensity. It was aggravated by exposure to light or sound. She also reported that her symptoms were consistent with the previous bout of meningitis. She was afebrile and her vitals were within normal limits. On neurological examination, her pupils were equal, round, and reactive to light but she had severe photophobia. Furthermore, both Brudzinki’s and Kernig’s signs were positive, pointing towards probable meningitis. The rest of the neurological examination was unremarkable. Initial laboratory investigations revealed leukocytosis. She was prophylactically started on vancomycin and ceftriaxone. Also, acyclovir was added to cover for concomitant viral etiology given her previous history of recurrent Herpes Simplex Virus-2 (HSV-2) positive meningitis. After ruling out features of raised intracranial pressure, a lumbar puncture was performed. Cerebrospinal fluid (CSF) analysis revealed a white blood cell count of 84/mm3 with lymphocyte predominance (93%), elevated protein (90.4 mg/dL), and, normal glucose levels. Her CSF also returned positive for HSV-2 PCR, but gram stain and culture reported no bacterial infection. In light of her previous CSF studies, which were consistent with aseptic meningitis, we diagnosed her with Mollaret's meningitis (MM). Her empiric antibiotics were discontinued and only intravenous acyclovir was continued. On day four of hospitalization, the patient had a complete resolution of symptoms and was discharged home successfully.

IMPACT/DISCUSSION: Aseptic meningitis is defined as serous inflammation of the lining of the central nervous system without a positive CSF gram stain or culture. Mollaret's Meningitis (MM) is a form of recurrent benign aseptic meningitis, an uncommon illness characterized by greater than three episodes of fever, and meningismus lasting for two to five days, followed by spontaneous resolution. Only 69 cases have been reported between 1990-2010. There are various criteria for the diagnosis of MM, some involve excluding the etiological agent, while others do not. This has led to further underdiagnosis and misclassification of cases. Cases of MM have an excellent prognosis, with no evidence to suggest the use of antimicrobials in the management.

CONCLUSION: Often Mollaret's Meningitis presents indistinguishable from its life-threatening counterpart, bacterial meningitis. It is necessary to diagnose a case promptly and have a high index of suspicion. Given the excellent prognosis of the condition, overzealous treatment with antimicrobials should be avoided in cases with a previous history of recurrent aseptic meningitis.

MONKEYPOX PRESENTATION IN A PATIENT WITH UNCONTROLLED HIV

Trung Nguyen, Robert Buxton, Shamis Khan, Madeline Graham, Jeffrey T. Bates

Internal Medicine, Baylor College of Medicine, Houston, TX. (Control ID #3871769)

CASE: A 40-year-old man with a history of uncontrolled HIV (CD4 count of 52 cells/uL in 2017, not taking highly active antiretroviral therapy) presented with three weeks of painless, non-pruritic, ulcerated 2-3 cm skin lesions. They were initially acne-like but continued to enlarge and then scabbed over. They first presented on the face and then spread to the tongue, abdomen, back, and groin. He had been sexually active with a male partner one week prior to lesions onset. Physical examination showed 11 lesions on the face, 1 on the tongue, 15 on the upper/lower back, 5 on the chest and abdomen, 5 on the groin, and 1 on the urethral meatus. The patient had a CD4 count of 6 cells/uL, viral load of 134,000 copies/mL, negative Cryptococcus antigen, and negative Gonorrhea/Chlamydia NAAT. Otherwise, laboratory results were normal. The patient had no pain or fevers/chills. On hospital day 1, orthopox PCR of two separate lesion swabs returned positive, suggesting a monkeypox diagnosis. On day 3, given his stable condition, the patient was discharged with tecovirimat for 14 days, bictegravir-emtricitabine-tenofovir, and trimethoprim-sulfa. One day later, the monkeypox PCR returned positive.

IMPACT/DISCUSSION: Although historically endemic in Africa, monkeypox has spread to multiple other countries, with thousands of cases reported. Patient demographics consist mostly of young men who have sex with men. Initial transmissions were animal-to-human via bites/scratches (Titanji et al., 2022). Geographical expansion within Africa has been attributed to closer contact between humans and animals through deforestation, climate change, and population growth (Durski et al., 2018). The spread to non-endemic regions has been associated with travel and import of animals (Reed et al., 2004). Human-to-human transmission may be due to direct contact with lesions or indirect contact with fomites and respiratory droplets. Whether monkeypox is sexually transmitted is still being studied. Current management includes symptomatic treatments and isolation. Managements for smallpox like the vaccinia vaccine, cidofovir, and vaccinia immune globulin may be used (Kaler et al., 2022). Data from 1980-1984 Zaire patients showed that the vaccinia vaccine has around 85% efficacy against monkeypox (Jezek et al., 1986). Additionally, although its efficacy in human has not been fully evaluated, tecovirimat was licensed for monkeypox treatment in 2022 due to its efficacy in treating smallpox in animals. According to surveys where patient received tecovirimat after a median duration of 7 days since symptoms onset, subjective improvement was reported within a median duration of 3 days of treatment (O’Laughlin et al., 2022). In comparison, monkeypox symptoms resolve 3-4 weeks after onset without treatment (Moore et al, 2022).

CONCLUSION: Since the peak in August 2022, monkeypox case number has been decreasing (CDC, 2022). More research is being done to study the modes of transmission of monkeypox and the efficacy of tecovirimat.

MORE THAN MCV: RECOGNIZING ATYPICAL SIGNS OF VITAMIN B12 DEFICIENCY

Mohit Uppal, Ana Maria Davila Morales, Jeremy T. Stephan, Sven Wang, Michelle Sweet

Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #3875074)

CASE: A 66-year-old male with a history of sickle cell trait presented to the emergency department after routine blood work evidenced anemia during a primary care visit. He denied fatigue, easy bruising, petechiae, melena, and hematochezia. On physical exam, no organomegaly or jaundice was appreciated, and the patient had no focal neurological deficits. Labs were notable for Hgb 6.0 g/dL, MCV 84.1 fL, HCT 20.6%, Iron 20 ug/dL, TIBC 200 ug/dL, Iron % Saturation 10%, Ferritin 95 ng/mL, Vitamin B12 140 pg/mL, LDH 992 U/L, T Bili 1.4 and Haptoglobin 17 mg/dL. He was transfused with 1 unit of packed red blood cells and admitted for further workup. The direct Coombs test was negative. His reticulocyte count was found to be increased to 2.12%, and his absolute reticulocyte count was calculated to be 1.0. Vitamin B12 deficiency was suspected as the cause of his anemia, further supported by Serum Homocysteine and Methylmalonic Acid elevations of 50.64 umol/L and 4,893 nmol/L, respectively. Intrinsic Factor Antibody titer was found to be increased to 18.5 AU/mL, and the patient was subsequently diagnosed with pernicious anemia. During the hospitalization, he received 2 units of pRBCs, IV iron sucrose, and IM cyanocobalamin with subsequent improvement in Hgb to 7.9 g/dL at discharge. He was discharged on IM cyanocobalamin and ferrous sulfate.

IMPACT/DISCUSSION: The classical presentation of B12 deficiency is a macrocytic anemia; however, this case demonstrates that B12 deficiency can uncommonly present with a normal MCV and signs of hemolytic anemia characterized by increased lactate dehydrogenase, elevated indirect bilirubin, and decreased haptoglobin. Absolute reticulocyte count, which is derived from reticulocyte percentage and red cell count, was assessed, as opposed to raw reticulocyte percentage, to differentiate between hypoproliferative and hyperproliferative anemias accurately. Anemia associated with B12 deficiency, as was noted in this case, is hypoproliferative due to ineffective erythropoiesis. Intramedullary hemolysis has been noted in a minority of cases associated with vitamin B12 deficiency, including this one. Although vitamin B12 deficiency is typically associated with macrocytosis, the normal MCV, in this case, may be explained by concomitant iron deficiency and the average size of macrocytes and schistocytes. Some reports have suggested that up to 84% of cases of vitamin B12 deficiency could be missed if considering only macrocytosis as part of the diagnostic criteria. Treatment options for vitamin B12 deficiency include intramuscular, oral, and intranasal formulations of cyanocobalamin supplementation.

CONCLUSION: B12 deficiency can uncommonly present with features similar to hemolytic anemia, and absolute reticulocyte count can further differentiate hypoproliferative and hyperproliferative hemolytic anemias. Additionally, vitamin B12 deficiency can present with normocytic MCV, as opposed to the macrocytic anemia of which it is classically associated.

MORE THAN WHAT MEETS THE EYE: A CASE OF POLYMICROBIAL BACTEREMIA Kayla M. Meyer¹; Cole J. Evans⁴; Ashwatha Thenappan⁴; Jamie A. Sutton^2,3

¹University of Michigan Medical School, Ann Arbor, MI; ²VA Tennessee Valley Healthcare System, Nashville, TN; ³Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN; ⁴Department of Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI. (Control ID #3871927)

CASE: A 70 year-old male with a past medical history notable for extensive abdominal surgery, severe malnutrition requiring jejunostomy tube placement, and a sacral pressure ulcer, presented to the emergency department (ED) with rigors, fevers, and altered mental status. In the weeks prior he also reported intermittent dysuria. He was an active smoker, but denied alcohol or illicit drug use. Family history was noncontributory. His medications included amlodipine, aspirin, lansoprazole, and insulin.

In the ED, he was febrile to 103 degrees F, blood pressure 126/64, heart rate 100, and SaO2 98%. Labs were notable for leukocytosis to 16, lactic acid of 2.9, and positive leukocyte esterase and leukocytes in the urine analysis. Urine culture (UCx) was sent and blood cultures (BCx) were drawn from two different locations in the ED. He was empirically started on IV vancomycin and piperacillin/tazobactam. BCx from the first location grew Proteus mirabilis, Staphylococcus epidermidis, Streptococcus mitis/oralis, and methicillin- sensitive Staphylococcus aureus. UCx grew Proteus mirabilis. Antibiotics were changed to IV cefazolin and vancomycin. BCx results from the second location grew Bacteroides fragilis and Streptococcus anginosus. Metronidazole was subsequently added. Sacral MRI showed coccygeal and sacral vertebral osteomyelitis with a left-sided soft tissue abscess. CT scan revealed a gas collection within the gluteal soft tissues adjacent to sacral decubitus ulcer with small amount of likely epidural gas in the sacral spinal canal, and moderate right hydronephrosis secondary to an obstructing 2 mm calculus. Urology placed a right ureteral stent. Patient’s symptoms resolved and he was discharged on a prolonged antibiotic course of cefazolin and metronidazole.

IMPACT/DISCUSSION: Polymicrobial bacteremia (PMB) is defined by the presence of at least two distinct microorganisms found in a blood culture and is associated with higher mortality rates and longer hospital stays. A higher Charlson Comorbidity Index score, unknown source of infection, and inadequate empiric antibiotic therapy may contribute to this increased mortality.

Clinicians must not only be able to recognize complex patients presenting with sepsis but importantly identify the most likely infectious source and subsequently initiate appropriate empiric antibiotic therapy early. It is important to obtain repeat BCx from multiple sites and days and keep the antibiotic therapy broad until cultures and susceptibilities result. Given the importance of source control in patients found to have PMB, early imaging can be a vital diagnostic tool to assess for an underlying asymptomatic nidus of infection.

CONCLUSION: In cases with unclear bacteremia from multiple potential sources,

- Broad antibiotics should be empirically initiated and subsequently de-escalated as additional information is acquired

- Consideration of early imaging may be warranted

MOSQUITOS VS. TICKS: CLINCHING THE DIAGNOSIS IN THE SETTING OF MULTIPLE EXPOSURES

Natalie A. Kapadia³; Elizabeth McWilliams¹; Catherine Callister²

¹Hospital Medicine, University of Colorado, Denver, CO; ²Hospital Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ³University of Mumbai, Mumbai, Maharashtra, India. (Control ID #3837224)

CASE: An otherwise healthy 33 year-old Thai man presented to the ED with a 2-week history of daily fevers, nausea, abdominal pain, vomiting and non-bloody diarrhea. He denied any rash, joint pain or swelling, or sick contacts. Travel history included a trip to Missouri two weeks prior where he was bitten by mosquitoes, ticks and swam in a water body. He had lived in Thailand more then 15 years prior to admission. Admission labs were significant for Na 120, ALT 652, AST 435, Bilirubin 2.9. CBC was notable for a normal WBC, Hgb 13.5, and Platelets 90. Ferritin was >37500. Notable imaging included a CT Abdomen/Pelvis with mild distension of bowel with air fluid levels, concerning for enteritis, and moderate to marked hepatosplenomegaly. Further testing was negative for malaria, entamoeba histolytica, histoplasma, and viral hepatitis. Acetaminophen level <10, phosphatidyl ethanol not detected. A GI PCR was positive for c diff and the patient was started on Vancomycin. A wide autoimmune panel was negative. Additional tests included PCR antigen/ antibody tests for rocky mountain spotted fever, treponema palladium, leptospirosis. Ehrlichia and anaplasma were sent as well. Given the history of exposure to ticks, Doxycycline was started empirically.

Within a couple days the patient was afebrile, his abdominal pain had resolved and his diarrhea had started to improve. Four days into his admission, ehrilichia chaffeensis was detected by PCR, IgG >1:1,024, IgM 1:64. On the autoimmune panel, sILR2 came back high (3414.2). and that along with his hyperferritinemia suggested a possible secondary form of HLH. He was discharged on Vancomycin for c diff and doxycycline and was asked to follow up with his PCP to get LFTs checked in a week.

IMPACT/DISCUSSION: Ehrlichiosis is a relatively rare tick-borne bacterial infection most commonly caused by ehrlichia chaffeensis. It can be severe with up to >50% of diagnosed cases requiring hospitalization. Symptoms can be non-specific and often include fever, malaise, muscle pain, GI symptoms, and less frequently AMS or rash. This case illustrates the importance of taking a thorough travel and exposure history to help narrow an initially broad differential.

Ehrlichiosis can lead to a prolonged illness and dangerous systemic complications if left untreated. This case illustrates the importance of starting doxycycline therapy early when a tick-borne illness such as ehrlichiosis is suspected, as the confirmatory test will not return for several days. Though potentially a mild case, the patient met 5/9 criteria for HLH, of note NK cell activity and bone marrow biopsy were not obtained. It should be noted that ehrlichiosis can rarely cause HLH which typically resolves by treating the ehrlichiosis with doxycycline.

CONCLUSION: This case highlights the importance of early doxycycline use where ehrlichiosis is suspected. It also serves as a reminder that infection can be a trigger for HLH.

MULTIPLE MYELOMA IN THE SETTING OF ACQUIRED VON WILLEBRAND DISEASE Namita Saraf²; Yu-Min Shen¹; Larry Anderson²; Gurbakhash Kaur²

¹Blood Disorders, The University of Texas Southwestern Medical Center, Dallas, TX; ²Multiple Myeloma, The University of Texas Southwestern Medical Center, Dallas, TX. (Control ID #3876851)

CASE: A 46-year-old female with a history of heavy, prolonged menstrual bleeding s/p partial hysterectomy, and uncontrolled epistaxis, was admitted to the ICU with severe anemia with a hemoglobin of 6.3 (baseline11.5 g/dL), and syncope from uncontrolled epistaxis. She was transfused 4 units of packed red blood cells and underwent embolization of the internal maxillary arteries for bleeding control. She has no family history of bleeding disorders and did not significantly bleed with her 3 vaginal deliveries, or dental extractions.

There was a concern for an underlying acquired bleeding disorder; platelets, PT and INR were normal, but aPTT was abnormal at 45 seconds. An aPTT mixing study showed complete correction, suggesting a factor deficiency. Factor VIII activity was low at 17%; von Willebrand factor (vWF) activity and antigen were low at <10 % (normal 51-215%). VWF collagen binding was decreased, and multimer analysis showed very low levels of all multimers. vWF propeptide was normal and vWF gene mutation analysis did not show any pathologic mutations.

ANA was borderline positive, echocardiogram showed no structural abnormalities, and SPEP was positive for 0.54 g/dL of IgG lambda. Bone marrow biopsy showed 15-20% atypical plasma cells and no evidence of lytic lesions on PET/CT. She had no evidence of multiple myeloma defining event per SLiM CRAB criteria. She was diagnosed with acquired von Willebrand syndrome (aVWS) due to underlying plasma cell disorder and was started on daratumumab and dexamethasone. Her bleeding resolved and her von Willebrand labs have normalized. After 4 cycles of therapy, the vWF antigen is 89%, vWF activity is 74%, and the vWF collaging binding assay is 65%.

IMPACT/DISCUSSION: The following must be considered as possible causes of aVWS–cardiac structural defects, autoimmune disorders like lupus, essential thrombocythemia with extreme thrombocytosis, lymphoproliferative disorders and plasma cell neoplasm.

AVWS in the setting of a monoclonal gammopathy has been described in the literature to be a myeloma defining event. However, the mechanism of disease and the relationship between aVWS and multiple myeloma are currently unknown. This case demonstrates the clinical findings present in those with new onset aVWS preceding a myeloma diagnosis.

Further, this case is unique because the patient had undetectable vWF antigen or activity and no vWF type 3 phenotype. It is suspected that this patient’s aVWS results from autoantibodies that eliminate vWF, making the antigen undetectable.

CONCLUSION: -Timely diagnosis will prevent complications of bleeding in patients with undiagnosed bleeding disorders. This patient had many visits over 2 years for uncontrolled epistaxis, yet a bleeding disorder was not considered

-aVWS due to MGUS is a known rare phenomenon reported only in cases reports

-Treatment of the underlying plasma cell disorder led to correction of vWF levels

MYASTHENIA GRAVIS BEFORE CRISIS: A CASE OF NEW ONSET MYASTHENIA GRAVIS IN A 67-YEAR-OLD MALE

Erin Bammann¹; Jess Bartley^1,2; Lindsey E. Fish^1,3

¹Internal Medicine, University of Colorado Denver, Denver, CO; ²Denver Health, Denver, CO; ³Denver Health, Denver, CO. (Control ID #3868016)

CASE: A 67-year-old male with hypertension and chronic neck pain presented to urgent care with six weeks of nasal congestion and three weeks of difficulty swallowing, jaw weakness with chewing, and voice changes. ROS was remarkable for intermittent eye drooping, urinary stress incontinence, fecal urgency, episodic weakness of neck muscles, and a single episode of bilateral lower extremity weakness occurring late in the day. Vital signs were BP 150/78 HR 78 RR 20 SpO2 95% T 36.1 C. Physical exam revealed progressive difficulty with phonation and enunciation throughout conversation, ptosis of the right eye, and symmetrical weakness of facial muscles without additional focal neurological deficits. The fatigable bulbar muscle weakness and ptosis raised concern for MG that could progress to myasthenic crisis. He was advised to go to the hospital for further evaluation. There, his negative inspiratory force (NIF) was – 20 cmH₂O, warranting admission to the ICU for further monitoring and treatment. He was also found to have sinusitis, thought to have precipitated his symptoms. He was treated for sinusitis and for presumed MG. NIF was monitored every 4 hours. He did not ultimately require intubation. Serum testing confirmed the diagnosis of MG. By day 5 of hospitalization, his symptoms had significantly improved, and he was discharged on high- dose corticosteroids with outpatient follow-up.

IMPACT/DISCUSSION: MG most commonly presents with fluctuating skeletal muscle weakness that is worse with continued use (i.e. fatigable muscle weakness).¹ Classically, it presents with ocular, bulbar, respiratory, axial, and limb muscle weakness. However, it can present with weakness of any skeletal muscle in the body. An estimated two-thirds of patients may present with ocular symptoms. About 75% of patients will develop generalized weakness typically within the first 2-3 years.¹ Approximately 10-15% of patients can present with bulbar weakness including dysphagia, dysarthria, dysphonia, and jaw fatigue with chewing. Respiratory muscle weakness can occur in up to 40% of patients and roughly 15-20% of patients will experience myasthenic crisis.¹ When patients present with new and progressive symptoms concerning for MG in the outpatient setting, they should be referred to a setting where respiratory muscle strength can be evaluated and the patient can be initiated on appropriate monitoring and treatment. There are several bedside tests that can be used to estimate respiratory muscle strength,² but vital capacity (VC) and NIF are gold standard.^3,4

CONCLUSION: 1) MG should be considered for all patients presenting with fatigable muscle weakness in the outpatient setting.

2) In patients suspected to have MG with progressive symptoms, consider transfer to a setting capable of assessing respiratory muscle strength with NIF/VC and where early treatment can be initiated in an effort to reduce the risk of progression to myasthenic crisis.

MYCOBACTERIAL CULTURES COMING IN HANDY: TUBERCULOSIS OSTEOMYELITIS OF THE WRIST

Grace Kim¹; Kate E. Lee²; Daniel Cox²; Isabelle Byers²; Anand Shah²; Madeleine Hamilton²; Kevin Wu¹; Anisha Chandiramani²; Brian C. Griffith²; Saumil Chudgar²; Jessica Seidelman²; Lana Wahid²

¹School of Medicine, Duke University School of Medicine, Durham, NC; ²Internal Medicine, Duke Medicine, Durham, NC. (Control ID #3873676)

CASE: A 56-year-old man with controlled type 2 diabetes mellitus presented with two and a half years of progressive wrist swelling and decreasing mobility. A nodule on his right volar wrist appeared after a forearm IV placement with appearance of a second nodule. Over the year, the nodules persisted. Surgical debridement was scheduled but not done. Wrist mobility decreased with worsened swelling and wrist warmth the month before re-presentation. Subsequent four-week empiric treatment with trimethoprim-sulfamethoxazole was ineffective. Development of fever, pain, and spontaneous nodule deroofing led to current presentation where computed tomography showed wrist osteomyelitis.

On admission, he had normal vital signs and was well appearing with no night sweats, cough, or weight loss. The right volar wrist had two, four-centimeter abscesses, with a dorsal fluid collection but no redness or warmth. White blood cell count was normal; erythrocyte sedimentation rate (ESR) was elevated. Blood cultures had no growth and HIV antibody test was negative. Magnetic resonance imaging showed wrist and metacarpal septic arthritis-osteomyelitis, multi-compartmental tenosynovitis, and wrist abscesses. Antibiotics were deferred pending microbiology. He had surgical debridement with tissue cultures and pathology collected. Cultures grew methicillin-resistant Staphylococcus aureus on day 2 and Enterococcus faecalis on day 4; he was started on vancomycin. Pathology showed granulomatous osteomyelitis on day 6. After two weeks, cultures grew Mycobacterium tuberculosis (TB). He was started on rifampin, isoniazid, pyrazinamide, and ethambutol.

IMPACT/DISCUSSION: Musculoskeletal (MSK) TB of the wrist is rare. 20% of TB cases in the United States are extrapulmonary (1). Isolated MSK TB is mostly spinal, with few cases of wrist infection documented (2, 3). Immunosuppression is the biggest risk factor for extrapulmonary TB (1, 4). This patient was immunocompetent and had not been in TB endemic areas, though he did have remote history of substance use and incarceration.

With the rarity of TB osteomyelitis, diagnosis is often unnoticed until there is soft tissue or joint involvement (2). One-third of cases have soft tissue fluctuance or drainage, without redness and warmth seen in bacterial infections, with normal cell counts and elevated ESR. Imaging is nondiagnostic, and surgical debridement with cultures is recommended (4). This patient’s long course and fluid collections without warmth or redness pointed away from bacterial causes and led to collection of mycobacterial cultures and pathology, ensuring TB was not missed in the context of initial bacterial growth.

CONCLUSION: In atypical presentations of osteomyelitis, it is vital to consider uncommon causes such as mycobacterial infections. Since its rarity can lead to delays, timely collection of cultures and pathology is critical. Keeping a broad differential with atypical clinical presentations is important and can help lead to the correct diagnosis and treatment.

MYCOBACTERIUM ABSCESSUS MENINGITIS ASSOCIATED WITH INTRATHECAL STEM CELL INJECTIONS DURING MEDICAL TOURISM

Arun Chandnani¹; Lakshmi Chauhan¹; Sarah Mann¹; Kelli Money¹; Brian Montague¹; Daniel M. Pastula¹; Andrew Wolf¹; Shanta Zimmer¹; Charles Daley²; David Griffith²

¹School of Medicine, University of Colorado, Denver, CO; ²National Jewish Health, Denver, CO. (Control ID #3876331)

CASE: A 38-year-old female with a history of multiple sclerosis (never on disease modifying therapy or other immunosuppressive medications) presented with a four-week history of headaches and fevers following travel to Mexico for intrathecal stem cell injections. She had multiple prior emergency department and inpatient evaluations leading to empiric treatment for meningitis with a carbapenem. However, after completing treatment her symptoms recurred.

Physical exam was remarkable for the absence of meningismus or focal neurologic deficits. Laboratory studies were notable for cerebrospinal fluid (CSF) with a nucleated cell count of 104 (56% neutrophils, 42% lymphocytes), protein of 47 mg/dL, and glucose of 31 mg/dL. Initial CSF gram stain and bacterial cultures were negative. Brain computed tomography and magnetic resonance imaging showed stable demyelinating lesions consistent with multiple sclerosis.

She was treated for a presumed CSF leak and incompletely treated bacterial meningitis. A week later, CSF

fungal cultures grew acid fast bacteria, prompting her readmission.

The patient was treated empirically with azithromycin, ciprofloxacin, imipenem, trimethoprim- sulfamethoxazole and tedizolid pending identification. The bacteria was confirmed to be Mycobacterium abscessus. Based on susceptibilities, the regimen was changed to imipenem, ceftaroline, eravacycline, tedizolid, and azithromycin.

The patient demonstrated signs of initial clinical improvement on antibiotic therapy, with resolution of headache and fever. Long term therapy is anticipated to include at least 12 months of multi-drug regimen with repeat lumbar punctures to monitor therapeutic response.

IMPACT/DISCUSSION: Mycobacterium abscessus complex (differentiated into 3 subspecies: abscessus, massiliense, and bolleti) is a group of opportunistic rapidly growing non-tuberculosis mycobacteria, ubiquitous in the soil and water. The bacteria are frequently multi-drug resistant and most commonly cause lung, skin, and soft tissue infections. M. abscessus infections in the central nervous system (CNS) are rare and typically associated with an indwelling device or penetrating trauma. In this case, the patient acquired M. abscessus from inadequately sterilized or contaminated materials used for her stem cell injection. M. abscessus infections typically require prolonged treatment with at least 3-4 antibiotics. This case demonstrates the challenges in diagnosing and treating non-tuberculous mycobacterial infections, including delays in diagnosis and complex drug resistance patterns. Additionally, this case demonstrates the dangers of invasive procedures during medical tourism.

CONCLUSION: Mycobacteria abscessus is a rare cause of meningitis; however, it should be on the differential for patients with chronic meningitis, especially in the setting of recent procedures, trauma, or international travel for medical care.

MYCOBACTERIUM AVIUM COMPLEX IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME IN A YOUNG PATIENT WITH RECENTLY DIAGNOSED HIV/AIDS– DIAGNOSTIC CHALLENGES

Manasa Bhatta¹; Adiac Espinosa Hernandez¹; Elliot Eisenberg¹; Kathryn Dubowski¹; Rachel Chasan²

¹Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3877107)

CASE: A 26 year old male with AIDS presented to the emergency department (ED) with pleuritic chest pain, abdominal pain, rash, and weight loss. Symptoms began shortly after HIV diagnosis three months prior, when his CD4 count was 45 cells/mm³ (20%) and viral load was 11,900 copies/ml – he had been adherent to antiretroviral therapy (ART) since diagnosis. He was born in New York City with no prior travel, residence in a shelter, or incarceration.

In the ED, blood pressure was 89/59, heart rate was 116, temperature was 36.7, and oxygen saturation was 98%. Most recent CD4 count was 138 cells/mm³ (29%) and viral load was 288 copies/ml. CT scan demonstrated mediastinal, hilar, and abdominal lymphadenopathy with hypodense areas of necrosis, mediastinal masses with pleuroparenchymal involvement, and pulmonary nodules up to 9mm. Interferon- gamma release assay (IGRA) was negative. Three sputum smears were negative for acid fast bacilli (AFB). Transbronchial needle aspiration of a mediastinal node suggested caseous material. Pathology demonstrated necrosis and granulomatous inflammation with positive AFB stain.

The patient was started on empiric rifampin, isoniazid, pyrazinamide, ethambutol, and azithromycin for mycobacterium avium complex (MAC) and mycobacterium tuberculosis (MTB) while awaiting culture growth and speciation. GeneXpert MTB/RIF assay was negative. Lymph node aspirate culture grew MAC two weeks after hospital discharge. At one month follow-up, his presenting symptoms had essentially resolved. His regimen was ultimately narrowed to target disseminated MAC.

IMPACT/DISCUSSION: In this case, we describe a patient with AIDS diagnosed with disseminated MAC, with likely immune reconstitution inflammatory syndrome (IRIS). The worsening clinical and radiographic presentation four weeks after ART initiation in the setting of increased CD4 count meets proposed criteria for IRIS. MAC IRIS can present as fever and painful lymphadenitis one to eight weeks after initiation of ART. A thoracic form of MAC IRIS disease with pulmonary nodules and mass-like consolidation has been described.

Central attenuation due to necrosis, especially in thoracic nodes, is more common in MTB than MAC. Because of the pathology results and low sensitivity of sputum AFB smears and IGRA in HIV-MTB co- infection, a decision was made to treat MAC and TB pending mycobacterial culture results, which can take on average three weeks. GeneXpert MTB/RIF assays result faster than mycobacterial cultures and are highly sensitive for MTB in AFB stain positive samples in patients with HIV.

Overall, this case demonstrates the challenge of ruling out MTB, given the potential for a similar presentation to MAC IRIS. An understanding of the strategies to test for MAC and MTB was needed to establish a diagnosis.

CONCLUSION: 1) MAC IRIS can present as a necrotic lymphadenitis with thoracic findings that may mimic TB.

2) Disseminated MAC and MTB are challenging to diagnose - empiric therapy may be appropriate if degree of suspicion is high.

MYELODYSPLASTIC SYNDROME MASQUERADING AS THROMBOTIC THROMBOCYTOPENIC PURPURA

Jawairia Sahar Mirza¹; Mithin Mathew¹; Diana I. Zamora²; Makardhwaj S. Shrivastava²

¹Internal Medicine, Creighton University School of Medicine Phoenix Regional Campus, Phoenix, AZ; ²Hematology/Oncology, Dignity Health Cancer Institute, Phoenix, AZ. (Control ID #3875563)

CASE: A 64-year-old male with history of CAD, smoking and stage III squamous cell carcinoma of the larynx, treated with laryngectomy and concurrent chemoradiation with cisplatin in June-July 2020, presented to the hospital in May 2022 with acute normocytic anemia. Laboratory results showed hemoglobin of 3.2 g/dL and platelets of 8000/uL, LDH 248 units/L, bilirubin 2.1 mg/dL and serum creatinine 2.4 mg/dL. Peripheral smear showed 2+ schistocytes/hpf. No blast cells noted. Clinical and laboratory picture was suspicious for thrombotic thrombocytopenic purpura (TTP), and patient was started on plasmapheresis and prednisone. After 5 sessions, his platelets improved to 73,000/L. LDH levels improved. Initial ADAMST13 level was 20% and repeat levels post plasmapheresis was 53%. A month after hospital discharge, his platelets trended down to 31,000/uL. Bone marrow biopsy showed a cellular bone marrow with trilineage hematopoiesis without evidence of malignancy. Other differentials including immune mediated thrombocytopenia were considered. He was empirically treated with IVIG, rituximab and eltrombopaq with no significant response and his platelet counts continued to deteriorate. He was re-hospitalized and was started on plasmapheresis, to which he did not respond. A repeat bone marrow biopsy was performed in August 2022 (3 months after the previous biopsy) which showed therapy related Myelodysplastic syndrome (MDS), cytogenetics concerning for complex karyotype and molecular genetics showed TP53 mutation. Patient was then started on hypomethylating agent- azacytidine. His condition quickly progressed to acute myeloid leukemia. Due to poor performance status and patient preference, he was transitioned to hospice.

IMPACT/DISCUSSION: MDS is characterized by cytopenias and abnormal hematopoiesis, whereas TTP is characterized by hemolytic anemia, thrombocytopenia along with systemic microthrombi. Both these disorders are potentially life threatening and require different management approaches. Plasma exchange should not be delayed if the clinical suspicion for TTP is high, as mortality rate is high if untreated. MDS is treated with chemotherapy.

Another striking feature here is the rapid evolution of MDS within a span of 3 months as noted between the two bone marrow biopsies. Therapy related MDS secondary to an alkylating agent usually takes 5-7 years to evolve, also the cytogenetics seen in such cases involves complex karyotype which was found in our case.

CONCLUSION: This puzzling case highlights the challenges encountered when navigating to the final diagnosis and differentiating between the provisional diagnoses. When sustained response is not noted, then it is important to have other differential diagnoses considered and worked up. In our case, it was probably very early stage of MDS which was masquerading and missed on earlier bone marrow biopsy leading to working diagnosis of TTP. Eventually revealing itself when a repeat bone marrow biopsy was performed and molecular cytogenetics pursued.

MYXEDEMA: A RAPIDLY CURED PSYCHOSIS IN THE SETTING OF BIPOLAR DISORDER Kavanya Feustel¹; Kelly S. Schulte²; Jeffrey Ramsey²; Joel Witter¹

¹Internal Medicine, HCA Healthcare, Nashville, TN; ²Internal Medicine, Sky Ridge Medical Center, Lone Tree, CO. (Control ID #3875553)

CASE: A 51-year-old female with bipolar II disorder, hypothyroidism, and migraines presented twice to the emergency department for new onset auditory hallucinations. She revealed difficulty obtaining her medication on her initial presentation and was discharged home with a refill of lurasidone after preliminary negative workup. She returned two weeks later complaining of worsening background and command auditory hallucinations associated with lethargy, anhedonia, decreased appetite, disorientation to time and the sensation of living behind a frosted window. This was preceded by one week of a depressive episode. Vital signs were significant for sinus bradycardia (35 beats per minute). Physical exam revealed bilateral lower extremity non-pitting edema, symmetrical 3+ strength and 1+ deep tendon reflexes throughout. She had a flat affect, bradyphrenia, shallow breathing, and was responding to internal stimuli. CBC, CMP and urine

analysis were within normal limits, toxicology screen was negative. TSH was 91.27 mclu/mL and free T4 0.53 ng/dL. Head CT without contrast was negative for acute abnormalities. She was treated with one day of 100mcg intravenous levothyroxine, transitioned to 100mcg orally and switched to risperidone from lurasidone to treat the acute hallucinations. The auditory hallucinations receded to the volume of a whisper within two days. The patient was re-oriented to time without bradyphrenia or bradycardia on discharge.

IMPACT/DISCUSSION: The pathophysiology of myxedema psychosis is not fully elucidated. A combination SPECT and MRI study identified decreased cerebral blood flow to the right parieto-occipital, posterior cingulate, lingual, fusiform, precentral and postcentral gyri, the cuneus and insula in patients with hypothyroidism. Auditory hallucinations are primarily studied in patients with schizophrenia, an fMRI study identified increased activation of the right superior and middle temporal gyri, posterior insula, precentral gyrus, hippocampus and parahippocampal gyrus during auditory hallucinations. These studies may not explain our patient’s hallucinations given the discordant hypoperfusion and activation patterns. One long- standing theory remains unsupported that both auditory and visual hallucinations originate from misinterpreted vivid or intrusive memories. It is possible that the hypothyroid-driven cerebral hypoperfusion causes vivid memories to emerge to bridge gaps in perceived reality. Her bipolar disorder could have transformed to be with psychotic features since her depression preceded the hallucinations. However, as she had no prior hallucinations during the two decades since her bipolar diagnosis, her psychiatric illness was not deemed the primary culprit.

CONCLUSION: Thyroid dysregulation should be considered in any patient presenting with altered sensorium.

Hypothyroid psychosis is quickly and easily reversible with exogenous hormone supplementation.

MYXEDEMA MADNESS; A UNIQUE CASE OF DECOMPENSATED HYPOTHYROIDISM PRECIPITATING A FASCINATING, MULTISYSTEM FRENZY

Emily Buerschen¹; Akruti P. Prabhakar¹; Roselle Bea P. Almazan²; Nathan Boyce³; Maher Al-Samkari²

¹Internal Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH; ²Wright State University Boonshoft School of Medicine, Dayton, OH; ³University of Kentucky, Lexington, KY. (Control ID #3874591)

CASE: A 44-year-old man presented to the hospital with confusion and auditory hallucinations that developed over the past 48 hours. He had a medical history of obesity (BMI 50.2), hypothyroidism, depression and had a rapid 40-pound weight gain over the previous 90 days; all without changes in his diet or routine. He was hypothermic on exam and had macroglossia with a large tongue laceration, cushingoid body habitus, and non-pitting lower extremity edema. Laboratory evaluation demonstrated hyponatremia to 124 mEq/L. Chest x-ray showed mild cardiomegaly. Workup for causes of acute metabolic and toxic encephalopathy were all normal. His agitation and disturbing auditory hallucinations required regular haloperidol, and ultimately he was intubated for airway protection given worsening macroglossia. Remarkably, further workup revealed a TSH elevated to 121 MCIU/ML, and T4 levels undetectable <10 NG/DL, which indicated a severe decompensation of his hypothyroidism and a diagnosis of myxedema coma. The acute event was suspected to be long-term non-compliance with his home levothyroxine, precipitated by recent COVID-19 infection. He was started on levothyroxine 200 mcg IV daily along with a one-time liothyronine 10 mcg bolus, followed by 5 mcg every 8 hours. He was also started on high-dose IV steroids. Despite sedation with propofol, the patient was increasingly agitated and required frequent boluses of fentanyl, benzodiazepines and transition to dexmedetomidine drip to maintain comfort over the next few days. His TSH and T3/T4 were checked daily, and showed downtrending TSH and normalizing T4. His agitation calmed as his thyroid levels normalized. After 4 days, he was successfully extubated. He was discharged to an ECF, where he made a full recovery on levothyroxine dosing at 250 mcg daily.

IMPACT/DISCUSSION: Myxedema coma is a serious complication of an exacerbation of underlying hypothyroidism that can lead to multiple organ failure and mental status deterioration. Despite advances in treatment options, mortality remains high. Early intervention is the greatest predictor of good patient outcomes; thus, identifying signs of myxedema is imperative. Suspicion should be raised in patients with altered mental status and a history of hypothyroidism. Further red flags include hyponatremia, bradycardia, hypoglycemia, heart failure, and a history of non-compliance with thyroid replacement or recent infection. The diagnosis of myxedema is rare, and there are few documented case reports; therefore, diagnostic criteria are not universally established. Further literature should strengthen the current scoring system proposed for myxedema coma to create a universal scoring system that would help providers more quickly identify and treat this perilous condition.

CONCLUSION: - Recognize the red flags consistent with decompensated hypothyroidism to prevent the development of myxedema coma.

- Ascertain understanding of the urgency to provide rapid, directed treatment of myxedema coma to improve mortality.

NALTREXONE: AN UNEXPECTED INFECTANT

Brandon Call¹; Rebecca Wig¹; Ashley Scott²; John Bloom²; Tammer El Aini²

¹Internal Medicine, Banner University Medical Center Tucson, Tucson, AZ; ²Banner University Medical Center Tucson, Tucson, AZ. (Control ID #3875437)

CASE: Case is a 33 year old male with a past medical history of alcohol use disorder and type 2 diabetes who presented to the hospital with fever, chills, lethargy, and persistent dry cough producing scant white sputum for the past 3 days. His home medications included metformin and naltrexone, last received 3 days prior. History was notable for previous incarceration and time spent living in Mexico. He denied any smoking, allergies, or sick contacts.

In the ED he was found to be tachypneic (24) and hypoxic to 85%, requiring 6L oxygen. Labs showed leukocytosis of 14.5 with predominant eosinophilia of 1.11. Chest X-ray and CT were done [Figure 1,2]. Extensive workup including viral panel, blood cultures, AFP, cocci serology, legionella, fungitell were negative. Pulmonology service was consulted and a Bronchoalveolar lavage was performed which showed colorless slightly hazy fluid that was notable for eosinophilia of 45%, lymphocytosis of 31%, macrocytes 22%. Parasitic and allergen panels were negative. During the admission, the patient’s oxygen requirements returned to room air and a repeat chest X-ray showed near complete resolution of opacities [Figure 3]. Patient was diagnosed with acute eosinophilic pneumonia likely secondary to intramuscular naltrexone. Given improvement in symptoms, the patient was discharged with outpatient follow up.

IMPACT/DISCUSSION: Eosinophilic lung diseases are a group of disorders with varying etiologies defined by increased eosinophils in BAL (>25%). Acute eosinophilic pneumonia (AEP) is further distinguished by an acute febrile illness with diffuse respiratory infiltrates and acute respiratory failure (1). AEP is a diagnosis of exclusion and should only be suspected after other causes of pneumonia have been investigated. The most common trigger is tobacco smoke but other causes include inhaled lung irritants and infection (typically parasitic and fungal). The most commonly associated drugs are daptomycin, mesalamine, sulfasalazine, minocycline and nitrofurantoin (2). The standard of treatment is glucocorticoids, although patients often improve spontaneously as in this case.

CONCLUSION: Internists should recognize that patients with unexplained pneumonia and eosinophilia require further workup that often includes a bronchoalveolar lavage. A broad differential should be considered in these patients. When more common etiologies are ruled out it is important to consider drug induced reactions as a potential cause of the patient’s symptoms.

NEUROENDOCRINE TUMOR DISGUISED AS UNCONTROLLED DIABETES

Tyler Ryan¹; Sowmya Korapati²; Prateek Shukla³; Minesh Nandi²

¹Internal Medicine, University of Massachusetts Chan Medical School, Worcester, MA; ²Hematology-Oncology, University of Massachusetts Chan Medical School, Worcester, MA; ³Endocrinology, University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #3876786)

CASE: A 61-year-old male with a history of well-controlled type 2 diabetes mellitus for the past ten years on metformin, glimepiride, and insulin glargine presents to the endocrinology clinic for uncontrolled diabetes despite lifestyle modifications and medication adherence. He also noticed 80-pound unintentional weight loss and fatigue, abdominal pain, constipation, diarrhea, and facial flushing over the past year. Physical exam was unremarkable, and hemoglobin A1C was 10.8% from 6.7% eighteen months prior. His insulin and glimepiride were increased; GLP-1 receptor agonists and DPP-4 inhibitors were deferred until gastrointestinal pathologies could be worked up. A CT of the abdomen and pelvis with contrast showed numerous hepatic masses concerning for metastatic disease without evidence of a primary mass. Liver biopsy revealed metastatic well-differentiated neuroendocrine tumor grade 2 prompting oncology referral. On presentation to the oncology clinic, he was hypotensive, diaphoretic, and nauseated requiring hospital admission. After stabilization, 24-hour urinary 5-hydroxyindoleacetic acid (5HIAA) level was elevated, and plasma metanephrines were normal. He was diagnosed with carcinoid crisis and started on octreotide. PET CT showed focal DOTATATE uptake in the tail of the pancreas likely representing the primary neuroendocrine tumor (NET). Ki-67 level supported the use of chemotherapy, and he started FOLFOX with subjective improvement in symptoms and modest improvement in A1C.

IMPACT/DISCUSSION: Type 1 and Type 2 diabetes are the most common forms of diabetes in adults. Secondary causes of diabetes such as NETs, Cushing syndrome, pancreatic malignancies, and others contribute only to 1-5% of all diabetes cases. Secondary causes may go undetected until defining symptoms develop. This case serves as an opportunity to review the presentation, diagnosis, and treatment of NETs and carcinoid crisis. Patients with NETs often remain asymptomatic. However, metastasis to the liver allows hormones including 5-HIAA, prostaglandins, and bradykinins to bypass first-pass metabolism and enter the systemic circulation. These hormones cause systemic symptoms that may include facial flushing, diarrhea, abdominal pain, bronchospasm, and labile blood glucose–a pattern called carcinoid syndrome, or carcinoid crisis in severe cases that precipitate hemodynamic instability. Treatment involves somatostatin analogues such as octreotide that bind to somatostatin receptors on NET cells and inhibit hormone production. Surgical resection is indicated for isolated lesions, while embolization or chemotherapy may be used in select cases.

CONCLUSION: The differential for uncontrolled diabetes is broad and includes endocrinopathies and gastrointestinal malignancies.

Carcinoid crisis may present with facial flushing, diarrhea, abdominal pain, bronchospasm, labile blood glucose, and hypotension.

Management of carcinoid crisis includes somatostatin analogues, surgical resection, or chemotherapy for select cases.

NEW GROWTHS ON THE BLOCK: A CASE OF LIBMAN-SACKS ENDOCARDITIS ON THE AORTIC VALVE PRESENTING WITH COMPLETE HEART BLOCK

Hywel Soney¹; Manavjot S. Sidhu²

¹Internal Medicine, Methodist Dallas Medical Center, Dallas, TX; ²Cardiology, Methodist Dallas Medical Center, Dallas, TX. (Control ID #3877112)

CASE: A 77-year-old female with a history of systemic lupus erythematosus (SLE) and paroxysmal atrial fibrillation presented to the emergency department after feeling lethargic and was found to be bradycardic at a primary care visit. Electrocardiography revealed complete atrioventricular block with a slow escape rhythm at 30 beats per minute. Isoproterenol was initiated and the patient was admitted to the Intensive Care Unit. Transthoracic echocardiogram (TTE) identified aortic valve (AV) vegetations. Due to concerns for infective endocarditis, blood cultures were drawn and the patient was planned for pacemaker placement if initial blood cultures were negative at 24 hours. The patient remained hemodynamically stable with an improved heart rate on isoproterenol. The patient was brought to the electrophysiology lab for a transesophageal echocardiogram (TEE) and pacemaker placement but upon initiation of sedation, patient became asystolic and cardiopulmonary resuscitation was initiated. Atropine and epinephrine were given, but due to a very slow escape rhythm, pacing would be necessary and a temporary pacing wire was placed after which hemodynamics improved. TEE demonstrated vegetation visualized on the AV valve but without any aortic abscess or other valvular pathologies. After pacemaker placement, patient continued to have improved hemodynamics.

Infectious workup was unrevealing with no growth on blood cultures and vegetations was diagnosed to be Libman-Sacks (LS) endocarditis. The patient underwent successful biventricular permanent pacemaker placement, continued on anticoagulation, and was eventually discharged.

IMPACT/DISCUSSION: LS endocarditis is a form of nonbacterial thrombotic endocarditis that has been shown to be present in 6-11% of patients with SLE. Vegetations can appear in any valve but most commonly appear in the mitral, followed by the aortic valve. The most common functional abnormality identified in patients with valvular involvement is regurgitation and less commonly stenosis, and presenting with arrhythmias without significant functional valvular change is rare. The precise incidence of endocarditis associated with complete heart block is unknown although there are reported cases of endocarditis and perivalvular abscesses presenting with complete heart block, but no reported cases of LS endocarditis with complete heart block were found. While the case presents unique pathology, it also illustrates a unique clinical scenario of necessitating an invasive pacemaker placement prior to ruling out an infectious etiology.

CONCLUSION: This case presents a rare scenario of LS endocarditis presenting with complete heart block demonstrating the complexities involved in the management of complete heart block in the setting of identified endocarditis. Complete heart block in the setting of endocarditis, represents a complicated clinical scenario needing interdisciplinary care to optimize outcomes.

NEWLY DIAGNOSED DKA IN THE SETTING OF ACUTE PANCREATITIS DUE TO SEVERE HYPERTRIGLYCERIDEMIA AND ALCOHOL ABUSE: A CLINICAL CONUNDRUM

Shalva Eliava¹; Ross Lavine¹; Anesha White¹; Veronica L. Jacome¹; Hayder Al-khafaji¹; Dipal R. Patel²

¹Internal Medicine, Englewood Hospital and Medical Center, Englewood, NJ; ²Dept of Medicine, Englewood Health, Englewood, NJ. (Control ID #3877030)

CASE: 34-year-old Hispanic male with no known illnesses presented with acute epigastric pain that radiated to the back following consumption of ~6 beers per day and shots of liquor daily. He was hypertensive, tachycardic, and had epigastric abdominal tenderness. Clinical Institute Withdrawal Assessment (CIWA) score was 22.

Lab tests revealed hyponatremia of 124, mild leukocytosis, hemoconcentration, hyperglycemia with a high anion gap metabolic acidosis (AG 19, HCO3 16), HbA1C 11.2%, negative Gad-65 Antibody, severe hypertriglyceridemia (HTG) of >5,680 mg/dl and elevated lipase of 396 U/L. Non-contrast CT abdomen revealed features of acute pancreatitis(AP) without biliary or main pancreatic duct dilation.

He was admitted to ICU for management of AP due to severe HTG and alcohol (EtOH) abuse, new-onset diabetes mellitus (DM) with diabetic ketoacidosis (DKA), and EtOH withdrawal. He was treated with insulin infusion, IV fluids, folic acid, thiamine, and lorazepam as needed.

During the first 24-48 hours his clinical status worsened with persistent tachycardia, intermittent fevers, and AKI. Empiric antibiotics were initiated and hematology had planned for plasmapheresis the following day. However, there was rapid improvement in triglyceride (TG) levels and it was not needed. With improvement in TG levels, the patient was bridged with subcutaneous insulin and started on fenofibrate and atorvastatin. AKI resolved.

IMPACT/DISCUSSION: The most common causes of AP are ETOH use and gallstones. The risk of developing AP is 5 % when serum TG >1000 and 10-20% when > 2000 mg/dL. Pancreatic lipases break down TG into toxic FA which can cause AP. In addition to genetics, less common etiologies of HTG include uncontrolled DM, obesity, and EtOH use. Our patient presented with a common cause of AP and his severe HTG could have easily been missed had a lipid panel not been sent on admission. The American College Of Gastroenterology 2013 guidelines recommends checking lipid panel in patients with no obvious etiology for AP. In a 2019 supplement, moderate evidence was noted for checking LFTs, TG, and calcium in patients with AP. There are limited case reports where DKA coincided with HTG-induced pancreatitis. Data comparing plasmapheresis and insulin therapy for the treatment of HTG AP has been limited only to observational studies. A retrospective study showed that patients with mild and moderately severe AP can be treated effectively and safely with insulin compared to plasmapheresis, with no statistical significance noted in the length of stay and clearance rate.

CONCLUSION: ETOH is a well-known cause of pancreatitis. However other etiologies must be taken into consideration such as HTG, especially in high-risk patients. Anchoring to the most common diagnosis and stigmatization of nationality and social history must be avoided. In our patient, adequate and early medical management helped him to avoid a fatal course. Insulin therapy can be similarly effective to plasmapheresis in HTG pancreatitis

NOCARDIA BRASILIENSIS ARTHRITIS IN A PATIENT WITH STAGE IV LUNG CARCINOMA Ahmed Raza¹; Saman Razzaq²; Sarah R. Gillett¹

¹Internal Medicine, University of Vermont Medical Center, Burlington, VT; ²Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #3877312)

CASE: A 55-year-old woman with stage IV non-small cell lung carcinoma with brain metastasis and on active treatment with Osimertinib presented with a ten-day history of bullous skin rash and generalized left leg pain, predominantly in the knee. She denied any recent fever, headaches, cough, or difficulty breathing. Her vital signs were within normal limits at the time of presentation. Physical exam revealed photophobia, no focal neurologic deficits, multiple draining superficial skin abscesses on the left leg, and left knee effusion.

Initial lab results were significant for leukocytosis, anemia, and mild hyponatremia. CT scan of the left knee revealed suprapatellar and prepatellar knee joint effusion with multiple intra-muscular rim-enhancing fluid collections. Brain MRI revealed multiple abscesses, and chest CT showed no new abnormalities. A small volume of bloody synovial fluid was aspirated and analysis revealed leukocytosis with predominantly neutrophils; gram stain was negative for bacteria. Orthopedics performed knee arthrotomy, irrigation, and debridement for left knee septic arthritis. She was treated empirically with vancomycin, cefepime, and metronidazole. Synovial fluid ultimately grew Nocardia brasiliensis and the treatment was switched to trimethoprim-sulfamethoxazole (TMP-SMX), minocycline, and amikacin. Six weeks of therapy with antibiotics resulted in significant improvement in clinical symptoms. Repeat brain MRI also noted improvement after treatment.

IMPACT/DISCUSSION: Nocardia brasilinesis (NB) predominantly causes pulmonary disease and may cause CNS and skin manifestations in immunocompromised hosts. Septic arthritis is a rare nocardiosis manifestation, with aproximately 37 cases reported in recent literature. Surgical debridement and antimicrobial therapy (with TMP-SMX) result in significant improvement of clinical symptoms. Nocardia are opporunistic pathogens that can result in severe infections in patients with defects in cell mediated immunity. Skin rash and septic arthritis in immunocompromised patients should raise suspicion of Nocardiosis.

CONCLUSION: Clinicians should consider nocardiosis in differential diagnoses for skin and joint infections in immunocompromised patients. Though two-thirds of patients have lung involvement, hematogenous spread and disseminated disease are possible from cutaneous infections.

NOMADIC NEMATODE: A CASE OF DISSEMINATED STRONGYLOIDIASIS AND HYPERINFECTION SYNDROME

Kemar Barrett¹; Roshni Culas²; Devon Scott¹; Veronica R. Jacome Lopez¹; Gil Redelman-Sidi²; Natasha Rastogi¹

¹Internal Medicine, Englewood Health, Englewood, NJ; ²Infectious Diseases, Memorial Sloan Kettering Cancer Center, New York, NY. (Control ID #3877083)

CASE: A 59-year-old Jamaican man presented with 1-week of nausea, vomiting and diarrhea associated with abdominal pain. He denied fever, cough or rash. He was diagnosed with human T-cell lymphotropic virus type-1 (HTLV-1)-associated adult T-cell Leukemia/Lymphoma (ATLL) 3 months prior and completed 1 cycle of chemotherapy with Prednisone. He was afebrile but tachycardic at 126 bpm and hypotensive at 74/55 mmHg. Physical exam revealed a distended abdomen with generalized tenderness. Labs showed anemia to 7.7 g/dL, leukocytosis of 15 K/uL without eosinophilia, lactic acidosis of 4.1 mmol/L and acute kidney injury with creatinine 2 mg/dL. CT abdomen showed right-sided colitis. Blood cultures, HIV serology, stool studies and gastrointestinal (GI) pathogen panel were negative. Given no clinical improvement after 48 hours, he underwent upper GI endoscopy with biopsy showing active duodenitis/gastritis associated with Strongyloides stercoralis (S. stercoralis) infection. He developed acute hypoxic respiratory failure, acute encephalopathy

and septic shock requiring supplemental oxygen and fluid resuscitation. Repeat CT scans showed new ileus and bibasilar lung consolidations. Neuroimaging and lumbar puncture were unremarkable. Given the constellation of clinical findings, he was diagnosed with disseminated strongyloidiasis (DS) and hyperinfection syndrome (HIS) and was started on Cefepime and subcutaneous veterinary Ivermectin with gradual improvement in his symptoms.

IMPACT/DISCUSSION: S. stercoralis is an intestinal nematode endemic to tropical regions with an estimated global prevalence of 30-100 million people.

HIS occurs when increased autoinfection leads to high parasite burden in the lung and GI tract. DS occurs when this increased parasite load causes severe GI or lung involvement or disseminates to ectopic sites. The associated mortality approaches 100% if untreated. Our suspicion was high given the presenting GI symptoms, pneumonia, shock, encephalopathy and paralytic ileus. HTLV-1 co-infection causes cellular impairment and coupled with recent corticosteroid use, was a major risk factor for the development of DS/HIS. Duodenal biopsy was diagnostic and has been shown to be more sensitive than standard wet mount analysis of stool.

Ivermectin is the treatment of choice and should be continued for at least 2 weeks after 3 negative stool tests. The presence of ileus precludes oral delivery and warrants parenteral formulation. Empiric antibiotics that target enteric pathogens are also recommended due to potential bacterial translocation with larvae.

Our patient likely acquired S. stercoralis infection prior to emigrating to the US, and that this episode of DS/HIS was a complication of his chronic infection and immunosuppressive therapy.

CONCLUSION: DS/HIS are fatal complications of chronic S. stercoralis infection. HTLV-1 infection and corticosteroids are major risk factors for DS/HIS. Timely diagnosis and prompt initiation of anthelminthic therapy are key to decreasing mortality.

NON-CUTANEOUS MELANOMA: AN ELUSIVE DISGUISE

Edmond Ling, Nicoleta Rus

Rocky Vista University College of Osteopathic Medicine, Parker, CO. (Control ID #3861532)

CASE: Melanoma is the most severe form of skin cancer, being fifth most common cancer in the United States. Melanomas usually present as pigmented skin lesions and most forms are impacted by cumulative sun damage (CSD), with an increased incidence with age. Early diagnosis is crucial to improve prognosis and mortality. Non-cutaneous melanomas and uncommon variants of cutaneous melanoma are rare, but they pose a significant challenge for diagnosis.

We report a case of a 63-year-old male who presented to the clinic with a concern of right shoulder mass that had been progressively growing in the past month. Past medical history includes hypertension, hypothyroidism, hyperlipidemia, but no history of skin lesions, trauma or malignancies. The patient had prior elevated levels of PSA, but prostate biopsy ruled out prostate cancer, making unlikely prostate related metastasis. Physical exam was significant for non-tender, firm, mobile mass about 2 cm, over the anterior right deltoid, and no concerning skin lesions overall. Ultrasound showed hypoechoic, part solid complex mass with minimal internal blood flow, with lobular border with maximum diameter 2.1 cm, prompting further imaging with MRI. MRI with contrast revealed suspicious malignant solid mass of the anterior shoulder situated at the junction between the subcutaneous compartment and the underlying deltoid muscle. The biopsy of the right shoulder was compatible with metastatic melanoma. Whole body PET-CT imaging revealed further metastasis in the lower lobe of the right lung, left gluteal medius muscle, subcutaneous level of the left lower back, and right axillary node, but there was no primary lesion found. Treatment was initiated with double immunotherapy, respectively with ipilimumab and nivolumab. Patient developed several medication sides effects such as rash, diarrhea, and uveitis, well controlled with symptomatic treatment. He reported also persistent cough, highly concerning due to his lung metastasis, however his cough resolved after discontinuation of lisinopril, used for hypertension. Our patient responded overall well to immunotherapy, with significant, progressive decrease in size of metastasis after 6 months, but metastatic stage at diagnosis exposes him to a reserved long-term prognosis.

IMPACT/DISCUSSION: Although there is evidence that melanoma cases are over-diagnosed clinically, diagnosis of melanomas remains challenging in uncommon presentations such as this case. While cutaneous melanomas are diagnosed clinically with a high sensitivity and specificity, non-cutaneous, mucosal melanomas are usually diagnosed on an advanced, metastatic stage. Non-cutaneous primary melanomas are a complex group of malignancies with unique biologic findings. Anatomic location raises specific diagnostic and management challenges.

CONCLUSION: It is important for physicians to be aware of melanomas that present with uncommon patterns, for prompt intervention, as survival depends on the stage of the disease at the time of diagnosis.

NOT A CONTAMINANT: A CASE OF S. EPIDERMIDIS BACTEREMIA WITH ENDOCARDITIS AND ABSCESS FORMATION

Charlotte Ezratty¹; Michelle Nanni¹; Rex Hermansen²

¹Internal Medicine, Mount Sinai Health System, New York, NY; ²Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3876609)

CASE: A 56-year-old woman with a past medical history significant for end stage kidney disease (ESKD) on dialysis, peripheral arterial disease, coronary artery disease, and psychogenic nonepileptic seizures (PNES) presented to the Emergency Department after witnessed seizure-like activity while at dialysis. On arrival, she was noted to be febrile to 38.2 degrees Celsius, so two sets of blood cultures were obtained. She complained of pain in her right lower extremity after bumping into a park bench recently, but otherwise denied any recent infectious symptoms.

After 16 and 18 hours of incubation, both sets of blood cultures from admission grew gram positive cocci in clusters. She was empirically started on IV vancomycin; however, once the cultures speciated to Staphylococcus epidermidis, antibiotics were discontinued as they were felt to likely represent contamination. It was presumed that both sets of blood cultures were sent from the same venipuncture site.

Unfortunately, the patient became agitated during her hospital stay and declined to have repeat labs drawn for approximately 48 hours. Once obtained, repeat blood cultures also grew Staphylococcus epidermidis in both sets. A CT with contrast was performed of her right lower extremity identified a 5cm abscess which was drained surgically; these cultures also grew S. epidermidis. She was noted to have a new 4/6 systolic murmur, and a transthoracic echocardiogram revealed a 1.36 cm vegetation on the mitral valve. She was evaluated by cardiac surgery who felt that her surgical risk was prohibitively high and prescribed a prolonged course of IV vancomycin as recommended by Infectious Diseases.

IMPACT/DISCUSSION: Coagulase-negative staph constitute part of normal human skin flora and thus are frequently considered to be contaminants when isolated from a single blood culture [1]. However, Staphylococcus epidermidis is one of the most common causes of nosocomial blood infections [2]. In our patient, given the incubation time and lack of other evidence of active infection, the blood cultures were erroneously attributed to contamination and antibiotics were discontinued. One of the most important factors allowing coagulase-negative staph to thrive is the production of biofilms; thus, S. epidermidis has been identified as an important cause of infections in implanted medical devices and prosthetic valves, but is less often associated with abscess formation, as was seen in our patient [3]. The unfortunate delay in obtaining repeat blood cultures left the patient untreated while they were presumed to be a contaminant; however, multidisciplinary team involvement eventually lead to the appropriate diagnosis and treatment.

CONCLUSION: Blood culture results, even common contaminants, should be carefully evaluated with appropriate follow up testing in the setting of significant patient risk factors. Careful assessment and multidisciplinary team involvement is critical for appropriate diagnosis and treatment.

NOT ALL PAIN IS FIBROMYALGIA: A CASE OF PARATHYROID CARCINOMA

Rebekah E. Scott, Rebecca Nekolaichuk, Pratima Kumar, Steven Taylor

Department of Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #3872294)

CASE: A 28-year-old woman with a 3-4 year history of worsening fatigue, depression, generalized weakness, and diffuse limb aches diagnosed as fibromyalgia in an outpatient setting presented to the emergency room with new-onset right shoulder pain after reaching for an object on a shelf. Lab studies showed calcium 15.0 mg/dL, phosphorus 2.3 mg/dL, PTH >2500 pg/mL, and alkaline phosphatase 1604 units/L. Shoulder CT showed diffuse sclerosis with innumerable bone lesions in all osseous structures and a large left paratracheal soft tissue mass. Neck sonogram showed the mass to be a 5.3 cm complex lesion concerning for a giant parathyroid adenoma posterior to the left thyroid lobe. Abdomen/pelvis CT showed bilateral nephrolithiasis, likely medullary nephrocalcinosis, and diffuse osteosclerosis with lytic lesions throughout the appendicular skeleton likely representative of brown tumors. Medical management of her hypercalcemia included aggressive normal saline IV infusion and bisphosphonate therapy. The neck mass was resected, and surgical pathology demonstrated parathyroid carcinoma with focal angioinvasion in the tumor capsule without extension into surrounding tissue.

IMPACT/DISCUSSION: We present the case of a parathyroid carcinoma as a cause of severe primary hyperparathyroidism in a young woman. This case gives us an opportunity to consider the clinical course of untreated hyperparathyroidism, as well as how provider biases around patient age and pain may impact evaluation and treatment. The outpatient assessment did not include a comprehensive metabolic panel (CMP) before the patient was diagnosed with fibromyalgia, and a CMP may have identified the hypercalcemia earlier. Including in young women, it is important to consider hypercalcemia and hyperparathyroidism in the differential diagnosis for diffuse musculoskeletal pain. Approximately 90% of hypercalcemia results from primary hyperparathyroidism or malignancy. The most appropriate initial test to evaluate hypercalcemia is a PTH level to distinguish between PTH-dependent and PTH-independent etiologies.

As in this patient, untreated primary hyperparathyroidism may present as osteitis fibrosa cystica. Parathyroid mass resection may lead to the complication of hungry bone syndrome, which requires ICU-level monitoring and repletion of phosphorus and calcium.

The annual incidence of parathyroid carcinoma is about 3.5-5.7 cases per 10,000,000 people. Parathyroid carcinoma is associated with <1% of primary hyperparathyroidism cases. The peak incidence of cases is at ages 50-59, with patients under age 30 accounting for less than 4% of cases. These facts highlight the rarity of parathyroid carcinoma causing primary hyperparathyroidism in a young person.

CONCLUSION: Hypercalcemia and hyperparathyroidism should be on the differential for all patients with diffuse musculoskeletal complaints and may be easily missed in young women. Severe hypercalcemia and hyperparathyroidism require aggressive management, potentially including surgery.

NOTHING TYPICAL ABOUT THIS: DIAGNOSING EBSTEIN-BARR VIRUS (EBV) MONONUCLEOSIS IN AN ADULT WITH ATYPICAL LYMPHOCYTOSIS

Nicholas B. Safian¹; Shyam Sundaresh²

¹Internal Medicine, Mount Sinai Health System, New York, NY; ²Department of Medicine, Mount Sinai Health System, New York, NY. (Control ID #3873812)

CASE: A 69-year-old woman with past medical history significant only for hyperlipidemia presented to clinic with two weeks of fever, fatigue, night sweats, and rash. Physical exam was notable for afebrile, diffuse shotty lymphadenopathy, splenomegaly, macular erythematous rash on bilateral thorax, with absence of pharyngeal erythema, and joint findings. Patient took no medications. Initial laboratory studies were significant for a white blood cell count of 8600/uL, with 10% atypical lymphocytes, and aspartate transferase elevated to 58 U/L. Erythrocyte sedimentation rate, C reactive protein, creatine phosphokinase, and alanine transaminase were within normal limits; HIV antigen/antibody non-reactive. Additional testing revealed an elevated EBV viral capsid antigen (VCA) IgM, which returned to within normal limits, along with complete blood counts with differential, on repeat testing three weeks later. Symptoms had fully resolved at this time.

IMPACT/DISCUSSION: This patient’s symptoms of rash, fatigue, fever, and night sweats, and lab findings of atypical lymphocytosis and positive EBV VCA IgM––which normalized after several weeks––represent a case of infectious mononucleosis.

Atypical lymphocytosis is defined as ≥10% of circulating lymphocytes. The general internist’s consideration of this laboratory finding should include primary hematologic processes, such as chronic lymphocytic leukemia (CLL). While CLL often presents with B symptoms, diagnosis is made with ≥5,000 B lymphocytes/uL seen in the peripheral blood for at least 3 months, confirmed by flow cytometry, and immunophenotype/cytogenetic testing. Thus, atypical lymphocytosis in a patient with normal absolute peripheral blood counts (as seen in this case) is definitively not hematologic malignancy. Other causes of atypical lymphocytosis are reactive and include viral (EBV, HIV, CMV), bacterial (pertussis, cat-scratch disease), drug reaction, rheumatoid arthritis, and hyperthyroidism.

The large majority of infectious mononucleosis cases caused by EBV occur between the ages of 15-25 years. Incidence is less than 5/100,000 in adults older than 30. While rare, the general internist should be prepared to recognize the presentation of EBV infection in adults, as it often differs from traditional presentation. In younger patients, lymphadenopathy and pharyngitis occur in 94% and 84% of cases, respectively, compared to 47% and 43% of cases in patients >40 years. Other symptoms for older patients include fever (95%), splenomegaly (33%), hepatomegaly (42%), rash (12%), and jaundice (27%). Lab abnormalities include atypical lymphocytosis and self-limited elevation in aminotransferases.

CONCLUSION: 1. Consider infectious causes in addition to hematologic, autoimmune, and hypersensitivity-related processes in the clinical evaluation of atypical lymphocytosis.

2. Rule out infectious mononucleosis caused by EBV in adult patients with atypical lymphocytosis, rash, fever, and fatigue as pharyngitis is often absent in patients >40 years old.

NOT JUST FOR KIDS: A CASE OF ADULT-ONSET RECURRENT ABDOMINAL MIGRAINES Jessica A. Erickson

Division of General Internal Medicine, UCSF Medical Center, San Francisco, CA. (Control ID #3872159)

CASE: A 47-year-old man with depression, migraines, obesity, and prior cholecystectomy presents to clinic for recurrent abdominal pain with nausea/vomiting. In the past 14 months, he had 5 episodes of severe left abdomen pain. Episodes had no trigger and self-resolved in 2-3 days. He was asymptomatic between episodes and had no related dietary, medication, bowel, substance use, or life changes. Two weeks prior, he presented to the ED with “deep aching” pain in the LLQ, with associated nausea, vomiting, fatigue, and headache. No diarrhea, constipation, melena, fever, or sick contacts. On exam he had tenderness in the LLQ/LUQ. Labs (CBC, CMP, lipase, troponin, lactate, UA, Covid) and imaging (KUB, CT A/P) were unremarkable. He was given hydromorphone and discharged with presumption of gastroenteritis. In clinic, he reports no active symptoms; vitals and exam were unremarkable. GI was e-consulted. Given the patient’s personal and family history of migraines, associated nausea, vomiting, and headache, the cyclical nature of episodes and negative workup, abdominal migraines was suspected. The patient was counseled on behavioral modifications and recurrence was effectively managed with early sumatriptan use.

IMPACT/DISCUSSION: This case highlights the diagnosis and management of abdominal migraines, a rare cause of image-negative cyclical abdominal pain. Because abdominal migraine is predominantly a pediatric disorder, there are only a few case reports of this in adults. Although rare, abdominal migraines should be considered after a negative GI workup, especially in those with a personal or family history of migraines. The condition can be diagnosed using criteria from the International Classification of Headache Disorders and the Rome IV Classification of Gastroenterology Disorders. These include: 5+ attacks of abdominal pain lasting 1-72 hours, associated anorexia, nausea, vomiting, headache, photophobia, or pallor, intervening asymptomatic periods, and a negative GI workup. Treatment is challenging as symptoms are often refractory to conventional therapies such as analgesics, antiemetics, and antacids. Migraine prophylactic (divalproex, topiramate, metoprolol, propranolol) as well as abortive (triptan) therapies have been described in case reports with variable success. Recurrent abdominal migraine can cause substantial distress and disability. Early recognition and treatment is important to alleviate symptoms and prevent unnecessary, invasive testing and therapies.

CONCLUSION: Consider abdominal migraines in the differential for image-negative cyclical abdominal pain in adults with a personal or family history of migraines

Diagnostic criteria include: recurrent episodes of abdominal pain lasting > 1 hour with associated anorexia, nausea, vomiting, headache, photophobia, or pallor with intervening asymptomatic periods and a negative GI workup

Treatments include prophylactic (divalproex, topiramate, metoprolol and propranolol) and abortive (triptan) medications

NOT JUST LACTULOSE DEFICIENCY: A RARE CAUSE OF ALTERED MENTAL STATUS IN A CIRRHOTIC PATIENT

Richard Lowell T. Barr, James Ngoyi, Ivonne V. Lollett

Internal Medicine, University of Virginia, Charlottesville, VA. (Control ID #3873741)

CASE: A 55 year old female presented to the emergency department after having been referred there by her hepatology clinic for generalized weakness and altered mental status. Her past medical history was remarkable for decompensated cirrhosis secondary to alcohol use and now-treated Hepatitis C. Her cirrhosis has been complicated by refractory ascites, non-bleeding esophageal varices, hepatic encephalopathy, and recurrent hepatocellular carcinoma. On evaluation, the patient’s family member noted that she had experienced progressive weakness over the past several months accompanied by increased thirst. She was not compliant with most of her medications including diuretics and lactulose, had been constipated for several days, and was only drinking bottled soda due to poor appetite and nausea. She denied alcohol or drug use.

The patient was hemodynamically stable and afebrile on admission. Physical exam was remarkable for dry mucus membranes, mildly distended abdomen without fluid wave, generalized symmetric weakness, marked cognitive slowing, and no asterixis. Blood counts were remarkable for chronic thrombocytopenia. A metabolic panel revealed a corrected sodium of 136 mEq/L, glucose 795 mg/dL, bicarbonate 26 mg/dL, and an anion gap of 10. Urinalysis was negative for ketones. Hemoglobin A1C was 14.2%. C-Peptide was 0.8 ng/mL. The patient’s mental status improved rapidly with the administration of intravenous fluids and insulin. Upon further chart review, no previous hemoglobin A1C values were found. She was diagnosed with new-onset Type II Diabetes complicated by hyperglycemic hyperosmolar non-ketotic state (HHS) and discharged several days later with subcutaneous insulin.

IMPACT/DISCUSSION: While hepatogenous diabetes is a well-described phenomenon, this case is unique and deserves attention. Cirrhosis and insulin resistance are closely-related disease states, with a recent meta- analysis finding a prevalence of 31% of diabetes in cirrhotic patients. Several proposed mechanisms linking the two, including changes in insulin clearance and impaired beta cell function. Despite this, HHS appears to occur very rarely in cirrhotics. Only one case report exists describing HHS in the context of cirrhosis, and this is from more than twenty years ago. This case adds to the literature by redemonstrating a rare simultaneous occurrence of 2 common disease states. More broadly, this case provides an example of the importance of avoiding anchoring bias when approaching cirrhotic patients with altered mental status. Although hepatic encephalopathy is a common cause of altered mental status in this patient population, other causes should be ruled out before simply increasing lactulose.

CONCLUSION: -Although a link between cirrhosis and insulin resistance has long been understood, hyperosmolar hyperglycemic nonketotic state (HHS) is only rarely seen in cirrhotic patients.

-While rare, HHS can be a cause of altered mental status in cirrhotic patients.

NOT OK TO HAVE NO K

Janteshpreet Sandhu¹; Angelina Lo¹; Akash Patel²; Cameron Harding²

¹School of Medicine, University of California Irvine, Irvine, CA; ²Internal medicine, University of California Irvine, Irvine, CA. (Control ID #3875434)

CASE: A 29-year-old female with past medical history of hypertension, atrial fibrillation on digoxin, hyperthyroidism on methimazole, and type 2 diabetes mellitus on insulin presented to the emergency department with complaint of weakness in the left lower extremity. Earlier that day, she had experienced generalized weakness and inability to rise from a seated position due to weakness in the left leg. Additionally, the patient noted that she had minimal oral intake for some time and had unintentionally lost 20 pounds in three months. She attributed this to emotional distress from losing 3 family members, including her mother, to COVID-19 in the past year. She stopped taking her medications for about one month due to the anxiety she experienced from these events.

On arrival to the emergency department, her blood pressure was 152/80 and heart rate was 100 bpm. Initial studies showed a potassium of 2.0 mEq/L and glucose of 204 mg/dL. Free T4 was elevated at 4.41 ng/dL and her TSH was undetectable. EKG showed atrial fibrillation with prominent U waves and T wave inversions on leads II and in V5-V6. Chest X-ray showed an enlarged cardiac silhouette with some vascular congestion. CT of the head was unrevealing. She was admitted to medicine for management of possible hyperthyroid hypokalemic periodic paralysis.

The patient was restarted on most of her home medications, including methimazole. Her digoxin level was found to be subtherapeutic, however this medication was discontinued due to increased risk of digoxin toxicity from her hypokalemic state. An aldosterone level was found to be normal, ruling out mineralocorticoid excess as a possible cause of hypokalemia. After 4 days of hospitalization and normalization of hypokalemia, the patient was discharged with significant resolution of initial weakness.

IMPACT/DISCUSSION: Uncontrolled hyperthyroidism results in upregulation of Na/K ATPase activity, resulting in hypokalemia and possible periodic paralysis. Although the total body stores of potassium remain unchanged in hyperthyroidism, the intracellular shift can result in profound hypokalemia. In this case, the patient's emotional distress from losses experienced during the COVID-19 pandemic led to self- discontinuation of methimazole. The unmasked hyperthyroidism resulted in severe hypokalemia and paralysis that ultimately prompted her to seek further care. While her symptoms can be largely attributed to her thyroid dysregulation, her history of digoxin use may have compounded her hypokalemia.

CONCLUSION: Hyperthyroid hypokalemic paralysis may be triggered by emotional distress, poor nutritional intake, or temporary pause in thyroid suppressing treatment. While this condition is readily reversible with correction of hypokalemia, controlling thyroid function is the greatest aspect of preventing its recurrence.

NOT SO WATER FAST: A CASE OF WATER FASTING INDUCED NUTRITIONAL DEFICIENCY CARDIOMYOPATHY

Zachary Stauber¹; Kenneth M. Fifer²

¹Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY; ²Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3874479)

CASE: A 26-year-old male with a history of morbid obesity presented to the emergency department with bilateral lower extremity swelling, shortness of breath and decreased exercise tolerance. 3 months prior to presentation he initiated a water fasting diet to promote weight loss, consuming only water for 22 days and initially lost 45 pounds. He then began to liberalize his diet, and after several weeks noticed increasing lower extremity edema that gradually progressed to groin and abdominal edema. Initial exam was significant for profound anasarca and 4+ pitting edema to the lower abdomen. Labs were notable for albumin 1.8 g/dL, prealbumin 5.50 mg/dL (nl 20-40 mg/dL), TSH 5.198, free T4 0.54, BNP 7495. TTE demonstrated a severely reduced ejection fraction of 14% with multiple left ventricular thrombi, with concern for cardiogenic shock prompting transfer to the cardiac ICU. He was diuresed aggressively with 115-pound weight loss and initiated on guideline-directed medical therapy (GDMT) with carvedilol, sacubitril/valsartan and spironolactone, as well as wafarin for the ventricular thrombi. He was given partial parenteral nutrition in order to replete nutritional deficiencies which included a thiamine of 66.9 nmol/L (nl 65-200 nmol/L), selenium 94 ug/L (nl 91-198 ug/L) and zinc 44 ug/dL (nl 56-134 ug/dL). Cardiac MRI and PET scan revealed a likely inflammatory myopathy. Subsequent endomyocardial biopsy was unrevealing. During hospitalization, he demonstrated significant clinical improvement, with 3 and 6 month follow up TTE's demonstrating ejection fractions of 27% and 52%, respectively.

IMPACT/DISCUSSION: Given the paucity of data surrounding the entity, no firm criteria have been established for the diagnosis of NDCM, though it should be considered in patients with evidence of malnutrition and heart failure in which more common etiologies have been ruled out. While a variety of micronutrient deficiencies have been implicated in the development of NDCM, coenzyme Q10 (CoQ10), thiamine, carnitine, taurine, selenium, and niacin have been particularly recognized as essential components for metabolic pathways involved in myocardial energy production and calcium balance. Repletion of key nutritional components via partial parenteral nutrition and improved oral intake via patient education, along with GDMT led to rapid clinical improvement. While NDCM as a result of chronic malnutrition is a well- documented entity, the effects of acute malnutrition (i.e., water fasting), are less well understood. Given the increasing promotion of so-called "fad diets", this case further highlights the importance of informed patient counseling surrounding lifestyle and dietary change for safe and effective weight loss.

CONCLUSION: 1) Nutritional deficiency cardiomyopathy (NDCM) is a serious and potentially life- threatening complication of water-fasting.

2) Nutritional supplementation, informed patient counseling and guideline-directed medical therapy can significantly improve outcomes in patients with NDCM.

NOVEL CORONAVIRUS (COVID-19) INDUCED MYOSITIS- CASE REPORT

Natalie Sorial¹; Eric Nielsen²; Conor Grogan³

¹Internal Medicine, University of Massachusetts Chan Medical School, Worcester, MA; ²Internal Medicine, UMass Memorial Medical Center, Worcester, MA; ³Hospital Medicine, University of Massachusetts Chan Medical School Department of Medicine, Worcester, MA. (Control ID #3874395)

CASE: Seven weeks after a mild COVID-19 illness, a 41-year-old woman presented to the ED with 40 pounds of weight gain over 3 weeks with associated fevers, dyspnea on exertion, and worsening myalgias. She had diffuse crackles at her bilateral lung bases, proximal muscle weakness, and non-pitting edema in her face and four extremities.

She was found to have significant hypoalbuminemia, nephrotic range proteinuria, elevated inflammatory markers, and transaminases greater than 10 times normal. Liver biopsy showed nonspecific inflammation. She also had significant elevations in CK, beta-2-microglobulin, and urine myoglobin, suggesting tubular nephropathy likely from a catabolic rhabdomyolysis picture. She had elevated troponin and Ck-MB, with a nonsignificant EKG and a TTE suggesting myocardial involvement in an inflammatory myositis. Testing for autoimmune myositis resulted + anti-Jo 1 antibodies, weakly positive anti-SRP, and a +cANCA with negative MPO and PR3. MRI of the right arm showed diffuse signal abnormality consistent with inflammatory myopathy.

An EMG and muscle biopsy were not pursued due to anticipated low yield given the extent of the patient’s anasarca. The anasarca responded minimally to diuresis and was complicated by orthostasis. After shared decision making with the patient to pursue empiric steroids despite not having a firm diagnosis, her symptoms improved within days, marked by improved peripheral edema, resolution of nephrotic range proteinuria, and downtrending CK and ALT/AST. At follow-up with rheumatology two weeks later, her symptoms continued to improve but she had evidence of ongoing inflammation with persistently elevated CK, troponin, and proteinuria. She is pending multi-specialty follow up, possible kidney biopsy and consideration of IVIG and/or azathioprine for steroid sparing therapy.

IMPACT/DISCUSSION: The working diagnosis of this unusual presentation is COVID-19 myositis with potential false positive auto-antibodies. As we continue to learn about longitudinal complications of COVID-19, the ways in which we manage acute complex illness becomes exceedingly important. This case highlights the importance of discussing the risk and benefit of electing an empiric treatment versus arriving at a firm diagnosis with a patient and subspecialist teams to guide care. Our patient's multi-system inflammation made interdisciplinary teamwork critical to her care, but competing concerns from different specialties for a firm diagnosis may have led to a delay in treatment and increased patient suffering. The choice was

ultimately made to start empiric steroids without diagnostic tissue biopsy, and while it clouded the diagnostic certainty, it may well have saved her life.

CONCLUSION: - Interdisciplinary teamwork in medically complex cases can inadvertently lead to delays in diagnosis and treatment

- Shared decision making is a tool when considering implications of empiric treatment versus reaching a firm diagnosis

NYSTAGMUS AND NUTRIENTS: RAPID OCULAR CHANGES IN AN HIV/AIDS PATIENT Olivia Reszczynski¹; Justin Kusiel²; Linnea Mitchem²; Benjamin Kalivas²

¹College of Medicine, Medical University of South Carolina, Charleston, SC; ²Medical University of South Carolina, Charleston, SC. (Control ID #3876274)

CASE: A 24-year-old woman with a past medical history of HIV/AIDS, with viral load greater than one million, and depression presents with months of headaches, worsening blurry vision and one week of diplopia. She described the headaches as bilateral and frontal in location. The headaches improved with ibuprofen and were made worse with lying flat. She also reported a 23-pound weight loss over the last 9 months due to a loss of appetite following a COVID diagnosis, with months of nausea and vomiting. She had also noted worsening of her mood over this time with a suicide attempt two weeks prior.

On initial physical exam, her vital signs were normal and she was alert. Her neurologic exam revealed a bilateral 6^th nerve palsy but was otherwise normal. The rest of her physical exam was essentially normal. During the patient’s hospital course, her abducens nerve palsy progressively worsened. Dilated fundal exam showed no evidence of chorioretinitis or vasculitis. CT head, MRI brain, cervical spine, and orbits were all unremarkable. Cerebral spinal fluid analysis revealed normal protein and no evidence of infection, including histoplasma, toxoplasma, and cryptosporidium. Serum IgM for Toxoplasma was slightly positive, but serum PCR was negative.

After a negative workup for infectious and structural causes of her symptoms, thiamine and heavy metal serum labs were drawn, and the patient was empirically started on 500 mg IV thiamine three times daily for three days. The patient’s ophthalmoplegia and blurry vision markedly improved with thiamine therapy.

IMPACT/DISCUSSION: Thiamine deficiency in AIDS patients can occur when patients become cachectic and develop poor nutritional status. Hyperemesis syndromes are also associated with AIDS. Because thiamine is not harmful even at high doses, there should be a low threshold for starting thiamine supplementation in HIV/AIDS patients, especially considering the potential to progress to irreversible Korsakoff dementia. Opportunistic infections, such as cytomegalovirus and herpes zoster, can cause nystagmus, and infectious etiologies should be investigated. Anchoring bias is a cognitive error where a physician relies too heavily on initial assessment or results, in this case, the threat of an opportunistic infection in a patient with AIDS. This case emphasizes the importance of remaining vigilant of the other causes of neurologic symptoms, like vitamin deficiencies, even when more academically interesting possibilities, like opportunistic infection, need to be ruled out.

CONCLUSION: Thiamine deficiency can occur in patients with repetitive vomiting and chronic malnutrition. Immunocompromised patients with focal nerve palsy elicit large differential diagnoses in addition to thiamine deficiency including meningitis, encephalitis, multiple sclerosis, and neoplasm.

OCULAR NEUROSYPHILIS IN THE SETTING OF HIV CO-INFECTION AND ACUTE WORSENING OF OCULAR SYMPTOMS POST-JARISCH-HERXHEIMER REACTION

Chloe LaRochelle, Dianne Goede

College of Medicine, University of Florida, Gainesville, FL. (Control ID #3872398)

CASE: A 42-year-old male with history of depression who presented for 2-3 weeks of new-onset bilateral vision loss and associated headache. He had no recent trauma, flashes, floaters, fevers, or vomiting. He had no past history of STIs but reported recent IV drug use and unprotected sex with men and women. Physical exam was significant for a papulosquamous rash on the palms and soles, bilateral panuveitis, and a normal neurologic exam. Infectious work-up revealed newly diagnosed HIV infection and neurosyphilis. Penicillin was started and complicated by a Jarisch-Herxheimer (JH) reaction. He underwent 21 days of inpatient IV penicillin treatment with HIV therapy started on day 10 of admission. On day 7/21 of penicillin, he developed new-onset floaters and pain with ocular movements. Ophthalmology continued closely following. His headache improved with persistence of baseline blurred vision at discharge. Social work helped coordinate HIV care and outpatient ophthalmology follow-up, which was never completed, though later ED visits noted stable visual acuity from discharge.

IMPACT/DISCUSSION: The incidence of syphilis has been rising in the United States since the 2000s, with a 6.8% increase from 2019 to 2020 (1). HIV and syphilis co-infection has also risen, with co-infection facilitating transmission of these diseases (2; 3). HIV co-infection can advance the progression of syphilis, increase the likelihood of syphilis treatment failure, and lead to recurrence of syphilis (4; 2). The most common presentation of ocular syphilis is panuveitis (2) with several studies noting that panuveitis is more common in HIV+ patients as was our patient’s case. (5; 6; 7). This highlights the importance of considering HIV and syphilis co-infection in the setting of panuveitis.

The incidence of JH reactions is likely similar amongst HIV+ and HIV- patients, though one study notes a non-significant higher incidence of the reaction amongst HIV+ patients (8). Risk factors for JH reactions include RPR titers ≥ 1:32, early syphilis, and prior penicillin treatments (8). Our patient was at reduced risk of developing a JH reaction with an RPR titer of 1:4. Importantly, patients with ocular syphilis may have abnormal JH reactions, including rapid vision loss (9). Our patient had a traditional JH reaction with worsening ocular symptoms after the initial reaction resolved, which is a unique presentation that has not been previously described. Prompt treatment with IV penicillin provides the best visual acuity outcomes for patients with ocular syphilis, with one study noting over 80% of patients followed improved by at least 1 Snellen line and another noting near recovery to baseline in several patients (10; 11).

CONCLUSION: Maintain clinical suspicion for neurosyphilis with HIV co-infection when patients present with panuveitis

Patients with co-infection of syphilis and HIV may be at increased risk of developing JH reactions with atypical presentations

OH SNAP: CELLULITIS FROM A SNAPPING TURTLE BITE

Yassmin Hegazy, Luke Joseph, Daniel Balkovetz

Medicine , University of Alabama at Birmingham, Birmingham, AL. (Control ID #3874854)

CASE: A 51-year-old male with a history of hypertension and hyperlipidemia presents with a two-day history of worsening right hand pain and swelling. The patient reported symptom onset following a snapping turtle bite in an Alabama river. He reported associated fever and chills as well as swelling and erythema extending to his wrist. Patient with an unremarkable family and surgical history with a social history notable for occasional alcohol and tobacco use. Vitals were remarkable for an elevated blood pressure (164/110) and physical exam significant for multiple abrasions over the right thenar eminence with associated swelling and erythema extending up to the wrist with mildly decreased thumb range of motion and grip strength. Labs were notable for a white blood cell count (WBC) 12.7 as well as a hand X-ray and ultrasound showing ill- defined fluid tissue expansion in the deep planes of the right ventral palpable without fractures. The patient underwent thenar aspiration with plastic surgery with wound cultures growing enterobacter cloacea, aeromonas veronii, and coagulase negative staphylococcus. He was given a tetanus vaccination and started on ceftriaxone transitioned to amoxicillin/clavulonic acid and doxycycline for a two week course with hand swelling and range of motion improvement to baseline.

IMPACT/DISCUSSION: Animal bite incubation times can vary depending on the organism and site with secondary polymicrobial infection being common especially in aquatic environments as seen in our patient. Similar to our case presentation, the type of animal, site of bite, as well as wound cultures are important factors to tailor antibiotic treatment and duration of therapy. Previous case reports have shown various species associated with amphibian and marine bites with commonly associated species including aeromonas with an incubation time within twenty-four hours and mycobacterium marinum with an incubation time of a week following the initial bite. Similar case reports have shown that early surgical consultation and imaging is important when assessing patients with animal bites especially in the setting of an aquating environment given the higher likelihood of polymicrobial exposure and infection.

CONCLUSION: Vaccination and immunocompromised status is vital to prognosis and important to evaluate on presentation given a worse prognosis in immunocompromised patients. When a patient presents with worsening swelling and pain following an animal bite with exposure to an aquatic environment, cellulitis should be on the differential diagnosis.

OM1 SPONTANEOUS CORONARY ARTERY DISSECTION

PALLABI SHRESTHA¹; Aaron Bertolo¹; Amith Rao¹; JR Exequiel Pineda²

¹Internal Medicine, The University of Arizona College of Medicine Tucson, Tucson, AZ; ²Cardiology, The University of Arizona College of Medicine Tucson, Tucson, AZ. (Control ID #3877045)

CASE: A 37-year-old female with no significant past medical history presented with sudden onset crushing non-exertional chest pain that radiated to left arm. ASA 324 mg and nitroglycerin were given but had minimal effect on her chest pain. She had a similar episode two weeks earlier, which had self-resolved. EKG demonstrated inferolateral STEMI. CT angiography ruled out aortic dissection. Initial Troponin was elevated at 1457 and UDS was positive for methamphetamine. Coronary angiography revealed single-vessel disease in the distal OM1, TIMI 3 flow, concerning for Spontaneous Coronary Artery dissection (SCAD). Chest pain and ST elevations on EKG resolved immediately following coronary angiogram. Patient was managed medically and discharged home on daily ASA 81mg, statin and carvedilol with plans for follow-up coronary CT angiogram as outpatient.

IMPACT/DISCUSSION: SCAD is a sudden non traumatic separation of coronary artery and is an important cause of non-atherosclerotic acute coronary syndrome (ACS). SCAD was initially thought to be a rare cause of ACS predominantly affecting peri-partum women. Advances in coronary imaging have demonstrated that SCAD is much more common. It is theorized to be the cause of 1-4% of all acute coronary syndrome presentations and occurs overwhelmingly in women. 35% females under the age of 50 suffer from a myocardial infarction due to SCAD. The pathophysiology of SCAD is currently unknown. Two mechanisms have been proposed – 1. intimal tear leading to blood propagation in media and 2. Intramural hemorrhage due to ruptured vasa vasorum without intimal tear. Risk factors include pregnancy, fibromuscular dysplasia, inflammatory disease, hormone replacement therapy, and undue physical or emotional stress. It is hypothesized that the catecholamine surge associated with these stressors induce coronary artery shear stress leading to SCAD. Diagnosis and management for this condition is challenging due to limitation in information and standard guidelines. We present a case of SCAD in a young female undergoing coronary angiography which revealed tortuous OM1 with a focal 60 to 70% stenosis/haziness noted in distal part of the OM1. Lesion remained same after the patient received up to 350 mcg of intracoronary nitroglycerin.

CONCLUSION: Our patient was homeless with history of methamphetamine use but she did not demonstrate any of the other more common risk factors for SCAD. This case illustrates the importance of considering SCAD early in the presentation of acute ACS in young females with minimal cardiac risk factors. It highlights the importance of clinical caution when determining the indication for PCI and also reinforces conservative management strategies including aspirin and beta blockers, long-term management plans for prevention of SCAD and improved quality of life like BP control, cessation of recreational drugs and stress management, and assessment of extra coronary vascular abnormalities.

OPSOCLONUS-MYOCLONUS SYDNROME IN A PATIENT WITH WEST NILE VIRUS NEUROINVASIVE DISEASE

Ali Hamza Khair, Muhammad Waqar Sharif, Joud Enabi, Roman Karkee, Maida Faheem, Alejandra Garcia Fernandez

Internal Medicine, Texas Tech University Health Sciences Center, Odessa, TX, US, Odessa, TX. (Control ID #3874847)

CASE: A 64-year-old male with no known past medical history was transferred to our facility after EMS found him lying on the floor at home, surrounded by excrement. Patient’s family had called EMS as he had not been returning their calls. On arrival, he had altered mentation with a GCS of 11, unable to clear secretions and protect his airway, requiring transient intubation. Following extubation, patient had fluctuating mentation, with incomprehensible speech. Muscle strength and reflexes were normal and symmetrical, however, there were prominent, involuntary, myoclonic muscle jerks in the upper and lower extremities. The patient's gaze was also disrupted by bursts of high frequency, conjugate ocular oscillations with multidirectional components, indicating opsoclonus. The rest of the cranial nerve examination was normal. Lab work was unremarkable except for lumbar puncture revealing WBC count, 23 cells/mcL, RBC count, 2600 cells/mcL, 68% lymphocytes, 8% monocytes, 24% neutrophils, glucose level of 58 mg/dl and total protein of 96 mg/dl. EEG was abnormal demonstrating slow background activity. MRI brain was unremarkable.

In the absence of a clear diagnosis, the patient was empirically treated with ceftriaxone, vancomycin, ampicillin, and acyclovir. These agents were discontinued after the detection of West Nile virus on serologic analysis and negative testing for HSV and VZV. ELISA results were positive for the presence of IgM and IgG antibodies to WNV. All other testing for autoimmune, and paraneoplastic syndromes was negative.

Patient had a protracted hospital stay secondary to various complications and was eventually discharged to an inpatient rehabilitation facility. The opsoclonus and myoclonus had resolved by the time of discharge, two months after admission.

IMPACT/DISCUSSION: Infection with West Nile virus can lead to a diverse set of presentations. Symptoms are seen in 20-40% of patients, either as West Nile fever or West Nile neuroinvasive disease (WNND). Advancing age and immunocompromised status confers the highest risk of WNND which can present as meningitis, encephalitis, flaccid paralysis, or as an ill-defined mixed picture.

Various ocular manifestations, including chorioretinitis, retinal hemorrhages, and vitreitis have been reported in association with WNND. Notably however, our research encountered only 3 reported cases of West Nile virus causing opsoclonus-myoclonus syndrome (OMS). OMS is most commonly associated with neoplasms, typically neuroblastoma in children and small cell lung cancer in adults. While reports of viral-associated OMS exist, they implicate Epstein-Barr virus, Coxsackie virus, and enterovirus, amongst others.

Our case therefore describes a highly unique presentation of an already challenging diagnosis, emphasizing the importance of keeping WNND on the differential for any patients presenting with otherwise unexplained neurological symptoms.

CONCLUSION: WNND can present with highly variable clinical presenations. OMS may be a feature of viral illness.

PAINLESS GENITAL LESION DUE TO MONKEYPOX; THE IMPORTANCE OF HAVING A BROAD DIFFERENTIAL ON CLINICAL SUSPICION.

Hector I. Roman Perez¹; George T. Kalapurakal²; Matthew E. Posen¹; Amar R. Chadaga¹; Frances Boly³

¹Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL; ²Internal Medicine, Advocate Aurora Health Inc, Milwaukee, WI; ³Infectious Diseases, Advocate Christ Medical Center, Oak Lawn, IL. (Control ID #3876915)

CASE: A 30-year-old male presented for evaluation of a painless penile ulcer accompanied by subjective fevers. His history was significant for Syphilis and Human Immunodeficiency Virus on Bictegravir, Emtricitabine and Tenofovir Alafenamide. He reported development of the lesion after having an unprotected sexual encounter with a male from Bali one week prior to admission. The rash was initially described as an enlarging small white papule that slowly began to ulcerate with surrounding erythema and pruritus without purulent drainage. During this time, he endorsed mild fevers, chills, diarrhea and three episodes of nonbilious, nonbloody emesis. Patient denied any recent travel, urethral discharge, or hematochezia or melenic stools. His physical examination was notable for a single painless umbilicated ulcerated lesion on the penile shaft, as well as a mildly tender left inguinal lymph node. Labs were notable for Rapid Plasma Reagin (RPR) titer 1:4, positive Treponema Pallidum antibody (TPA), negative Chlamydia Trachomatis, negative Herpes Simplex Virus 1 and 2 PCR, negative Chlamydia/Gonorrhea by Nucleic Acid Amplification, positive Orthopox PCR. Over the next few days, the patient developed multiple erythematous papules over his feet, back, and abdomen. He received Tecovirimat and was discharged with recommendations for isolation until all lesions healed.

IMPACT/DISCUSSION: Differentiating between Secondary Syphilis and Monkeypox can present a diagnostic challenge as both infections can present with diffuse painless lesions. In addition, patients who were recently treated for Syphilis can demonstrate serologic studies that are suggestive of Syphilis infection, such as a positive RPR and TPA. However, it is essential to realize that these patients can have low titers of non-treponemal tests and will have positive treponemal-specific antibodies. Diagnostic suspicion for Monkeypox should be maintained in the patient that describes a progressive rash with central umbilication that eventually crusts over.

As of December 2022, there are over 80,000 global cases and nearly 30,000 cases of Monkeypox in the United States of America (USA) according to the Center for Disease Control and Prevention (CDC). While lesions have a characteristic appearance, initial evaluation can be challenging, especially in the context of Syphilis history. It is important to keep a broad differential and a low threshold for additional workup in the presence of emergent zoonosis. Time has proven that virus mutations are potentially catastrophic and can lead to historic pandemics.

CONCLUSION: Monkeypox is a viral zoonosis of global public health importance due to its recent outbreaks. The physical findings are similar to those seen in Chickenpox, Measles, Bacterial skin infections, Scabies, and Syphilis. Consider maintaining a broad differential when working up a skin eruption in the presence of lymphadenopathy and prodromal state.

PANCOAST SYNDROME: A RARE PRESENTATION OF METASTATIC HEPATOCELLULAR CARCINOMA

Evan Shannon²; Margaret Slack³; Helen Shang³; Ien Li¹

¹David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA; ²Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA; ³Division of General Internal Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #3875092)

CASE: A 66-year-old male with systemic lupus erythematosus and unresectable hepatocellular carcinoma treated with transarterial chemoembolization and radiofrequency ablation presented to his rheumatologist with two years of progressive left wrist and forearm pain. He endorsed associated weakness and difficulty making a fist and typing. On exam, he displayed atrophy of the thenar compartment, decreased hand grip strength, and positive Phalen and Tinel signs. The suspected diagnosis was recurrence of severe carpal tunnel syndrome, and he was referred for EMG which showed evidence of cervical motor axonopathy. He was evaluated by a neuromuscular specialist who noted fasciculations in multiple muscle groups and no signs of upper motor neuron disease. A cervical spine MRI revealed a left upper lobe lung mass invading T1 and T2 vertebral bodies. The patient was then admitted for expedited evaluation. His exam was notable for the

aforementioned findings and negative for Horner Syndrome. Additional imaging characterized the tumor as a 7.9 x 4.0 x 6.8 cm FDG-avid calcified soft tissue mass with osseous destruction of the left first rib and a pathologic fracture of the T2 transverse process. Pathology showed poorly differentiated carcinoma containing metaplastic bone spicules. Immunohistochemical stains confirmed the mass was likely metastatic hepatocellular carcinoma as it was positive for albumin RNA, which is exclusively produced by hepatocytes. The patient was treated palliatively with radiation followed by chemotherapy with bevacizumab and atezolizumab. A neurosurgical intervention was not attempted due to the extent of spinal invasion. Pain was managed with high dose gabapentin and methadone.

IMPACT/DISCUSSION: Pancoast tumors arise in the apex of the lung and invade adjacent structures. They involve the thoracic autonomic chain and brachial plexus, inducing Horner Syndrome and pain and weakness of the upper extremity. While the majority of Pancoast tumors are non-small cell lung cancer, there are case reports of Pancoast tumors originating as metastatic malignancy of the larynx, thyroid, bladder, cervix, and in this case, liver. Biopsy is imperative in making the diagnosis and guiding targeted treatment. Pancoast tumors should be treated with chemotherapy and radiation, followed by surgical resection when feasible. Pain can be managed with opiates and neuropathic agents such as tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and gabapentinoids. Neuroablative procedures, nerve blocks, and intrathecal pump implantation should be considered for refractory pain.

CONCLUSION: Consider Pancoast Syndrome on the differential for unilateral upper extremity weakness, pain, or paresthesia and assess for evidence of brachial plexus compression or Horner syndrome.

Pancoast tumors may arise as metastatic lesions; it important to obtain a detailed history regarding personal history of malignancy or strong risk factors for malignancy when evaluating a patient for Pancoast Syndrome

PARANEOPLASTIC NECROTIZING MYOSITIS IN A PATIENT WITH METASTATIC CASTRATE-RESISTANT PROSTATE CANCER

Abbie West, Grace Pazienza, Elizabeth Macinnis

Internal Medicine, Prisma Health Midlands, Columbia, SC. (Control ID #3875722)

CASE: A 76 year old male with a pertinent medical history of high-grade invasive metastatic prostate carcinoma status post robotic prostatectomy and trans-urethral resection of the prostate and stage II chronic kidney disease presented to the hospital due to fatigue and weakness. Symptoms included weight loss and night sweats. He previously underwent radiation therapy and his medications included abiraterone, leuprolide, enzalutamide, ezetimibe, and rosuvastatin. Initial labs: creatinine phosphokinase (CPK) 6,400 IU/L, creatinine 11.2, BUN 211, potassium 5.7, and bicarbonate 10. The initial concern was for rhabdomyolysis, given statin usage and the elevation in creatinine/CPK. He subsequently developed 3/5 bilateral lower extremity weakness, broadening the differential. His CPK and creatinine trended down with fluids but slower than expected for rhabdomyolysis and required a sodium bicarbonate drip. MRI lumbar spine showed degenerative changes at L3-L5 but no stenosis. MRI pelvis and R/L femur showed generalized intramuscular edema. Myositis Specific 11 Antibody Panel and ANA with IFA were negative. Anti-HMG CoA reductase and anti-SRP antibodies were also negative. Left quadriceps biopsy demonstrated immune- mediated necrotizing myopathy (NAM) with type 2 muscle fiber atrophy and mild denervation changes. A diagnosis of paraneoplastic myositis was made and high-dose glucocorticoids were initiated. The patient’s lower extremity weakness improved with glucocorticoids, and he was discharged to rehab for physical therapy.

IMPACT/DISCUSSION: Initially, a diagnosis of rhabdomyolysis was made given the patient’s lower extremity weakness with elevated CPK. The patient had risk factors including statin usage and abiraterone. This case illustrates the importance of broadening a differential rather than anchoring on an initial diagnosis when the response to treatment does not follow an expected course. Usual biopsy results for NAM include muscle fiber necrosis with degeneration/regeneration in the absence of minimal inflammatory changes. The negative antibodies with the patient’s history of metastatic prostate cancer supported the diagnosis of paraneoplastic myositis. Paraneoplastic myositis was a diagnosis of exclusion; there are no exact tests but extensive workup ruled out other diagnoses. Prostate cancer can be a common urological malignancy associated with paraneoplastic myopathy, so having a broad differential is crucial.

CONCLUSION: It is vital to recognize the complications of malignant processes like prostate cancer given its frequency in the male population. Given the association between myopathies and neoplastic processes, diagnosing myositis symptoms quickly can help prompt the detection of potential underlying malignancies. Ultimately, earlier recognition can lead to earlier treatment and prevent prolonged comorbidity.

PATIENT WITH TYPE 1 DIABETES MELLITUS PRESENTING WITH HYPEROSMOLAR HYPERGLYCEMIC STATE

Sohiel Deshpande¹; Abhigna U. Kulkarni¹; Sabah Iqbal¹; Krishna Desai¹; Akhil Jain²; Aisha Shaik¹

¹Internal Medicine, Mercy Fitzgerald Hospital, Darby, PA; ²Medicine, Mercy Fitzgerald Hospital, Darby, PA. (Control ID #3877485)

CASE: A _56-year-old_ female with a past medical history significant type 1 diabetes mellitus (diagnosed at an age of 10 years and being managed with a basal-bolus insulin regimen) complicated by gastroparesis, retinopathy, peripheral neuropathy, HTN, who presented to the emergency room with abdominal pain. She had been experiencing diffuse abdominal pain, nausea, and vomiting which had worsened over the course of one day. She denied any fevers, chills, but endorsed being unable to take her regular medications including insulin. She lived alone in unstable housing. The emergency medical services reported glucometer reading HI. On arrival at the emergency room, her vital signs were within normal limits. Her mucous membranes were very dry, and had diffuse abdominal tenderness, neurological exam revealed intermittent confusion with her being oriented only to name and place but did not show any focal neurological deficits. Cardiovascular and respiratory exams were within normal limits. Laboratory values were significant for venous blood gas pH of 7.28, lactate 2.8 mmol/L, anion gap 16, bicarbonate 23 mmol/L, blood glucose 1597 mg/dL, potassium 6.4 mmol/L, sodium 132 mmol/L, creatinine of 1.07 mg/dL (baseline 0.6), urea nitrogen 48 mg/dL mild transaminitis AST/ALT 65/103. Complete blood count revealed anemia of chronic disease (Hb 11.5), but there was no evidence of leukocytosis. Urine analysis revealed glucose levels of >1000 but was negative for any ketones or any signs of infection. Urine drug screen was positive for cocaine metabolites and tetrahydrocannabinol. She was admitted to the medical intensive care unit and treated with aggressive IV hydration and IV Insulin. Her elevated anion gap closed within 9 hours of aggressive IV hydration. Her mentation was back to baseline within one day of treatment and blood sugars stabilized over the course of her hospitalization and she was transitioned to a basal-bolus insulin regimen.

IMPACT/DISCUSSION: Patient’s grossly elevated blood sugars with relatively mild increase in serum ketone bodies is suggestive of a diagnosis of hyperosmolar hyperglycemic state (HHS). High anion gap metabolic acidosis evident in this case is likely to be due to elevated lactate secondary to severe dehydration and cocaine abuse. It is important to understand that anion gap metabolic acidosis in the setting of severe hyperglycemia is not always due to diabetic ketoacidosis (DKA). Inspite of the severe hyperglycemia, patient did not present in a coma.

CONCLUSION: HHS can rarely be seen even in patients with type 1 diabetes mellitus. It is important to evaluate for other causes of metabolic acidosis in patients with severe hyperglycemia if ketone bodies are minimally elevated.

PEARLS OF SICKLE CELL CRISIS MANAGEMENT IN PATIENT WITH MULTIPLE COMORBIDITIES

Dileep K. Mandali

Internal Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #3876863)

CASE: 48 year old man with PMHx of sickle cell disease, multiple strokes with residual right hemiparesis at baseline, and bioprosthetic aortic valve on anticoagulation presented for four days of malaise and pain in chest, shoulders, lower back. He met SIRS criteria and was COVID+ on admission. Initial labs were significant for WBC 16.6, Hgb 6.2 (baseline ~8), Plts 66, Cr 1.6 (at baseline), LDH 377, hsTrop 123, BNP 1812, and blood cultures positive for MSSA. MRI Spine negative for abscess. CXR only significant for increased reticular markings with no effusion. Home medications, including opioids, were resumed.

On day 2, he became somnolent and was stepped up to ICU for a naloxone drip after failing two trials of Narcan. His Cr uptrended to 8.0, CT Head showed no acute changes. On day 4, his neurological deficits worsened; MRI Brain indicated acute stroke. Heme/Onc recommended for exchange transfusion with his existing central port, but ID recommended port removal due to suspicion of MSSA source. He underwent three simple blood transfusions followed by hemoglobin electrophoresis that downtrended Hgb S from 44.5% to 23%, minimizing his risk for another stroke event. Vascular surgery removed his central port, provided temporary LIJ trialysis line, and scheduled him for an AV-fistula for the long-term need of exchange transfusions. His pain became well-controlled with optimization of opioid pain regimen after his kidneys recovered. His central port tip grew negative cultures, TEE was unremarkable, and daily blood cultures were negative three days after starting IV antibiotics.

IMPACT/DISCUSSION: New evidence suggests that COVID-19 increases the risk of venous thromboembolic events. This may further increase the risk of MI or acute stroke in patients undergoing sickle cell crisis. As a result, it is important to consult Vascular Surgery or Interventional Radiology early to ensure uninterrupted IV access for IVF and antibiotics, especially in those with challenging IV access and on anticoagulation. In our patient, IV access became a challenge after his central line presumed to be the source of bacteremia and peripheral access could not be maintained. The decision to remove the central port by ID conflicted with recommendation for its use in exchange transfusion by Heme/Onc; this was further complicated by Vascular Surgery’s delayed timeline for procedure due to our patient on anticoagulation. Nonetheless, in the event exchange transfusion cannot be done, serial simple transfusions can be pursued to reduce Hgb S <30%, thereby reducing the risk of stroke, acute chest syndrome, etc.

CONCLUSION: -Consult Vascular Surgery or Interventional Radiology for early recommendations on uninterrupted IV access in complex sickle cell patients on anticoagulation.

-Establish direct line of communication between different sub-specialties to avoid delays in multi-specialty driven patient care.

-Consider serial simple transfusions for sickle cell crisis when exchange transfusion is not accessible.

PENILE CALCIPHYLAXIS IN ALPORT SYNDROME

Temitope O. Lawrence-Bello, Stephanie Spangler

Internal <medicine, Christiana Care Health Services Inc, Wilmington, DE. (Control ID #3876250)

CASE: 25-year-old male with history of CKD secondary to Alport disease and Severe Hemophilia A presented with 3 weeks of fatigue, nausea with occasional hematemesis and black stools. In the ED, labs were noted for hyperkalemia, anion gap metabolic acidosis, and acute renal failure with BUN of 249 and creatinine of 32.8. CBC was significant with hemoglobin of 4.7. Patient required packed red blood cell transfusion and desmopressin for uremic bleeding. Emergent, continuous renal replacement with NxStage was initiated in the medical ICU to slowly lower uremic toxins to prevent disequilibrium syndrome. EGD revealed esophageal ulcer requiring injection/clipping and daily factor VIII replacement was initiated. Course was complicated by the development of progressively worsening painful penile lesion, exquisitely tender to palpation with areas of ecchymosis and sloughing at the urethral meatus. Elevated PTH and phosphorus raised concern for calciphylaxis. Whole-body scan showed increased radiotracer uptake in subcutaneous tissues. Sodium thiosulfate and phosphate binders were intiated, and home calcium supplements were discontinued. He continued on dialysis with improvement in his symptoms.

IMPACT/DISCUSSION: Calciphylaxis is a rare and serious condition often presenting with skin necrosis due to arterial ischemia. Underlying pathology demonstrates a unique calcific thrombogenic vasculopathy.

Painful skin lesions are common,often characterized as violaceous,plaque-like nodules that progress to necrotic ulcerations with eschar formation. Although commonly occurring in ESRD, calciphylaxis is not limited to renal failure. Risk factors in ESRD patients are hyperphosphatemia, hypercoagulable states, autoimmune disease, hypoalbuminemia, medications such as warfarin and calcium-based binders. Studies in non-ESRD associated calciphylaxis noted association with primary hyperparathyroidism, malignancy, alcoholic liver disease, autoimmune disease, warfarin, and glucocorticoids. Diagnostic skin biopsy is often not necessary in patients with ESRD with classic skin findings.Technetium bone scans can support the diagnosis. Prognosis varies according to location proximal involvement carries a poorer prognosis compared to distal involvement. Systemic calciphylaxis is associated with highest mortality. Early diagnosis and aggressive management is critical. Sodium thiosulfate, thought to induce the chelation of calcium, is often initiated. Calcimimetics may be considered. Dialysis optimization in ESRD and wound care is essential. Although surgical options may be explored, parathyroidectomy has not been associated with improved mortality in small studies.

CONCLUSION: Calciphylaxis remains a poorly understood disease. Early identification is critical to initiation of standard treatment to reduce calcium deposition responsible for ischemia. Penile calciphylaxis though rare carries a high mortality. Multidisciplinary approach as outlined above is integral to prevent morbidity and improve survival.

PERICARDIAL TAMPONADE IN THE SETTING OF CHRONIC MYELOGENOUS LEUKEMIA Patrick McBride, Shazil Mahmood, Sachin Parikh. Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #3872680)

CASE: A 65-year-old female with a history of CML, DMII, HTN, and HLD presented for subacute exertional dyspnea which became progressive. She had orthopnea in the absence of chest pain/fevers. She was on Imatinib for 1 month prior to presentation for newly diagnosed CML. ECG showed electrical alternans, BNP was 50 pg/mL, and troponin was 6 ng/L. TTE demonstrated an EF of 60-65% with a large pericardial effusion and signs of right ventricular diastolic collapse. Pericardial drain had 400 mL output. Repeat TTE showed resolution of effusion. She was discharged on colchicine 0.6 mg daily and ibuprofen 600mg tid. Imatinib was held. 2 weeks later, she presented for progressive dyspnea. TTE demonstrated a moderately sized pericardial effusion. The patient had repeat pericardiocentesis, requiring a pericardial window. Pericardial biopsy showed chronic pericarditis without malignant cells. Cytology of the pericardial fluid was negative for malignancy. Patient was given colchicine .6mg bid and Ibuprofen 600mg tid at discharge. Hematology/Oncology decided to start patient on Bosutinib. At follow up 2 months later (5 months after symptom onset), patient was asymptomatic

IMPACT/DISCUSSION: Subacute cardiac tamponade is more subtle presentation than acute tamponade. Tyrosine kinase inhibitors can cause severe fluid retention. Severe fluid retention (pleural effusion, pericardial effusion, pulmonary edema, and ascites) was reported in 1.3% of newly diagnosed CML patients taking Imatinib and in 2-6% of other adult CML patients taking Imatinib.

The medication was discontinued at initial presentation, but the effusion recurred. In general, most side effects are reversible with temporarily interrupting or stopping therapy.

Correct dosing/duration of agents is essential for adequate treatment. Aspirin is dosed at 600-975mg tid-qid. Ibuprofen is dosed at 400-800mg tid. Both medications are given for 1-2 weeks initially, and 2-4 weeks if recurrence of symptoms. Colchicine is dosed 0.5-0.6 mg bid for up to 3 months (6 months for recurrence). The patient was asymptomatic prior to diagnosis of CML, making it interesting that biopsy 6 weeks after symptom onset showed chronic pericarditis. Chronic pericarditis is defined as inflamation lasting 3 months or more.

Of note, high-dose steroids have been associated with higher recurrence rates of pericarditis.

CONCLUSION: Pericardial tamponade/effusion secondary to tyrosine kinase inhibitors is a previously described entity that can present as a subacute process without classic signs and symptoms of acute tamponade/pericarditis. Traditionally, cessation of the drug was thought to be enough to prevent recurrence. Colchicine, Aspirin, or Ibuprofen are first-line agents. Steroids should generally be avoided. It is unclear if these traditional therapies are successful in treating chronic effusions associated with immunotherapy/malignancy.

PERSISTENT FEVER AND ELEVATED TRANSAMINASES: CMV INFECTION IN A PATIENT WITH CONGENITAL ADRENAL HYPERPLASIA

Michelle Rudshteyn, Eric Barna

Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3872771)

CASE: A 22 year old man with congenital adrenal hyperplasia (CAH) presented with 10 days of fevers, joint pains, and generalized malaise. One week prior he was seen at an urgent care and diagnosed with influenza. He completed a course of oseltamivir but continued to have fevers to 39.4°C. On evaluation he was tachycardic and febrile, with oral thrush and mild abdominal pain. He noted a faint macular rash over his abdomen which had resolved. Labs were significant for: WBC 16,300 (31% atypical lymphocytes, 16% lymphocytes, 47% neutrophils), ALT 291, AST 143, hypokalemia (3.3), and lactate 3.9. Chest x-ray and abdominal ultrasound were normal. He was given IV fluids, stress dose steroids, and broad-spectrum antibiotics. Blood cultures returned negative, as did tests for HIV, hepatitis, EBV, influenza, gonorrhea, and chlamydia. Fevers recurred during admission, to 38.8 °C on day 2. He was found to have an elevated Cytomegalovirus (CMV) viral load (27,300 IU/mL) with high IgM and positive IgG and was diagnosed with CMV mononucleosis. Given persistent symptoms and immunocompromised status, he was started on vanganciclovir. His WBCs and liver enzymes downtrended, with symptomatic improvement.

IMPACT/DISCUSSION: CMV is a highly prevalent infection, most often causing asymptomatic disease. Patients who develop symptoms typically present with mononucleosis – a syndrome with fever, fatigue, and sore throat. CMV causes up to 7% of mononucleosis cases, with symptoms indistinguishable from EBV mononucleosis. Labs show an increase in lymphocytes with at least 10% atypical lymphocytes, and often elevated liver transaminase levels up to 5 times normal. More severe presentations include myocarditis, pneumonitis, and icteric hepatitis. After infection the virus remains latent and may reactivate. Illness is self- limited, with antiviral therapy reserved for immunocompromised patients or those with severe disease. Data for other clinical situations is limited, but case reports have shown successful outcomes with antiviral therapy in patients with prolonged mononucleosis.

Patients with CAH have increased infection risk, both due to glucocorticoid use and the condition itself, with adrenal insufficiency associated with impaired NK cell activity. The most common cause is 21-hydroxylase deficiency, with a global incidence of 1 in 15,000 – 20,000 births. Clinical severity depends on degree of enzyme deficiency, with this patient having the most severe, salt-wasting form with cortisol deficiency. Adrenal crisis is a life-threatening condition and can present with hypotension, hypoglycemia, hyperkalemia, vomiting, and diarrhea. Management of infection in these patients requires early recognition and treatment with stress dose steroids.

CONCLUSION: CMV should be recognized as a potential cause of mononucleosis, and can lead to protracted symptoms with multi-organ involvement. Management of infection in patients with congenital adrenal hyperplasia requires close clinical monitoring and use of stress dose steroids.

PNEUMOMEDIASTINUM AND SUBCUTANEOUS EMPHYSEMA AS A RARE COMPLICATION OF RHINOVIRUS AND EPSTEIN BARR VIRUS CO-INFECTION.

Hector I. Roman Perez¹; George T. Kalapurakal¹; Spencer Deleveaux¹; Faizan Rahim¹; Xavier Fonseca Fuentes²

¹Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL; ²Henry Ford Hospital, Detroit, MI. (Control ID #3872673)

CASE: A 22-year-old female with no known past medical history presented to the emergency department with progressively worsening shortness of breath, chest pain, and vomiting. She endorsed one week of flu- like symptoms and on the day before admission, experienced episodes of non-bloody emesis with acutely worsening dyspnea and chest pain. Physical examination was significant for pharyngeal and bilateral tonsillar swelling, bilateral sternocleidomastoid muscle crepitus, tachycardia and tachypnea.

Investigation demonstrated mildly elevated white blood cell count to 12.7 K/mcL and arterial blood gas showing a mild respiratory alkalosis with pH of 7.47, positive Epstein Barr Virus (EBV) capsid IgM titers, and viral respiratory panel positive for Rhinovirus. Computed Tomography Angiogram of the Chest showed no evidence for pulmonary embolism (PE), but extensive pneumomediastinum along the esophagus, throughout the mediastinum, and contiguous with soft tissue emphysema in the bilateral lower neck. An esophagram study with contrast was normal with no evidence of esophagitis, esophageal laceration, nor esophageal leak suggestive of esophageal rupture. The patient was diagnosed with Spontaneous Pneumomediastinum (SPM). She showed clinical improvement with intravenous Ampicillin/Sulbactam and Fluconazole, along with supportive measures.

IMPACT/DISCUSSION: Spontaneous Pneumomediastinum most commonly presents in those with existing lung disease, trauma, or recent surgical procedure after a triggering event such as emesis or cough. SPM occurs from alveolar rupture due to high intra-alveolar pressures, low peri-vascular pressures, or both.

Patients with SPM complain of chest pain, commonly pleuritic, cough, and shortness of breath. Infrequently, viral respiratory illnesses can cause SPM with Influenza virus as the most common agent reported. Viruses less commonly responsible include EBV and Rhinovirus. EBV is a ubiquitous virus that often presents as a subclinical infection in most adults, while Rhinovirus is the most common virologic agent behind the common cold. The proposed mechanism for viral agents causing SPM include damage to the alveolar cell wall or intense coughing, or both. While EBV and Rhinovirus can cause mild cough, there have only been a few case reports that describe Rhinovirus induced SPM, all of which have involved the pediatric population. In fact, to our knowledge, there has only been one case of SPM reported in the adult population secondary to Rhinovirus and EBV co-infection.

CONCLUSION: Patients who present with chief complaints of sudden onset dyspnea and chest pain should be evaluated for life threatinening conditions Acute Coronary Syndrome, PE, and Pneumonia. Once those conditions are ruled out, clinicians should explore the possibliity of SPM regardless of age or past medical history.

POSITIVE AND NEGATIVE: A PARADOXICAL CASE OF TUBERCULOSIS

Sarah W. Takimoto, Nguyen V. Pham, Agnieszka Gryguc-Saxanoff

Internal Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #3876052)

CASE: A 28 year-old male with Crohn’s disease on infliximab presented with 2 days of fatigue and dyspnea. He reported a chronic cough unchanged over the last month. No travel since 2020 or sick contacts. Chest x-ray was notable for a large left pleural effusion. A chest tube was placed with pleural studies consistent with an exudative effusion.

On further review, the patient had a history of a low positive interferon-gamma release assay (IGRA) in 2021 prior to starting a TNF-alpha inhibitor. A chest x-ray was negative. A tuberculin skin test (TST) from 2020 was negative. The patient was from a high incidence tuberculosis (TB) country; however, he had no personal history of TB or known exposures. He was evaluated by infectious disease and a repeat IGRA was done, which was negative. It was ultimately determined that the original test was likely a false positive. He did not undergo treatment for latent TB.

This admission, the patient was started on empiric TB treatment. Sputum AFB culture and MTB PCR later came back positive. An HIV test was negative. Given no acute Crohn’s disease flare, infliximab was held.

The patient was discharged on RIPE with close follow up; however, he was readmitted two weeks later with recurrence of symptoms. The patient had a prolonged hospital course requiring repeat chest tube placement and supplemental oxygen prior to discharge home.

IMPACT/DISCUSSION: Patients on TNF-alpha inhibitors are at a high risk for reactivation of latent TB, which is why screening is recommended prior to starting treatment.¹ True-positive tests are more likely for individuals with associated risk factors such as residence in a high-incidence country. ²

Given the initial positive test, an online TST/IGRA interpreter score is available to help determine if treatment of latent TB is warranted.³ This score was not documented on initial evaluation; however in 2021, the patient had a PPV of 98% with a cumulative risk of active tuberculosis up to the age of 80 of 5.1% (increased to 27.26% on infliximab) and 0.3% probability of a clinically significant drug induced hepatitis . In this case, strong consideration for treatment of latent TB should have been considered despite a repeat negative test.

CONCLUSION: High risk individuals such as patients on TNF-alpha inhibitors or from high-incidence settings should be screened for TB. After an initial positive test, use of an online TST/IGRA interpreter score is available to determine need for treatment of latent TB.

References:

1. Campbell, J. R., Winters, N. & Menzies, D. Absolute risk of tuberculosis among untreated populations with a positive tuberculin skin test or interferon-gamma release assay result: systematic review and meta- analysis. BMJ 368, m549 (2020).

2. Linas, B. P., Wong, A. Y., Freedberg, K. A. & Horsburgh, C. R., Jr. Priorities for screening and treatment of latent tuberculosis infection in the United States. Am. J. Respir. Crit. Care Med. 184, 590–601 (2011).

3. The Online TST/IGRA Interpreter. http://www.tstin3d.com/en/calc.html.

POSITIVE MPOX, FORMERLY MONKEY POX, PCR FROM A NON-VESICULAR LESION: A CASE REPORT OF DISSEMINATED MPOX INFECTION IN AN UNVACCINATED, IMMUNOCOMPROMISED HOST

Abby Terlouw

Internal Medicine, Tufts Medical Center, Boston, MA. (Control ID #3874749)

CASE: A 36 year-old MSM man with history of uncontrolled HIV and methamphetamine use presented with painless, vesicular genital lesions and, later, fever. MPox PCR swab testing of the lesions was positive for MPox virus, and he was started on tecovirimat oral therapy. Two days after initiating treatment, the patient developed a diffuse, pruritic, maculopapular rash initially on his extremities, chest, and back. A skin swab MPox PRC test was sent from a thigh macular lesion with no vesicular lesions present and was positive for MPox virus. Vesicular lesions later appeared in the area of maculopapular rash. Given severe genital disease and disseminated infection progression despite tecovirimat in the setting of uncontrolled HIV, vaccinia immune globulin infusion was administered for one dose. The patient completed 10 days of tecovirimat and made a full recovery three weeks after initial diagnosis.

IMPACT/DISCUSSION: A global outbreak of human MPox virus infections, an orthopoxvirus-based zoonotic illness, has been ongoing since May 2022 with the World Health Organization declaring a public health emergency in July 2022. Historically, cases presented with prodromal symptoms 1-2 weeks after initial infection followed by characteristic umbilicated-vesicles classically around the head and progressing to the arms or legs; however, many cases are now presenting with genital lesions in the absence of prodromal symptoms. Our case highlights an instance where MPox virus was detected by PCR from a swab of a maculopapular rash without the characteristic vesicle present which has not yet been described. This suggests extremely high viral load possibly due to underlying uncontrolled HIV infection. Our patient was at risk for MPox, but was unvaccinated. Vaccinations for MPox/small pox are approved by the FDA or available under an Expanded Access Investigational New Drug protocol, yet the availability and administration of these vaccines to at risk individuals remains limited. Preliminary data suggests MPox incidence was 14 times higher among unvaccinated males age 18-49 eligible for MPox/small pox vaccination as compared to those who received one dose of the vaccine.

CONCLUSION: As this ongoing outbreak continues, a better understanding of infection risk, transmission and novel clinical presentations is vital in order to adapt our methods of identification, isolation of infected individuals and timely treatment. The general internist will need to expand his or her differential of rashes, macular and vesicular, to include MPox. Furthermore, all those who care for persons at risk of the disease should note currently available preventative measures and be prepared to discuss these measures with patients. Lastly, expansion of vaccine access and vaccination for people at risk need to be scaled to the actual need.

POST-EMBOLIZATION SYNDROME: AN IMPORTANT SEPSIS MIMICKER THAT’S MORE COMMON THAN YOU MIGHT THINK

Oliver Bawmann²; Julie Smith¹; Neelam Mistry¹

¹Department of Medicine, University of Colorado, Denver, CO; ²University of Colorado, Denver, CO. (Control ID #3854024)

CASE: A 33-year-old G2P1011 woman who was 6 days postpartum from an uncomplicated vaginal delivery presented with acute right flank pain, hypotension, tachycardia and new onset anemia. CT abdomen/pelvis (CT AP) revealed a 21.5cm right renal angiomyolipoma (AML) with an associated bleeding pseudoaneurysm and retroperitoneal hemorrhage. She underwent catheter-directed embolization with interventional radiology (IR) on hospital day #1 (HD#1).

On HD#2 she had persistent flank pain and tachycardia. On HD#4, she developed fever. She had stable right upper quadrant pain, but otherwise normal abdominal and pelvic exams. Antibiotics were started for presumed sepsis of unknown source. Repeat CT AP confirmed stable AML, no continued hemorrhage, or infectious complications. Additional work up including blood and urine cultures, CTPE and respiratory viral panel was negative. Fever and tachycardia persisted despite antibiotics. In discussion with urology and IR, her presentation was most consistent with post-embolization syndrome (PES). Antibiotics were discontinued at 72 hours as no infectious source was identified. Her fever and tachycardia gradually improved, and all infectious cultures were negative at 7 days.

IMPACT/DISCUSSION: PES is the most common complication of AML embolization and occurs in approximately 54% of cases, though with a wide range of variability in the literature [1,2]. The syndrome includes fever, flank pain, leukocytosis, nausea and vomiting [3]. Infarcted tissue leads to a systemic inflammatory response like a sepsis presentation. Treatment involves supportive care. Small studies show that prophylactic steroids may reduce the incidence of PES, however, larger randomized trials are needed to validate these results [4].

As fever and leukocytosis are the most common presenting signs of PES [2], clinicians will also have concern for sepsis when caring for these patients. PES can present 1 to 7 days after the embolization, which may further cloud the picture, as was this case for our patient. However, studies demonstrate that after AML embolization, sepsis and infection are much less common than PES [1].

CONCLUSION: AMLs are being increasingly detected; those that are large, symptomatic or have high risk features warrant intervention. Catheter directed embolization is increasingly used for management of these tumors, given roughly equivalent major complication risk and improved sparing of renal function relative to surgical partial or complete nephrectomy [1-3]. As such, clinicians should be prepared to encounter patients presenting with PES, including those presenting with fever and leukocytosis up to 7 days after their procedure. This case highlights that PES must be considered in the differential diagnosis in a patient presenting with systemic inflammatory response syndrome after IR directed embolization treatment; it may be prudent to observe off antibiotics if patients are hemodynamically stable with no suspected source of infection.

POST- MYOCARDIAL INFARCTION PSEUDOANEURYSM COMPLICATED WITH FREE WALL RUPTURE

Muhammad Waqar Sharif, Joud Enabi, Maida Faheem, Alejandro J. Herrera-Ramos, Kejal Shah

Internal Medicine, Texas Tech University Health Sciences Center, Permian Basin, Odessa, TX. (Control ID #3859649)

CASE: A 70-year-old female with a past medical history of rheumatoid arthritis presented to our service after an out-of-hospital cardiac arrest. The patient collapsed then the daughter called 911. When EMS arrived, the patient had bradycardia with no pulse. After 4 minutes of CPR, ROSC was achieved. She was intubated on the field and was transferred to the emergency room. Upon arrival, her pulse was again lost, and she was found to have ventricular tachycardia. Synchronized cardioversion was done, and a Norepinephrine vasopressor was initiated. EKG revealed sinus rhythm and T wave inversions in Inferior leads II, III avF. Computerized tomography angiography for pulmonary embolism revealed a large volume hemopericardium with moderate collapse of the right atrial chamber. There was a 10 mm rounded focus of contrast material communicating with the left ventricular chamber and penetrating the free wall of the left ventricular myocardium, suspicious of left ventricular pseudoaneurysm as the source of hemopericardium. On the echocardiogram, the right ventricle appears to have collapsed and compressed by extrinsic compression with a large clot in the pericardial space. The cardiothoracic surgeon was consulted, and pericardiocentesis was attempted. However, the patient went into cardiac arrest again during the procedure and died.

IMPACT/DISCUSSION: The incidence of free wall rupture has significantly decreased with the widespread use of percutaneous coronary intervention (PCI) nowadays[1]. The majority of deaths in patients with post- myocardial infarction(MI) free wall rupture occur in out-of-the-hospital settings like in our patient [2]. Left ventricular free wall rupture(LVFWR) has a very high estimated mortality rate that may reach up to 88.2%[3]. Although LVFWR is considered a rare complication post-MI, it happens more frequently than other complications like interventricular septal rupture, papillary muscle rupture, or pseudoaneurysm[1]. The incidence of LV pseudoaneurysm after MI is 0.2% to 0.3%[4]. LV pseudoaneurysm carries a high risk of rupture if left untreated, as high as 30% to 45% [5]. Early reperfusion and the surgical approach to such conditions remain the mainstay of treatment for LVFWR and help reduce mortality. This mechanical complication mainly leads to pericardial effusion, which can get complicated by sudden cardiac arrest. The main risk factor that can lead to LVFWR is the delay in immediate perfusion post-ischemia [6]. Around half of the cases of LVFWR commonly occur within 3–5 days post-MI (early rupture), and 90% in the first two weeks (late rupture). This case report is unique as post-MI pseudoaneurysm complicated with LVFWR is considered to be a rare complication post-MI due to the greater accessibility to PCI nowadays.

CONCLUSION: In the era of PCI the mortality rates due to myocardial infarction have declined consistently [7,8]. Nonetheless, mortality rates associated with post-acute myocardial infarction mechanical complications have not declined similarly [9].

POST-POLYPECTOMY SYNDROME–A RARE COMPLICATION THAT MIMICS COLONIC PERFORATION

Muhammad Ali¹; Muhammad Hassan²; Natasha Ghalib³; Valerie Cluzet⁴

¹Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ²Hematology/Oncology, Banner University Medical Center Tucson, Tucson, AZ; ³Internal Medicine, Montefiore Medical Center Jack D Weiler Hospital, Bronx, NY; ⁴Medicine/Infectious Diseases, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #3874833)

CASE: A 52-year-old male with no known medical conditions presented to the emergency department with subjective fever, malaise, nausea and generalized abdominal pain. He denied vomiting, diarrhea, rectal bleeding, melena, dysuria or increased urinary frequency. He underwent a screening colonoscopy and removal of a 50mm polyp from the hepatic flexure by a hot snare approximately 24 hours before the onset of his symptoms. On admission, the patient was febrile to 101.8F, hypotensive to 94/68 mmHg, tachycardic to 101 bpm, and saturating at 94% on room air. Blood work revealed a WBC count of 10000/uL, normal hemoglobin, renal and liver function, lipase, and lactic acid levels. Urinalysis did not reveal any evidence of urinary tract infection. A CT scan of the abdomen and pelvis with IV contrast revealed annular wall thickening in the right colon approximately 4 cm in size but did not reveal evidence of intestinal perforation or intraperitoneal air. EKG showed normal sinus rhythm. Chest x-ray revealed clear lung fields. A diagnosis of post-polypectomy syndrome was made given the lack of imaging findings concerning for intestinal perforation .The patient was admitted to the hospital. He was managed with IV fluids, analgesics, antiemetics, and broad-spectrum antibiotics. His symptoms resolved completely after 24 hours, and he was discharged home in stable condition.

IMPACT/DISCUSSION: Post-polypectomy syndrome, a rare complication of colonoscopic polypectomy, occurs due to an electrocoagulation injury to the colonic wall that causes a transmural burn and localized

peritoneal inflammation without evidence of perforation on radiographic imaging. This syndrome presents with signs and symptoms that mimic colonic perforation such as abdominal pain, fever, leukocytosis, abdominal tenderness, and guarding. These patients are managed conservatively with antibiotics, intravenous fluids, analgesics, antiemetics and bowel rest.

CONCLUSION: -Post-polypectomy syndrome is a rare complication of colonoscopic polypectomy.

-Post-polypectomy syndrome presents usually within 24-48 hours after the polypectomy with abdominal pain, fever, nausea, emesis, abdominal tenderness, guarding and leukocytosis.

-Abdominal imaging most commonly with CT scan must be obtained to rule out intestinal perforation before a diagnosis of post-polypectomy syndrome can be established.

-Management is conservative with IV fluids, antibiotics, analgesics, antiemetics and bowel rest.

PRESENTATION OF ACUTE CORONARY SYNDROME WITH FOCAL NEUROLOGICAL DEFICITS

Rohit Rao

Tulane University School of Medicine, New Orleans, LA. (Control ID #3877167)

CASE: A 51-year-old woman with a past medical history of anxiety and tobacco use presented with sudden onset substernal chest pain at rest, diaphoresis, left-sided sensory deficits, and weakness. Soon after arrival, the chest pain had resolved, but she was noticeably anxious. Over the past year, she has experienced intermittent chest pain associated with exercise that resolved with rest. She denies abdominal pain, shortness of breath, nausea, or vomiting. She denies any previous cardiac or neurologic history. Physical examination is notable for midline splitting hypoesthesia over her entire left side and left lower extremity pronator drift.

ACS and stroke protocols were initiated. EKG on admission showed 1 mm ST depression of inferior leads with an elevated troponin of 55. Repeat EKG was normal. Stroke workup showed no evidence of ischemia and thrombolytics were not administered. A third EKG showed T-wave inversions at the anterior leads with an uptrending troponin of 372. She was admitted for a non-ST elevation myocardial infarction (NSTEMI) and coronary angiography revealed 95% occlusion of the proximal LAD. She was immediately sent to cardiac catheterization for stenting. Her neurological symptoms resolved the following morning. TTE with bubble study showed a normal left atrium with no evidence of intracardiac shunt. After two days in the hospital, she was discharged with appropriate medications.

IMPACT/DISCUSSION: This patient had a non-ST-elevation myocardial infarction (NSTEMI) characterized by angina and elevated troponin levels without ST elevation on EKG. The typical acute MI presentation includes substernal chest pain and diaphoresis, as seen in this patient, as well as dyspnea and left arm pain. Commonly known atypical presentations include abdominal pain, indigestion, and nausea. Our patient presented with focal neurologic deficits with a negative stroke and transient ischemic attack (TIA) workup. Since a TEE was not performed, a TIA cannot be fully excluded. In addition, midline splitting full- body sensory deficit could be a psychosomatic manifestation of anxiety or conversion disorder in addition with the acute MI. This highlights the importance of adhering to ACS protocols to rule out atypical or delayed MI presentation. If we had anchored on the neurological deficits on admission, the delayed EKG changes and up-trended troponins might have been missed leading to a poor outcome for this patient.

CONCLUSION: Focal neurologic deficits are not commonly associated with acute coronary syndromes. It is important for healthcare providers to be aware of atypical presentations and to adhere to ACS and stroke protocols as appropriate.

PROGRESSIVE NEUROPATHY DUE TO IMMUNE MEDIATED SMALL FIBER NEUROPATHY

Jamie Yao

Hospital Medicine, University of California San Francisco, San Francisco, CA. (Control ID #3856062)

CASE: A 42-year-old woman with history of migraines presents with painful tingling in her face and bilateral hands and feet for three weeks. The patient first started feeling shooting pain in the antecubital fossa, followed by painful tingling in the thumb and first digit and finally in the bilateral feet. She was unable to feel cold in her mouth. On examination, the patient had normal vital signs. Her neurologic exam was normal other than diminished sensation to light touch on the first three digits of the hands and soles of her feet. Labs revealed normal CBC, CMP, HIV, thyroid stimulating hormone, rapid plasma reagin, anti-nuclear antibody, copper, zinc, hepatitis C antibody, serum/urine protein electrophoresis, Vitamins B1, B6, B12, and E, and paraneoplastic profile. Her urine heavy metals test was elevated. Sensory GM1 IgM was 1:800 (ref < 1:800), or moderately elevated. Her CSF studies had no pleocytosis, though protein was mildly elevated at 49. Oligoclonal bands and meningoencephalitis panel were negative. MRIs of the brain, cervical, and thoracic spine were unremarkable. Electromyogram/nerve conduction studies (EMG/NCS) were consistent with mild right carpal tunnel syndrome affecting sensory nerve fibers only.

IMPACT/DISCUSSION: Given the rapidly progressive nature of her symptoms with unknown etiology, the patient was hospitalized for expedited work-up. Initial evaluation searched for infectious and structural causes that would be life threatening, without cause found. Her elevated urine heavy metals was a red herring, likely due to a shellfish-based supplement, and such a toxicity involving heavy metals typically also causes weakness that the patient did not have. Sensory variant of Guillan-Barre syndrome was considered, however EMG/NCS did not show demyelination.

Overall, her clinical presentation was consistent with an immune mediated small fiber polyneuropathy, possibly triggered by a viral infection. Given her GM1 antibody positivity and suspected immune etiology of neuropathy, intravenous immune globulin (IVIG) was administered and subsequently improved some of her paresthesias. She had residual neuropathic pain in the upper and lower extremities, which improved with pregabalin. Overall, her prognosis is favorable with expected continued improvement.

CONCLUSION: There has been growing interest in IVIG therapy for idiopathic or presumed immune mediated small fiber neuropathies (SFN), with a case series showing improvement in pain after IVIG treatment for cases with elevated levels of auto-antibodies to TS-HDS or FGFR-3¹

Another key component of management of SFN is medication, such as pregabalin and serotonin–

norepinephrine reuptake inhibitors like duloxetine

1 Grayston R, Czanner G, Elhadd K, Goebel A, Frank B, Uceyler N, Malik RA, Alam U. A systematic review and meta-analysis of the prevalence of small fiber pathology in fibromyalgia: Implications for a new paradigm in fibromyalgia etiopathogenesis. Semin Arthritis Rheum. 2019 Apr;48(5):933-940

PROGRESSIVE PETECHIAE, PURPURIC PAPULES, PATCHES, AND PLAQUES

Kristie Hsu¹; Gabriel M. Ortiz²

¹Internal Medicine, University of California San Francisco School of Medicine, San Francisco, CA; ²Division of Hospital Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA. (Control ID #3854137)

CASE: A 55-year-old Vietnamese-speaking man presented to the emergency room of a large safety-net hospital with a two-month history of progressive petechiae, purpuric papules, patches, and plaques affecting all four extremities, and bilateral leg soreness causing ambulation difficulties. The patient had a history of hypertension, type 2 diabetes, and GERD. He also endorsed one month of easy gum bleeding with brushing teeth, fatigue, and generalized arthralgias. He denied other constitutional symptoms or bleeding. He had no family history of autoimmune or bleeding disorders. His home medications included amlodipine, lisinopril, atorvastatin, montelukast, loratidine, metformin, omeprazole, and a vitamin D supplement. Exam was notable for poor dentition, gingival hyperpigmentation, petechiae and perifollicular purpuric papules on bilateral lower extremities, large ecchymoses on the right thigh, purpuric patches and plaques on bilateral forearms, and generally scant hair on the extremities, which on closer inspection had distorted hair shafts. A complete blood count demonstrated a mild normocytic anemia (hemoglobin 13g/dL) and normal platelet count. Comprehensive serologies showed negative rheumatoid factor, ANA, ANCA, RPR, and HCV, normal C3 and C4 levels, and cleared HBV infection. Further history revealed that he worked as a dishwasher at a local restaurant, and his diet consisted completely of meat, fish, and rice, without any fruits, vegetables, or juice. The patient received empiric treatment with high-dose Vitamin C and multivitamin supplementation, and a registered dietician provided nutritional counseling. After completing supplementation and adding fruits and vegetables to his diet, the patient was “pleased" with his improvement. The initial serum Vitamin C level later came back as less than 5 umol/L, confirming the diagnosis of scurvy.

IMPACT/DISCUSSION: Though rarer in modern times, the prevalence of scurvy is as high as 7% in the United States. Vitamin C is a cofactor for many biochemical reactions in the body, particularly collagen synthesis. Thus, clinical manifestations of scurvy can be varied. The disruption of collagen synthesis can lead to gingival bleeding, perifollicular hemorrhages, petechiae, and ecchymoses, as well as microfracture in bones and arthralgias, as in this case. Among patients with scant body hair, a careful physical examination is helpful to determine the perifollicular nature of skin findings or the presence of hair shaft distortion rather than the classic corkscrew hairs. This patient presented with symptoms that mimicked a cutaneous small vessel vasculitis, but was determined to have scurvy after conducting a comprehensive social history.

CONCLUSION: Scurvy can present in many ways, such as mimicking a small vessel vasculitis with subacute petechial rash, purpura, arthralgias, and fatigue. A thorough social history, including screening for food insecurity and a detailed dietary history, is important among vulnerable populations.

PROLONGED SUPRATHERAPEUTIC LEVETIRACETAM IN AN ADULT WITH DEVELOPMENTAL DELAY

Rebecca E. Henkind²; Elijah Christensen¹; Yevgeniya Scherbak³; Christopher J. King¹

¹Medicine, University of Colorado, Aurora, CO; ²School of Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ³Pharmacy, University of Colorado, Aurora, CO. (Control ID #3876742)

CASE: 63-year-old man with a history of intractable epilepsy and developmental disabilities necessitating a full-time caregiver is admitted for altered mental status, dysarthria, and difficulty ambulating. Patient’s medications include Valproic Acid 0.5g daily, 0.75g nightly, and Levetiracetam 1g four times daily.

On admission, vital signs significant for heart rate of 132, and blood pressure of 150/85. Patient afebrile.

Physical exam and CT Brain unremarkable. Bedside EEG showed diffuse delta-theta background slowing with fragments of normal and symmetric PDR of 8-9 HZ seen intermittently. No epileptiform discharges or electrographic seizures observed.

Review of patient’s medications revealed patient had been receiving 4g Levetiracetam four times a day (16g total per day), not the intended 1mg 4 times a day, for at least nine days. Patient’s levetiracetam was held and serum levetiracetam level drawn 24 hours after admission was 55.7mcg/mL (therapeutic range 10.0-40.0mcg/mL).

Two days later the patient was noticeably less obtunded and felt subjectively improved. The patient was given instructions to restart Levetiracetam at the intended dose and was able to return home.

IMPACT/DISCUSSION: To our knowledge, this is the first documented case of prolonged supratherapeutic Levetiracetam ingestion in an adult. Previously described incidents of supratherapeutic levetiracetam ingestion involve either adults with a single large ingestion, or children with prolonged supratherapeutic ingestions.

First approved by the FDA in 1999, Levetiracetam is recommended as an adjunctive treatment for refractory focal epilepsy, refractory GTC seizures, and refractory myoclonic juvenile epilepsy. It is thought to act through the binding of SV2A. Oral bioavailability and brain penetration are both excellent. The drug is cleared through renal excretion. With a half-life of 6-8 hours, goal steady state of 12-40mcg/mL is usually achieved in 24-48 hours. Side effects of therapeutic usage include somnolence, infection, drowsiness, headache and tremor. Side effects of supratherapeutic ingestions include respiratory depression, blurred vision and ataxia.

Using a computational pharmacokinetic model, we estimate our patient’s Levetiracetam steady state plasma concentration to be 155mcg/mL.

As demonstrated by this case, medication administration errors are not limited to clinical staff; patients or caregivers are responsible for at least 4% of outpatient medication errors. Strategies to reduce medication administration errors among caregiver dependent patients have had limited discussion in the literature.

CONCLUSION: Prolonged supratherapeutic dosages of Levetiracetam in adults, if recognized in a timely manner, can be resolved with complete recovery. Patients who depend on caregivers or who have renal impairment are at particularly high risk for medication error.

PROSTHETIC VALVE ENDOCARDITIS CAUSED BY HACEK ORGANISMS REQUIRING LONG TERM ORAL ANTIBIOTIC SUPPRESSION THERAPY

Sabeeka Shah¹; Aishwarya Krishnaiah¹; Pragya Dhaubhadel²

¹Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA; ²Geisinger Community Medical Center, Scranton, PA. (Control ID #3876329)

CASE: 82 year old male with a past medical history of new onset atrial fibrillation and aortic stenosis status post bioprosthetic valve (13 years ago), presented with generalized weakness, anorexia and weight loss. He presented afebrile with leukocytosis, but developed fevers with a Tmax of 101F. Computed tomography chest revealed pulmonary congestion. Transthoracic echocardiogram showed no vegetations or bioprosthetic valve abnormalities. Preliminary blood cultures grew gram positive cocci and Vancomycin was started. Transesophageal echocardiogram showed a large aortic root abscess extending into the ascending aorta, causing severe paravalvular aortic insufficiency. Finalized blood cultures grew Aggregatibacter actinomycetemcomitans. Antibiotics were de-escalated to Ceftriaxone and the patient was transferred for surgical evaluation, but was not deemed a candidate secondary to high surgical risk. Patient completed six weeks of IV antibiotics and transitioned to oral Amoxicillin indefinitely. Unfortunately, the patient developed acute heart failure secondary to non-ischemic cardiomyopathy and died.

IMPACT/DISCUSSION: Prosthetic valve endocarditis (PVE) is more commonly seen with HACEK organisms. Additionally, within HACEK endocarditis (HE), A.actinomycetemcomitans are more common than H.parainfluenzae for PVE [1]. Studies have shown that bacteremia with A. actinomycetemcomitans have a 100% positive predictive value for IE compared to other HACEK organisms [2]. Isolation of this species in a single blood culture has the potential to be a major Duke criteria for diagnosis of IE. Requirement for surgical valve replacement was seen to be lower for HACEK PVE compared to PVE overall. Current surgical guidelines for IE, as per AHA, include valve dysfunction with heart failure, paravalvular extension, abscess or high risk of embolism. Due to high perioperative risk, 20-40% of patients eligible for surgery do not undergo surgery [3]. For patients with surgery indicated and not undergoing surgery IE (SINUS-IE), antibiotic durations are not sufficiently evidence-based due to the lack of randomized controlled trials [4]. Long term antibiotic therapy, including long term oral suppressive antibiotic therapy (LOSAT) is a consideration for such patients. Our patient was started on oral suppressive therapy with Amoxicillin. Since the patient died from complications, we were not able to assess the efficacy and long term effects of LOSAT with Amoxicillin. Due to the relative rarity of HE, LOSAT has not been concretely established and based more so on individualized treatment.

CONCLUSION: For patients with HE not deemed surgical candidates LOSAT is a treatment option, but due to the rarity of such cases, it has been challenging to develop concrete guidelines. Further studies, along with case reports, will be an asset to determining such guidelines. Furthermore, isolation of a single positive blood culture with A.actinomycetemcomitans should be a consideration for major Duke criteria.

PROTEIN LOSING ENTEROPATHY COMPLICATING DISSEMINATED MAC INFECTION Meghan E. Murphy, Alexander Logan

Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #3875369)

CASE: Mr. S is a 39 year old with a past medical history of HIV/AIDS, recently restarted on antiretroviral therapy, who presented with diarrhea, profound weight loss, and new abdominal distension. The patient endorsed 3 months of watery diarrhea. He also noted worsening abdominal distension and leg swelling for the last month. Review of systems was notable for night sweats for the last two weeks. He had no other significant medical history. Medications were notable for Dolutegravir and Emtricitabine/tenofovir. On exam, he was cachectic with a distended abdomen, 3+ pitting edema to the thighs bilaterally, and scrotal edema. His initial labs were notable for Na 129, Albumin 1.9, Total protein 3.5, Hgb 8.5, HIV VL 2.9 million, CD4<10. He had a CT chest, abdomen and pelvis notable for scattered bilateral pulmonary nodules, an incidental left lower segmental PE, moderate volume ascites, necrotic mesenteric lymphadenopathy, and diffusely thickened small bowel loops. He underwent an EGD and colonoscopy with EUS notable for duodenitis. Duodenal and mesenteric lymph node biopsies were positive for infiltration of the mucosa by foamy AFB-laden macrophages. Cultures grew mycobacterium avium complex (MAC). He was started on therapy for disseminated MAC. For his volume overload, he had a negative TTE and his UPCR was normal. A diagnosis of protein losing enteropathy was then confirmed with an elevated 24-hour alpha-1 antitrypsin stool clearance.

IMPACT/DISCUSSION: Protein-losing enteropathy (PLE) is a condition which results in excess loss of proteins through the gastrointestinal tract, resulting in severe hypoalbuminemia in the absence of significant proteinuria. PLE can be caused by inflammatory or infectious processes affecting the gastrointestinal mucosa leading to poor absorption and excess excretion of protein. In this case, we identified disseminated MAC as the underlying cause of PLE, secondary to significant inflammation in the small bowel. This case also highlights the clinical features of PLE: diffuse anasarca, lower extremity edema, and abdominal ascites. Our patient also had thromboembolism complicating PLE. The management of PLE involves treating the underlying condition; this patient was managed with empiric MAC treatment, antiretroviral therapy, diuretics to manage volume overload and total parenteral nutrition. To diagnose this uncommon condition, the clinicin must understand its pathophysiology and recognize its clinical features.

CONCLUSION: - PLE can complicate disseminated infections affecting the GI tract, including MAC.

- Early identification of the underlying etiology is essential for managing PLE.

- PLE involves loss of proteins including albumin and immunoglobulin, which can predispose to complications such as venous thromboembolism and immunodeficiency.

- The A1AT 24 stool clearance is the primary test used for diagnosis of PLE.

PULMONARY CRYPTOCOCCOSIS IN A HIV POSITIVE INDIVIDUAL

Kristopher A. Mosier¹; Jasmeet Kalsi¹; Abigail Entz²

¹Internal Medicine, Henry Ford Health System, Detroit, MI; ²Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #3874721)

CASE: We present the case of a 53-year-old male with a history of COPD, chronic hepatitis B, and HIV who presented for evaluation of productive cough, shortness of breath and pleuritic chest pain. Symptoms had been gradually worsening for two-weeks. He was no longer established with an Infectious Disease physician nor taking any antiretroviral medication. Initial lab work revealed a HIV viral load of 125,000 copies/ml and a CD4 count of 42 cells/μl. Further investigation revealed patchy airspace opacities in the mid-lung fields on chest x-ray, concerning for multifocal pneumonia. CT chest demonstrated ground-glass and tree-in-bud airspace opacities throughout all pulmonary lobes, with more nodular opacities seen in the left lower lobe. He was initially treated with ceftriaxone and azithromycin for community acquired pneumonia, and prednisone for coinciding COPD exacerbation. Despite 3 days of treatment, he failed to show any clinical improvement, which prompted broadening of infectious work-up. Serum cryptococcal antigen resulted positive with a titer of 1:10. Lumbar puncture was immediately performed to rule out CNS involvement, and he was started on amphotericin B while awaiting CSF cryptococcal antigen result. Within 48 hours of starting anti-fungal treatment, his shortness of breath improved drastically. Cryptococcal antigen in the CSF resulted negative, so he was deescalated to oral fluconazole. He was discharged with plan to continue fluconazole for 3 months. At follow-up appointment one month later, he continued to endorse improvement in his respiratory symptoms.

IMPACT/DISCUSSION: Pulmonary cryptococcosis is most often seen in immunocompromised patients, either as a primary infection or reactivation of a latent infection. Conditions that increase risk for pulmonary cryptococcosis include HIV infection, malignancies, chronic lung disease, and treatment with immunomodulating medications. In HIV positive patients, the presentation of pulmonary cryptococcosis is more severe, with symptoms inversely proportional to CD4 count. Most cases present with a CD4 count less than 50. Common presenting symptoms are cough, fever, dyspnea, and headache. Serum cryptococcal antigen is an excellent screening test, as it is positive in virtually all HIV patients with pulmonary cryptococcosis. This study is highly predictive of who will later develop Cryptococcal meningitis, on average detecting infection 2-3 weeks before symptoms of meningitis present. Early identification allows for treatment prior to the development of CNS manifestations, thus reducing morbidity and mortality.

CONCLUSION: Our patient highlights how pulmonary cryptococcosis presents in a patient with uncontrolled HIV. In this population, serum cryptococcal antigen is an excellent screening test as it is highly sensitive for active infection. In addition, it is predictive of patients who will later develop highly morbid cryptococcal meningitis, which allows for treatment prior to CNS involvement.

PULMONARY SEPTIC EMBOLUS AS THE PRIMARY PRESENTING SIGN OF ENDOCARDITIS Sameer Khan¹; Waldo J. Santiago Colberg²; Nathan Douthit^3,4

¹Internal Medicine Residency Program, East Alabama Medical Center, Opelika, AL; ²Internal Medicine, East Alabama Medical Center, Opelika, AL; ³Internal Medicine Residency, East Alabama Medical Center, Opelika, AL; ⁴Edward Via College of Osteopathic Medicine - Auburn Campus, Auburn, AL. (Control ID #3875534)

CASE: A 50-year-old female with past medical history of class 3 congestive heart failure, history of ventricular tachycardia status post defibrillator placement (with most recent exchange done 1 month prior to admission), and history of septic embolus secondary to AICD endocarditis (15 years prior to admission) presented to our emergency department due to three days of worsening back pain with dyspnea and shortness of breath. On admission, her vitals showed a T-max of 97.8°F, HR of 74bpm, BP 101/65 mmHg, and oxygen saturation of 98% on room air. Physical exam was significant for crackles in her right lower lung base and was otherwise unremarkable. Labs on admission were significant for a WBC of 15,000/mcL and CRP of 24.9 mg/dL. Patient had a chest CT done which showed multifocal cavitary infiltrates throughout both lung fields suspicious for septic embolus versus multifocal pneumonia. She had positive blood cultures in 4/4 bottles for Staphylococcus aureus. TEE showed a moderate sized mobile vegetation on the leaflet of the right ventricular lead. Patient was started on empiric antibiotics, vancomycin and cefepime, and cardiology was consulted for removal of her AICD. Patient had her AICD removed, PICC line placed for long term antibiotics, and discharged home with future plans of getting a replacement AICD.

IMPACT/DISCUSSION: AICD endocarditis is a rare disease, with a reported incidence ranging from 1-7% with septic embolus occurring in just 27% of those cases. This patient was at an increased risk of endocarditis given the recent exchange of her defibrillator just one month prior to her admission. This case represents the importance of recognizing acute pathologies in uncommon presentations. This patient presented without classical signs and symptoms of endocarditis, such as fever, chills, heart murmur, and negative SIRS criteria. However, the presence of mechanical hardware in her heart and cavitary lung lesions on CT chest prompted further workup to rule out endocarditis. The patient was treated appropriately with antibiotics and AICD removal, thus allowing her to have a favorable outcome.

CONCLUSION: ● Gathering a detailed history will help recognize even the most severe illnesses despite abnormal presentations.

● AICD devices must be removed in cases of bacterial endocarditis demonstrating lead vegetations or S. aureus bactermia.

PULSELESS ELECTRICAL ACTIVITY (PEA) ARREST UNMASKING PRE-EXISTING LIBMAN- SACKS ENDOCARDITIS.

SANDRA PASIAH, Tazeen Rizvi

Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL. (Control ID #3876640)

CASE: Case: 28-year-old female with a past medical history of Systemic Lupus Erythematosus (SLE), ESRD secondary to lupus nephritis, Nonrheumatic Tricuspid Valvular Insufficiency status post tricuspid valve annuloplasty who presented due to a lupus flare. Patient was initially being treated for a lupus flare, with IV Methylprednisolone 32 mg, followed by prednisone 20 mg once daily. Patient’s lupus flare was under control and she was getting ready for discharge until she had a PEA arrest, secondary to hypoxia, in the setting of pulmonary edema, as suggested by Chest X-ray. Initially, the volume overload and pulmonary edema was attributed to pre-existing tricuspid insufficiency. However, repeat TTE at the time revealed small vegetation or mass on the mitral valve, along with new severe mitral valve regurgitation. In order to better classify the mass, Transesophageal Echocardiogram (TEE) was performed, revealing severe mitral regurgitation, with anterior leaflet pathology, along with a bright mobile echo density prolapsing in to the left atrium. Additionally, her blood cultures continued to be negative, along with antibodies for brucella, Q-fever, bartonella, thus, favoring a diagnosis of Libman-Sacks endocarditis. Patient was eventually weaned off mechanical ventilation, however, was not deemed a stable candidate for mitral valve repair. Her symptoms of mitral valve regurgitation were conservatively managed with diuresis, and she was discharged to acute inpatient rehabilitation.

IMPACT/DISCUSSION: Discussion: Libman-Sacks endocarditis is defined as non-infectious lesions found on cardiac valves. Pathogenesis is unknown however; it is proposed to be associated with endothelial injury caused by circulating cytokines which may trigger platelet and fibrin deposition leading to a hypercoagulable state. Definite diagnosis is made via autopsy, revealing deposition of sterile platelet thrombi on heart valves often Mitral and Aortic valves. Libman-Sacks endocarditis is associated with advanced malignancy, systemic lupus erythematosus. Typical presentation of Libman-Sacks endocarditis includes Cerebrovascular Accidents and embolization to organs including the spleen, kidney and skin. However, rarely Libman-Sacks endocarditis fails to reveal itself, and may present itself differently as seen in this case.

CONCLUSION: The primary objective of this case is to highlight the unusual presentation of Libman-Sacks endocarditis, as it usually does not lead to pulmonary edema causing PEA arrest. However, it is vital to realize that the SLE population is at risk of this relatively rare complication and its catastrophic outcomes.

Hence, in order to prevent fatal outcomes in SLE populations from Libman-Sacks Endocarditis, we recommend these patients should get transthoracic echocardiograms annually for the purpose of valvular evaluation.

PURE RED BLOOD CELL APLASIA ASSOCIATED WITH COVID-19 INFECTION

Napat Rangsipat, Damian Casadesus, Zachary Elder, Hamed Heydari

Internal Medicine, Jackson Memorial Hospital, Miami, FL. (Control ID #3875082)

CASE: A 71-year-old female presented with shortness of breath, dizziness, headache and palpitation with near syncope. She had a history of gastritis, hypertension, diabetes and recurrent severe anemia requiring the treatment with transfusion every 2 to 3 months since her infection with COVID-19. On admission, she was found to have haemoglobin of 34 g/L. She started treatment with packet red blood cell (PRBC) transfusion and 1mg/kg Prednisone orally daily. The patient was admitted in another institution seven months prior to this admission. A bone marrow was performed and revealed decreased erythropoiesis. Esophagogastroduodenoscopy and colonoscopy were performed as outpatient and no source of anemia were observed. CT scan of chest and abdomen did not showed any suspected abdominal or chest mass such as a thymoma.

IMPACT/DISCUSSION: There are two previously published papers that discuss the linkage between COVID-19 infection and pure red blood cell aplasia. There is no clear cause why these patients developed a decreased or absent erythroid precursor in the bone marrow as many commonly known associations has been ruled out. One shared similarity between these cases is that PRCA developed concurrently or shortly after COVID-19 infection. A mechanism of how this viral infection can lead to varying disease presentation despite recovery from COVID-19 is still not well understood. However, a recent study has identified RBC precursor as a direct target of SARS-CoV-2 which is also shown to induce hemoglobin and iron metabolism dysregulation [6]. A deeper investigation into how SARS-CoV-2 effect on RBC precursors could possibly lead to development of PRCA can be beneficial in understanding the mechanism and treatment of the disease. We hope to provide useful information about blood related complications from SARS-CoV-2 infection, the linkage between preexisting cases and the connection to be made for future research.

CONCLUSION: A 71-year-old-female was admitted to the hospital due to severe anemia requiring recurrent blood transfusion every two to three months following her COVID-19 infection. A bone marrow biopsy was performed showing a near complete absence of erythropoiesis with rare erythroid precursor. The patient was diagnosed with pure red blood cell aplasia (PRBCA). With no clear association to the commonly associated cause of pure red blood cell aplasia such as hematologic malignancy, parvoB19 virus infection and thymoma, we believe that this could be the third case report of PRBCA associated with COVID-19 infection.

PUZZLING PROCTITIS: A PRESENTING SYMPTOM OF ACUTE PROMYELOCYTIC LEUKEMIA

Clark Stallings¹; Matthew N. Metzinger²; William Levin³

¹Internal Medicine, UPMC, Pittsburgh, PA; ²Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ³General Internal Medicine, University of Pittsburgh Medical Center, Gibsonia, PA. (Control ID #3876591)

CASE: A 32-year-old heterosexual cis-gender male without significant past medical history presented with 4 weeks of low grade fevers and 10 days of rectal pain in the Fall of 2022. His fevers started after his son contracted a febrile illness and initially were accompanied by pharyngitis, for which he was prescribed amoxicillin. After initially improving, he had onset of rectal pain and the return of fevers with night sweats. He also reported a minor paper cut with easier bleeding than usual. He denied new sexual partners, as well as receptive anal intercourse. On presentation he was found to have profound neutropenia and thrombocytopenia. Physical exam was negative for rashes or blisters. A contrasted CT scan of the abdomen and pelvis showed mild perirectal fat infiltration and rectal wall thickening concerning for proctitis. COVID/influenza/RSV swab, HIV, and Lyme testing were negative. Mpox testing was considered but he did not have a lesion that could be swabbed. He was started on cefepime and metronidazole for febrile neutropenic proctis. A peripheral blood smear showed occasional blasts and myelocytes. A bone marrow biopsy was completed, showing sheets of blasts and abnormal promyelocytes, consistent with Acute Promyelocytic Leukemia (APML). He was promptly started on all trans retinoic acid (ATRA). Fluorescence in situ hybridization (FISH) testing from his biopsy ultimately showed the PML/RARA fusion and his APML therapy was augmented to include Arsenic Trioxide (ATO). He was discharged to home and on follow up has been in remission.

IMPACT/DISCUSSION: APML is a hematologic emergency that most commonly results from a t(15;17) translocation of the retinoic acid receptor alpha (RARA) gene on chromosome 17 and the promyelocytic leukemia gene (PML) on chromosome 15. Mortality for this disorder increases markedly with delay of therapy, making prompt diagnosis a high priority. Presentation typically manifests with fatigue, easy bleeding/bruising and infection. In this patient, proctitis was the presenting finding and can be the initial presentation of febrile neutropenia as well as APML. Diagnosis of APML is by peripheral blood smear in addition to bone marrow biopsy and FISH testing for the PML/RARA translocation. Timely initiation of ATRA is a mainstay of therapy and vital to reducing mortality. In low risk AMPL as defined by white blood cell count less than or equal to 10,000, the addition of ATO has been shown to improve survival in clinical trials. In this patient presenting with fevers and rectal pain in Fall of 2022, an additional consideration on the differential was Mpox, though this patient ultimately did not have a characteristic rash nor risk factors.

CONCLUSION: In patients presenting with subacute fevers, pancytopenia, and proctitis, hematologic emergencies must be considered. While ultimately not consistent with the clinical picture, Mpox was a timely addition to the differential diagnosis of proctitis in the Fall of 2022.

RARE & DELAYED IFOSFAMIDE ENCEPHALOPATHY: A CASE REPORT OF CHEMOTHERAPEUTIC NEUROTOXICITY IN PRESUMED EWING SARCOMA

Ambika Menon¹; Chidi Enunwa¹; Kyle James²

¹Hospital Medicine, Emory University School of Medicine, Atlanta, GA; ²Hospital Medicine, Emory Univeristy Hospital Midtown, Atlanta, GA. (Control ID #3876295)

CASE: A 25-year-old female with past medical history of presumed Ewing Sarcoma of the mandible on chemotherapy presented with 2 days of encephalopathy. She was at her baseline until 2 days before admission, when she had non-sensical verbal outbursts, unprovoked crying spells & refused to follow commands. On arrival, vitals were within normal limits. Labs were significant for WBC count of 24 10³/mcL, calcium of 10.2 mg/dL, & negative urine drug screen. CT head without contrast & MRI brain were normal. Physical exam showed a 7.1-cm expansile lytic mass of the right mandibular body, fixed gaze without tracking, mild tremor & occasional grunting. Recent medications included alternating cycles of ifosfamide & etoposide with vincristine, doxorubicin & cyclophosphamide. These medications were first administered 14 days prior to presentation & last administered 7 days prior. Within 2 hours of admission, psychiatry & neurology were consulted. Electroencephalogram showed diffuse slowing. She continued to be intermittently encephalopathic with impaired attention & limited thought content. Behaviors included hair pulling, pulling at room fixtures & standing on furniture. Haloperidol, lorazepam & scheduled olanzapine were trialed without benefit. Oncology recommended trial of methylene blue for delayed ifosfamide toxicity. Her symptoms resolved after 5 days of methylene blue administration, & she was discharged with plans to adjust her chemotherapy regimen.

IMPACT/DISCUSSION: Ifosfamide is used as treatment in many solid organ & hematologic malignancies. Encephalopathy is a known adverse reaction of ifosfamide therapy, occurring in 10-30% of patients. Most neurotoxic side effects occur within the first 5 days post-infusion. Ifosfamide is metabolized by the liver into chloroacetaldehyde & chlorothylamine, which can cross the blood brain barrier & are neurotoxic. These can cause hallucinations, seizures, disorientation, coma, death & brain damage through direct neurotoxicity or inhibition of mitochondrial oxidative phosphorylation. Risk factors for ifosfamide toxicity are older age, female gender, low serum albumin, renal failure & oral route of administration. While a clinical diagnosis, the onset of encephalopathy is known to typically occur within 2 to 146 hours of infusion. Two case reports demonstrated delayed neurotoxicity, 7- & 16-days post-infusion, both resolving with methylene blue administration. Aside from hydration & discontinuation of the offending agent, methylene blue is the antidote for ifosfamide toxicity. Symptoms typically improve within 24 hours of administration, & time to improvement may correlate with timing of toxicity. Those with delayed onset of symptoms may also have delayed resolution with methylene blue, as seen in our patient, who received 5 days of treatment.

CONCLUSION: Delayed encephalopathy is a rare side effect of ifosfamide, but should be considered in patients receiving the drug, even several days post-treatment.

RARE CASE OF CELIAC ARTERY DISSECTION IN THE SETTING OF FIBROMUSCULAR DYSPLASIA

Pedram D. Maleknia¹; Ahmed Ali¹; John Fanning²; Yedla Parekha³

¹Internal Medicine, UAB Heersink School of Medicine, Huntsville, AL; ²Internal Medicine, The University of Alabama at Birmingham School of Medicine Huntsville, Huntsville, AL; ³Internal Medicine, UAB, Huntsville, AL. (Control ID #3868900)

CASE: A 47yoF presented to the ED with RUQ abdominal pain radiating to the right flank that started the night before. She described her pain as dull and achy, not related to food or movement, and without aggravating or alleviating factors.

On the morning of presentation, she developed acute severe central chest pain, nausea, and diaphoresis, that lasted for an hour. Her past medical history was remarkable for hypertension and obesity. Her surgical history included gastric sleeve and laparoscopic cholecystectomy done years prior. She denied any history of smoking, alcohol, or drug abuse.

The patient was afebrile and normotensive. Initial labs were notable for an ALT of 209, AST of 249, and an Alk phos of 98. Hepatitis panel (-). EKG unremarkable, and troponin levels were WNL. The initial CTA chest ruled out pulmonary embolism but was coincidentally remarkable for celiac artery dissection. A CTA abdomen and pelvis revealed focal dissection of the celiac artery with surrounding fat stranding but without extravasation. There was also a beaded appearance of the bilateral renal arteries, suggestive of FMD. Vascular surgery was consulted, and DAPT, esmolol drip, and pain medications were ordered. As there was no evidence of median arcuate ligament syndrome and the patient had excellent collateral blood flow, no surgical intervention was warranted. There was concern for hepatic ischemia as her liver enzymes peaked with an ALT of 667, AST of 865, and Alk phos of 182, but they later started to trend down over the next few days. After three days, the patient’s diffuse pain resolved. She was discharged on DAPT, metoprolol, and analgesics as needed and was instructed to follow up with vascular surgery, who later recommended conservative management.

IMPACT/DISCUSSION: The actual incidence of celiac artery dissection is unknown. It most commonly occurs in males 55 and older. Risk factors include hypertension, trauma, connective tissue disorders, and FMD. Without uncontrolled hypertension, and with the beaded appearance of our patient’s bilateral renal arteries, we believe the likely cause of her pathology to be FMD. FMD most commonly affects females at a 9:1 ratio and the renal and carotid arteries are the vessels most frequently involved. The most common presenting symptoms in patients are abdominal pain, nausea and vomiting, diarrhea, and diaphoresis with syncope. CTA of the abdomen and pelvis is the diagnostic test of choice.

The goal of treatment is to prevent progression of dissection into nearby vessels. Treatment options include conservative management or endovascular/surgical repair, which is generally only indicated for patients with end-organ ischemia, or those who failed first-line therapy.

CONCLUSION: Clinicians must have celiac artery dissection on the differential of a patient presenting with epigastralgia, especially in the absence of other clinical findings. Prompt diagnosis and consultation with vascular surgery are critical.

RARE CASE OF REFRACTORY HYPOXEMIA SECONDARY TO A HIDDEN PATENT FORAMEN OVALE

Sabah Iqbal¹; Kristal Pereira¹; Krishna Desai¹; Akhil Jain²; Sohiel Deshpande¹; Jayamohan Nair¹

¹Internal Medicine, Mercy Fitzgerald Hospital, Philadelphia, PA; ²Medicine, Mercy Fitzgerald Hospital, Darby, PA. (Control ID #3876018)

CASE: 35-year-old female with past medical history of end-stage renal disease, cirrhosis with recurrent ascites, chronic diastolic heart failure and chronic lymphedema was admitted to the ICU for acute hypoxic respiratory failure requiring intubation. Imaging revealed large pericardial effusions and ascites. Echocardiography revealed severe concentric left ventricular hypertrophy, severe pulmonary hypertension and large pericardial effusion without tamponade. She underwent paracentesis and pericardiocentesis with incomplete evacuation of 300 mL of bloody fluid. A pericardial drain was placed however due to minimal drainage, anterolateral pericardial window was created. Pericardial fluid grew E. coli for which cefepime was initiated. Patient was extubated but was reintubated within 48 hours due to increasing oxygen requirements despite BiPAP. The next day, code blue was called due to asystole and patient was revived per ACLS protocol. That night, due to worsening hypoxemia, CT chest was obtained which showed bilateral pulmonary embolisms. Despite continued serosanguineous drainage from pericardial drains, heparin drip was started, as benefits outweighed risks. Patient's ICU course was complicated by uncontrolled hypertension and frequent PVCs on EKG. Despite these measures, patient continued to be hypoxic prompting cardiologists to obtain repeat echocardiography with bubble study which revealed severely dilated right atrium, left interatrial septal bulge, very large amount of bubbles moving from right to left atrium and left ventricle. Prior to any intervention, patient had multiple episodes of asystole and could not be revived.

IMPACT/DISCUSSION: Refractory hypoxemia (RH) refers to inadequate arterial oxygenation despite application of optimal lung protective ventilation. Patent foramen ovale (PFO) is a common occurrence but rare cause of acute hypoxic and refractory respiratory failure. PFOs increase in size with advancing age hence posing a higher threat for complications. Significant tricuspid valve regurgitation in the presence of PFO further worsens the right-to-left shunt. An alarming sign of RH due to PFO would be orthostatic desaturations warranting further investigation. Agitated saline bubbles can help differentiate intracardiac with intrapulmonary shunts. A diagnosis can be made when >1 microbubble is seen in left chamber. Grade 0 shunt is visualizing no microbubbles, grade I is 1-5 microbubbles, grade II is 6-20 microbubbles, grade III is 21-50 microbubbles, and grade IV is >50 microbubbles. Treatment of choice is percutaneous transcatheter closure.

CONCLUSION: Acute respiratory distress syndrome is the most common cause however other etiologies such as sepsis, aspiration, smoke inhalation, massive blood transfusions and embolism should be ruled out. A cardiac shunt, though uncommon, should always be in the differential diagnosis. When evaluating patients with RH, a thorough evaluation including assessment for hidden PFO is imperative in improving clinical outcomes.

RARE COMPLICATIONS OF ROUTINE DENTAL PROCEDURES: LUDWIG’S ANGINA, LEMIERRE’S SYNDROME, AND CAVERNOUS SINUS THROMBOSIS FOLLOWING WISDOM TEETH EXTRACTION

Jasdeep Bathla^1,2; Ayat Abyad^1,2; Zubin Mukadam^1,2

¹Internal Medicine, Detroit Medical Center, Detroit, MI; ²Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #3875278)

CASE: A 24-year-old woman with no past medical history presented with neck swelling, pain, trismus, and dysphagia associated with decreased oral intake. She had 3 wisdom teeth extracted 11 days prior and developed facial pain and swelling before noticing purulent drainage from the extraction site. Due to development of trismus with worsening bilateral neck swelling, she presented to our facility where she was noted as afebrile and tachycardic without respiratory distress, but with leukocytosis of 34.3 K/CUMM showing left shift. Initial neck CT imaging showed a very large, left anterior abscess with extension into the left upper chest, left parapharyngeal space, and left submandibular and sublingual regions. She underwent emergent incision and drainage (I&D) of the deep neck abscess with placement of surgical drains and was intubated for post-procedural swelling. Intra-op cultures grew Streptococcus constellatus and Prevotella spp. She was started on vancomycin, ceftriaxone, and metronidazole. Imaging of the thorax showed bilateral pulmonary nodules and bibasilar consolidations consistent with septic emboli. Workup was negative for infective endocarditis. Severe facial swelling led to inability to open her left eye and CTA of the head/neck showed temporal and masseter abscess, cavernous sinus thrombosis, and left internal jugular vein septic phlebitis. She underwent repeat I&D with debridement of necrotic soft tissue. Antibiotics were continued along with fluconazole for new Candida albicans growth and heparin drip. She continued to improve with hyperbaric oxygen treatments prior to anterior cervical skin graft and was healing adequately at her outpatient follow-up visit.

IMPACT/DISCUSSION: Wisdom tooth extraction is a routine procedure however this case highlights the rare complications and complex management associated with dental procedures that may occur in otherwise healthy individuals. Ludwig’s angina can be fatal and rapidly progressive, therefore initial assessment revolves around airway protection. Due to close anatomy, Ludwig’s angina can frequently precipitate both septic cavernous sinus thrombosis and Lemierre’s syndrome. Although more commonly seen with fusobacterium, Lemierre’s syndrome can be caused by other facultative anaerobes such as Streptococcus anginosus group, which can then seed off as septic emboli, most commonly affecting the lungs.

CONCLUSION: Although rare, oropharyngeal emergencies such as Ludwig’s angina, Lemierre’s syndrome and cavernous sinus thrombosis are rapidly fatal and require high clinical suspicion to prevent delays in treatment. Special attention must be paid to those presenting with facial pain and swelling, trismus, and respiratory compromise.

RARE PRESENTATION OF MSSA BACTEREMIA WITH MULTIPLE SUB-ARACHNOID HEMMORHAGES AFTER COVID INFECTION

Umair Ahmad¹; Tania Waseem⁴; Shreedip Patel³; Samar Khan²

¹Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ²Critical Care Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ³Internal Medicine, MedStar Georgetown University Hospital MedStar Washington Hospital Center Internal Medicine Residency Program, Washington, DC; ⁴Internal Medicine, Nishtar Medical College and Hospital, Multan, Punjab, Pakistan. (Control ID #3868291)

CASE: 73-year-old male with a past medical history of hypertension, dyslipidemia, coronary artery disease, and recent hospitalization for COVID-19 pneumonia status post dexamethasone, remdesivir, and tocilizumab who was discharged home on oxygen supplementation presented to the hospital with progressively worsening weakness and confusion for 5 days. Per the EMS, the patient was found to have a nosebleed with systolic blood pressure in the 230s. He had a right facial droop and right-sided weakness. In the ED code stroke was initiated, and the CT head showed multiple acute subarachnoid hemorrhages. CT trauma protocol did not show any acute fractures. Lab workup revealed a platelet count of 29,000, sodium 120mEq/L, creatinine 1.8mg/dL, glucose 204gm/dL, LDH 553, ferritin 1145, haptoglobin 285, fibrinogen 494, INR 2.0, D-dimer 54., COVID PCR was positive and tickborne work-up was negative. He was admitted to the intensive care unit, started on a hypertonic saline solution, and maintained on Nicardipine drip to keep his systolic blood pressure below 140. Continuous EEG was negative for subclinical seizures. Sepsis work-up showed gram- positive bacteremia and the patient was started on broad-spectrum antibiotics. Hematology was consulted for persistent severe thrombocytopenia and coagulopathy despite multiple platelet transfusions. The patient subsequently developed multiorgan failure and was transitioned to comfort measures only

IMPACT/DISCUSSION: During the COVID-19 pandemic, there have been increased cases of bloodstream infections in patients who have been treated with immunomodulating therapies. Various studies have been conducted during the COVID-19 pandemic which shows an increased incidence of Staphylococcus aureus bacteremia during or after the viral infection with an increased risk of mortality. A recent study showed 14- day and 30-day mortality rates of 54.8% and 66.7% respectively in Staphylococcus aureus co-infection with COVID-19. The proposed mechanism for superimposed bacterial infections is related to virus-induced granulocytopenia and the role of IFN 1. It is not uncommon to see various bacterial and fungal co-infections in COVID-19 patients.

Thrombocytopenia, defined as a platelet count less than 150,000/μL, is associated with critical illness and found to have a strong association with an increased risk of mortality in septic patients. The incidence of thrombocytopenia is around 20-40% in the patients admitted to the ICU. It can lead to an increased risk of bleeding and life-threatening bleeding is seen with a platelet count of less than 30,000/μL. Sepsis-induced thrombocytopenia can be due to various mechanisms including platelet-associated antibodies and cytokine- driven hemophagocytosis of platelets.

CONCLUSION: This case highlights the short-term sequel of covid infection in elderly patients who are at risk of developing superimposed bacterial infection with associated systemic complications, which can lead to increased mortality in the elderly population.

RASH AND FEVER IN A PATIENT WITH MDS, SWEET!

Yuhong Yang¹; Megan R. D'Andrea²; Hong Yu Wang¹; Mina A. Shenouda¹; Jonathan Feld²

¹Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY; ²Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #3874020)

CASE: A 58-year-old male with myelodysplastic syndrome (MDS) diagnosed in August 2022 post cycle 2 of azacitidine was sent to the emergency department by his oncologist for fever in the setting of pancytopenia.

He also reported rash with weakness and malaise. Physical exam was notable for an erythematous, non- pustular, tender rash with plaques involving the patient’s arms and legs. Cefepime and vancomycin were started for neutropenic fever. A broad infectious workup came back negative but the patient had recurrent fevers, persistent neutropenia, elevated ALT/AST of 265/150 U/L, and progressive skin rash. He was started on liposomal Amphotericin B for possible fungal infection. His skin biopsy was negative for infection but showed septal and lobular panniculitis with neutrophils. A repeat skin biopsy was done due to high suspicion of Sweet syndrome, and neutrophilic dermatitis most consistent with Sweet syndrome was observed. The patient was started on prednisone 0.5 mg/kg. His skin lesions and fevers resolved within a week, and his ALT/AST normalized. Unfortunately, a bone marrow biopsy during this hospitalization revealed progression from MDS to acute myeloid leukemia (AML). He was started on azacitidine and venetoclax shortly after starting prednisone.

IMPACT/DISCUSSION: Our patient had malignancy-associated Sweet syndrome when his MDS progressed to AML. There are three types of Sweet syndrome: classical, malignancy-associated, and drug- induced. About 21% of Sweet syndrome cases are malignancy-associated (Cohen et al. 1993). Sweet Syndrome can be a sign of undiagnosed malignancy or the first sign of cancer recurrence; 85% of the associated malignancy is hematologic (Paydas 2013). A recent retrospective study showed that MDS was the most common hematologic malignancy associated with Sweet syndrome (Jung et al. 2022). Prior case reports have shown the co-occurrence of Sweet syndrome with the transformation of MDS to AML (Vera-Lastra et al. 2021).

Sweet Syndrome, also known as acute febrile neutrophilic dermatosis, is an inflammatory disorder characterized by the abrupt appearance of painful, edematous, and erythematous plaques/nodules on the skin. Fever and leukocytosis frequently accompany the cutaneous lesions. Extracutaneous manifestations are less common but can occur when neutrophilic infiltrates involve other organ systems (Cohen et al. 2012). Our patient's elevated ALT/AST was likely a hepatic manifestation of Sweet syndrome. The first-line treatment for Sweet syndrome is systemic glucocorticoids, typically prednisone 0.5 – 1.0 mg/kg. Malignancy- associated Sweet syndrome can resolve once the underlying cancer is treated.

CONCLUSION: Sweet syndrome is a rare condition most associated with myeloid malignancies. Its presence may rarely indicate the transformation of an MDS to AML. When neutropenic patients present with the abrupt onset of unexplained erythematous, non-pustular, and tender plaques, we should consider a malignancy work-up and referral to oncology and dermatology.

REACTIVATION OF LATENT TUBERCULOSIS: IMMUNOTHERAPY-RELATED OR STEROID- INDUCED?

Kyle Miyazaki²; Jean Kim¹. ¹Cardiovascular Medicine, University at Buffalo, Buffalo, NY; ²Internal Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY. (Control ID #3875382)

CASE: A 70-year-old Filipino male with a 40-pack-year smoking history presented with dyspnea and increasing cough with whitish sputum for several days. Patient denied fever, chills, chest pain, palpitations, night sweats, or weight changes. Of note, the patient was recently diagnosed with stage IV squamous cell carcinoma of bilateral lungs and underwent 3 cycles of chemotherapy with taxol and carboplatin with incomplete response, and was switched to immunotherapy with nivolumab. The course was complicated by immunotherapy-induced pneumonitis and encephalopathy which led to initiation of prednisone and discontinuation of nivolumab. Bronchoscopy with bronchoalveolar lavage (BAL) was obtained few months prior to this admission, and MTB/RIF assay, acid-fast smear, gram stain, and fungal culture of the BAL sample did not grow organisms. On presentation of this admission, vital signs were within normal limits, and the physical exam was pertinent for loud crackles in bilateral lung bases. White blood cell count was elevated to 24 x 10^3/ul with neutrophilic predominance and procalcitonin 0.22 ng/mL. SARS CoV-2 PCR, Influenza type A and B, Cryptococcus antigen, Aspergillus antigen, and Fungitell (1-3)-B-D-Glucan were negative. Sputum MTB/RIF Assay and acid-fast smear and culture were positive for MTB (Mycobacterium tuberculosis). CT chest showed interval worsening of multifocal patchy nodular opacities, worse at lung bases, compared to 2 months prior. A reactivation of MTB was concerned, and the patient was started on RIPE (rifampin, isoniazid, pyrazinamide, ethambutol) therapy and was tapered off of home prednisone.

IMPACT/DISCUSSION: Since the development of immune checkpoint inhibitors (ICI), the treatment of cancers has radically changed. ICIs have been shown to be associated with various toxicities, however, including infections. It is unclear if infections are directly associated with ICIs themselves or from concurrent use of corticosteroids or TNF-a inhibitors for immune-related adverse events (irAE). The mechanism of MTB infection or reactivation following ICIs is also unknown. While some studies describe that the concurrent use of corticosteroids or TNF-a inhibitors may play a role, other studies have reported MTB reactivation in patients without other concurrent medication use, suggesting MTB reactivation may be a direct complication of ICIs. Guidelines about whether to screen patients for latent and active TB prior to starting ICIs and/or agents for irAEs, and when to resume ICIs upon completion of MTB treatment are lacking.

CONCLUSION: This case highlights the further need for investigation regarding MTB reactivation associated with ICIs. MTB reactivation and acute MTB infection rates in patients on ICIs appear to be low in non-endemic areas, however clinicians in MTB-endemic countries should consider testing for latent TB prior to starting ICIs given increased MTB prevalence.

RECOGNIZING AND DEFINING XANTHOGRANULOMATOUS PYELONEPHRITIS

Emily Rider-Longmaid

General Internal Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #3877275)

CASE: A 76-year-old woman with a history of dementia and perforated C diff colitis s/p total colectomy presented with sepsis and abdominal pain. Her WBC was 26.2 and her creatinine was 4.04 from her baseline of 1. Her urinalysis was positive for blood, nitrites and leukocyte esterase, and microscopy showed 10-20 RBCs, 20-50 WBCs, and moderate bacteria. Urine culture showed fewer than 10K CFU/ml mixed bacterial flora and blood cultures were negative. She underwent a CT abdomen/pelvis showing obstructing right renal calculi with pyelonephritis, distortion of the renal contour, multiple new right perinephric abscesses, and a complex perihepatic abscess. She was started on broad spectrum antibiotics and underwent urgent percutaneous nephrostomy (PCN) placement. Fluid cultures grew E. coli. Her course was complicated by persistent fevers and leukocytosis to 42.6. A repeat CT abdomen/pelvis showed decrease in size of perinephric abscesses but continued perihepatic abscess. She underwent RUQ drain placement, and fluid cultures again grew E. coli. She was continued on a seven-day course of ceftriaxone and metronidazole, and transitioned to cefpodoxime and metronidazole until five days after RUQ drain removal. She was discharged home with PCN in place and urology follow up.

IMPACT/DISCUSSION: This patient’s presentation was initially concerning for urosepsis and highlights the importance of cross-sectional imaging given her complaint of abdominal pain and her significant acute kidney injury. The presence of multiple perinephric abscess and distortion of her renal contour in the setting of obstructing renal calculi represents a rare variant of pyelonephritis: xanthogranulomatous pyelonephritis (XPN). XPN occurs most often in patients with chronic pyelonephritis and renal calculi; upon further review of this patient’s chart, she had a history of recurrent UTIs and renal calculi. Renal calculi were obstructing her right ureteropelvic junction, causing increased pressure leading to rupture of her collecting system and development of abscesses and acute kidney injury. XPN can present with negative urine cultures, which can falsely be reassuring and so high clinical concern needs to be maintained. While antibiotics are the acute management, nephrectomy is the definitive management. This case highlights the importance of source control as the patient’s delay in perihepatic abscess drainage led to prolonged antibiotic course and deferral to outpatient for nephrectomy.

CONCLUSION: This case illustrates the common risk factors for XPN and reinforces the need for clinical suspicion despite negative urine cultures.

This case demonstrates a common presentation of XPN with urosepsis, AKI, and abomdinal pain. The radiographic results are also characteristic of XPN, including obstructing renal calculi, distortion of renal architecture, and perinephric abscesses.

This case highlights the importance of early source control and renal diversion in XPN to best reach the definitive treatment of nephrectomy.

RECURRENT ACUTE PANCREATITIS: CANNABIS AS AN OVERLOOKED ETIOLOGY

Sadia A. Tanami, Anass Dweik, Falah I. Abu Hassan, Saria Tasnim, Rahul Chandra

Internal medicine, Texas Tech University Health Sciences Center School of Medicine Amarillo, Amarillo, TX. (Control ID #3861630)

CASE: A 39-year-old female with a medical history of diabetes mellitus type 1, hypertension, and depression presented to the emergency department with complaints of epigastric abdominal pain, nausea, and vomiting for 2 days. On review of her history, she had multiple admissions secondary to acute pancreatitis without any common causative agents for the last four months. Social history was only positive for smoking marijuana 1 to 2 times per week for the past many years. Home medications include insulin, lisinopril, sertraline, and trazodone. On physical examination, the patient was hypertensive, tachycardic, and tenderness was present in the epigastric area. Labs showed a WBC of 10.9, Glucose 298, normal anion gap, lipase 1880, creatinine 2.1, normal IgG4, normal triglyceride level, and urine drug screen was positive for cannabinoids. Imaging modalities such as CT abdomen and pelvis without contrast and USG of the liver were unremarkable. The patient was treated with intravenous normal saline with analgesic and antiemetics. The patient felt symptomatically better in a couple of days and was counseled regarding the cessation of cannabis. IMPACT/DISCUSSION: Acute pancreatitis (AP) is an acute inflammation of the pancreas. The most common risk factors for AP are alcohol, gall stones, high triglyceride, autoimmune, and medications. Cannabis was first reported as a possible cause of AP in 2004 and only 26 total cases have been reported since then. The specific pathophysiology involving cannabis-induced pancreatitis (CIP) is not well understood. Currently, the hypothesis is that cannabis acts via two cannabinoid receptors (CB); CB I and CB II which are both prevalent in pancreatic tissue. The expression and activity of both receptors are increased during pancreatic inflammation. The physiologic effects of the CB I receptor can increase pancreatic amylase, lipase, ribonuclease, and IL-1 β secretions with the help of anandamide, an endocannabinoid. It is assumed that this interaction creates a similar physiological environment that is observed in AP. Some studies also suggested that the activation of the CB I receptor can cause impaired relaxation of the Sphincter of Oddi which can further precipitate pancreatitis. However, extensive molecular studies are needed to better understand the pathophysiology of CIP. Research also showed that all the patients who stopped using cannabis did not experience any further episodes of acute pancreatitis.

CONCLUSION: Our patient does not have any usual etiology to cause recurrent acute pancreatitis. Identification of CIP is challenging due to the lack of clear-cut diagnostic criteria. Cannabis should be considered as a differential diagnosis for the etiology of acute pancreatitis. A prompt accurate diagnosis and cannabis cessation can prevent rapidly progressive disease. Early identification of CIP can avoid unnecessary work-up and reduce health burden and cost.

RECURRENT CLOTS WITHOUT A CAUSE: A CASE OF NATIVE AORTIC VALVE THROMBUS

Aanchal Sawhney

Internal Medicine, Crozer-Chester Medical Center, Upland, PA. (Control ID #3875501)

CASE: A 25 year old female with past medical history of hypertension presented with acute onset of dizziness, slurred speech and right sided weakness ongoing for 1 hour. CTA head revealed distal basilar artery occlusion. Emergently taken for thrombectomy following which patient was initiated on clopidogrel.

Post stroke work up for coagulopathies and cardiac causes revealed a 1.5*0.5 cm hyper echoic density on the non coronary cusp of aortic valve with structurally and functionally normal aortic valve as seen on TEE. Coagulopathy workup including lupus anticoagulant, cardiolipin antibodies, prothrombin gene mutation, factor 5 leiden mutation, and protein C, S were negative.

The differential diagnosis for the hyper echoic density was either fibroelastoma or thrombosis of the aortic valve and treatment with warfarin initiated. One week later, this patient returned and was diagnosed with TIA. Outpatient TEE 4 weeks after the stroke revealed dissolution of previously identified mass on aortic valve favouring the diagnosis of thrombus over elastoma.

IMPACT/DISCUSSION: Native aortic valve thrombus is a rare diagnosis with only 74 cases reported worldwide. Most cases reported utilized thrombectomy to guide management but literature is not suffice to favor surgical clot retrieval over anticoagulation. The commonly identified etiologies include hyper coagulable state, idiopathic, left ventricular assist device (LVAD), Infective Endocarditis, and aortic root abnormalities. The common presentations include myocardial infarction, limb ischemia and stroke. Diagnosis is established by TEE or aortic root angiography with 100% accuracy. Treatment modalities for a native aortic valve mass include anticoagulation, fibrinolysis and thrombectomy.

CONCLUSION: Due to lack of randomized data, there is a lack of knowledge comparing the impact of early thrombectomy versus the antithrombotic versus anticoagulation alone on outcomes of native aortic valve thrombosis.

RECURRENT FLARES OF SYSTEMIC INFLAMMATORY SYMPTOMS IN A PATIENT WITH HIV

kamelah abushalha¹; Anirudh Gautam²; THOMAS Treadwell¹

¹Internal Medicine, MetroWest Medical Center, Framingham, MA; ²Lahy hospital and medical center, Burlington, MA. (Control ID #3877334)

CASE: A 42-year-old African man with history of HIV on ARV presents in November 2008 with weakness, intermittent diarrhea and severe anemia. He received several blood transfusions. The initial impression was anemia of chronic disease. He again presented in February 2009 with fever, weakness, and diffuse lymphadenopathy. He underwent an extensive workup, resulting in a negative QuantiFERON test ,parvovirus B19, and CMV tests. A thoracoabdominal CT showed diffuse lymphadenopathy and splenomegaly. A transbronchial biopsy was negative, a liver biopsy was consistent with nonspecific lobulitis, and a lymph node biopsy was consistent with follicular hyperplasia. All biopsies were negative for acid-fast organisms, granulomas and fungi. A bone marrow biopsy showed hypercellularity, no granulomas, no changes suggestive of lymphoma and reported as a markedly reactive marrow (nondiagnostic). He was started on anti- tuberculosis therapy but after failing to respond and a negative QuantiFERON test, this was discontinued.

The patient subsequently improved symptomatically and was discharged. The patient presented again in March 2010 with several days of persistent fever and weakness. Initial hematocrit was 14. On physical exam the patient was in shock (T 102.2, HR 114, BP 80/40) and displayed diffuse lymphadenopathy and hepatosplenomegaly. Initial labwork was significant for the following: sodium 127, potassium 5.2, calcium 7.1, albumin 2.0, hematocrit 13.8, platelets 101, haptoglobin 238. Patient was medically stabilized with fluids and transfusions. He was evaluated by hematology who raised a concern of Castleman Disease (CD). All tissue biopsies were reviewed again and sent for staining for HHV-8, a pathogen universally present in HIV patients with CD. HHV-8 in a perifollicular pattern was present in this patient. He has received chemotherapy with Rituxan with poor response. IV ganciclovir was effective, and was converted to maintenance oral valganciclovir. Patient continues to be followed in the infectious disease clinic.

IMPACT/DISCUSSION: CD is a rare lymphoproliferative disorder characterized by angiofollicular lymph node hyperplasia. CD has 2 distinct forms, localized and multicentric (MCD). Half the cases of MCD are caused by HHV-8 viral infection in HIV positive or immunocompromised patients. Symptoms reported on presentation commonly include fever, lymphadenopathy, hepatosplenomegaly, and less commonly pulmonary signs or symptoms, edema and ascites. Diagnosis requires pathologic review of lymph node meeting the classic histopathological features, such as the perifollicular pattern. Managament includes the initiation/continuation of antiretroviral therapy, rituximab, and/or pegylated liposomal doxorubicin.

CONCLUSION: CD should be suspected in HIV patients presenting with recurrent flares of systemic inflammatory symptoms. HHV-8 viral load and lymph node staining are useful tools for diagnosis.

RECURRENT HEADACHES WITH VISUAL FIELD DEFECTS ALARMING FOR HYPERTENSION V/S PITUITARY PATHOLOGY- MYSTERY OF PITUITARY MACROADENOMA SOLVED

Sara Malik, Richi Kashyap, Navneet Kaur, Jeffrey Naifeh, Khushdeep Chahal

Internal Medicine, North Alabama Medical Center, Florence, AL. (Control ID #3877369)

CASE: A 60-year-old Caucasian male with a history of hypertension,hypothyroidism,hypogonadism referred to the ER by the Neurosurgeon with c/o of blurred vision and recurrent headaches for the past 10 years. Symptoms were initially attributed to refractive error. While playing with his kids he would often miss the ball and later on realized he never saw the ball coming towards him. He kept ignoring this issue as he could drive and had no issue with ADLs. Later on went to the PCP, underwent lab work and was diagnosed with hypothyroidism and hypogonadism for which he was started on thyroid and testosterone supplementation. Headaches were initially attributed to high blood pressure for which he was started on antihypertensives. Despite having an optimal blood pressure, headaches persisted and he was referred to an endocrinologist who referred him to an ophthalmologist. He had visual field testing done and was found to have bilateral temporal hemianopsia. He was recommended to have CT scan of the head which showed large suprasellar mass measuring 3.0 x 2.3 cm. Subsequent MRI of the brain showed 2.8 X 2.01 X 2.8 cm sellar/suprasellar mass compressing the optic chiasma. Patient was referred to neurosurgeon who recommended surgical resection. Patient underwent trans-sphenoidal pituitary resection. The pituitary macroadenoma was removed in a piecemeal fashion microsurgically. He had marked improvement in his vision and complete resolution of headaches. Postop patient developed central diabetes insipidus which was managed with intranasal desmopressin. Patient was later discharged home and follow-up with endocrinology and neurosurgery was scheduled for close monitoring. Pathology of the resected tissue showed findings consistent with pituitary adenoma. No features suggesting ACTH producing tumor were seen.

IMPACT/DISCUSSION: As per literature 90% of headaches are primary headaches and 10% are secondary, but clinicians should begin with a broad differential and narrow it down as they work up for the causes of headaches including pituitary tumors etc and not give in to the bias often associated with the presenting complaints. Prevalence of pituitary adenomas ranges from 1: 865 adults to 1: 2688 adults. Approximately 50% are microadenomas <10 mm; remaining are macroadenomas ≥10 mm. Mass effects can cause headache, hypopituitarism, and visual field defects. Treatment options include transsphenoidal surgery, medical therapies, and radiotherapy.

CONCLUSION: This case reiterates the importance of engaging in detailed bedside discussions with patients to establsh differential diagnosis for headaches with visual field defects, especially when clinical progress is not appreciated after initial diagnosis and management. The diagnosis for our patient was missed for nearly 10 years and after detailed evaluation by interdisciplinary team of medical professionals later broadened the differential and appropriate work-up lead to the final diagnosis and appropriate management.

RECURRENT URINARY CANDIDIASIS COMPLICATED BY FUNGAL BEZOARS IN AN IMMUNOCOMPETENT PATIENT

Sulmaz Zahedi¹; Shing Chao¹; Mohamed Ramzi Almajed¹; Ahmed M. Ibrahim¹; Indira Brar²

¹Internal Medicine, Henry Ford Health System, Detroit, MI; ²Infectious Disease, Henry Ford Health System, Detroit, MI. (Control ID #3877052)

CASE: A middle-aged man with a past medical history of uncontrolled diabetes, urinary retention requiring temporary use of an indwelling foley catheter, and prior urinary tract infection, presented for evaluation of resistant hyperglycemia. Patients hyperglycemia had been occurring for a week and was not responsive to insulin use. On further questioning, the patient also endorsed increased urinary frequency, urinary urgency, and dysuria. The indwelling foley catheter was removed 3 months prior to this presentation and was in place for 2 weeks. Initial testing was significant for hyperglycemia with glucose of >500 mg/dL with normal beta- hydroxybutyrate and normal anion gap. Urinalysis showed large leukocyte esterase, >182 white blood cells, and few budding yeasts. Urine culture was positive for Candida tropicalis. A computed tomography of his abdomen and pelvis was obtained and showed bilateral hydroureteronephrosis as well as approximately 40 fungal bezoar balls measuring 1 to 4 cm each located throughout his urinary bladder lumen. Urology evaluated the patient, and he underwent cystoscopy with transurethral resection of extra-large fungal bezoar burden in addition to amphotericin B irrigation (Figure 1). Intraoperative cultures also grew Candida tropicalis. The patient was initially treated with intravenous fluconazole and later transitioned to oral fluconazole.

IMPACT/DISCUSSION: Fungal bezoars, also known as fungus balls, are rare complications of recurrent fungal urinary tract infections. Only a few case reports of Candida spp. Fungal bezoars have been reported in the literature. Risk factors for these infections include diabetes, prolonged bladder catheterization, antibiotic usage, and malignancy (1). In this patient’s case, his uncontrolled diabetes and prolonged bladder catheterization likely placed him at higher risk for development of fungal bezoars (2). Foley catheters are ubiquitously used in hospital setting despite their propensity towards fungal growth and proliferation, prompting more cognizant use of foley catheters. Furthermore, promptly establishing diagnosis in cases of fungal bezoars is paramount as treatment differs from those of typical fungal urinary tract infections, requiring both medical and surgical approaches. If left untreated, fungal bezoars can lead to urinary tract obstruction, urosepsis, renal damage, and even bladder rupture.

CONCLUSION: This is a very rare case of intravesical bezoar infection in a patient with recurrent fungal urinary tract infections. The patient was previously treated in an outpatient setting with fluconazole. This case highlights the importance of further investigation for underlying etiologies in patients with recurrent infections. Failure to identify fungal bezoar may result in life-threatening complications.

RED-EYED REMORSE: AN UNUSUAL CASE OF OCULAR SYPHILIS WITH PENICILLIN ALLERGY

Cameron Fateri, Kevin S. Tang, Stephanie Carlisle, Kevin Hua

Internal Medicine, University of California Irvine, Irvine, CA. (Control ID #3872097)

CASE: Mr. B was a 45-year-old male who presented to the Emergency Department with 2 weeks of bilateral conjunctival injection. There was no history of trauma, and the injection was non-remitting and constant throughout the day. He endorsed eye pain but denied purulence, itching, or blurry vision. He also noted a brown maculopapular rash on the trunk, palms, and soles 3 months prior to presentation, which resolved spontaneously.

Medical history was significant for coronary artery disease as well as a penicillin allergy identified 40 years ago involving dyspnea and feelings of impending doom. He endorsed having numerous sexual partners in the past ten years but had not been sexually active in the last year.

Physical exam was significant for bilateral conjunctival injection and bilateral Argyll-Robertson pupils. A slit lamp examination was performed with findings consistent with anterior uveitis. The remainder of the physical exam, including genital exam, were within normal limits. Lab findings were significant for a positive Treponema Pallidum antibody and lumbar puncture was positive for VRDL in CSF.

Given the physical exam and lab findings, a diagnosis of ocular syphilis was made. Following consultation with Allergy/Immunology, the decision was made to trial Mr. B with a penicillin skin test given the remote nature of his allergy. Mr. B tolerated the skin test and subsequent oral challenge without complications and was discharged on empiric treatment with 2 weeks of intravenous Penicillin G therapy.

IMPACT/DISCUSSION: This case explores several unique clinical aspects of tertiary syphilis diagnosis and treatment. Ocular syphilis is a rare manifestation ranging in prevalence from 0.17-3.5%. Typical symptoms include blurry vision, red eye, vision loss, and eye pain. However, symptomology may vary widely and should be considered in conjunction with physical exam findings and characteristic non-ocular symptoms of syphilis. Ocular manifestations are often associated with underlying neurosyphilis, and if untreated may lead to irreversible vision loss.

Despite being a commonly reported allergy, up to 90% of penicillin reactions do not constitute a true allergic reaction. Even in those testing positive for a penicillin allergy, 80-100% of subjects will test negative for a penicillin allergy 10 years after an initial positive test due to a decrease in circulating IgE antibodies. True anaphylactic tendencies will require penicillin desensitization, however in many cases of remote reactions this may not be necessary. In the appropriate context, the full desensitization protocol may be deferred for a skin test and oral challenge pending approval by Allergy/Immunology. Timely identification of such cases may allow for preservation of healthcare resources and prompter treatment.

CONCLUSION: -Ocular syphilis is a rare manifestation of tertiary syphilis

-Desensitization therapy may not be necessary in patients with a remote history of penicillin allergy

REFRACTORY DERMATOMYOSITIS? CONSIDER AN ALTERNATIVE DIAGNOSIS. A RARE CASE OF HYPOPHARYNGEAL CARCINOMA PRESENTING AS DERMATOMYOSITIS FOLLOWING A COVID 19 INFECTION.

Anthony D. Tran¹; Jaime Baker²

¹Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²Internal Medicine , University of Colorado School of Medicine, Monument, CO. (Control ID #3877378)

CASE: A 73-year-old Vietnamese man with no medical history presented with facial swelling, dysphagia, proximal upper extremity weakness and a heliotrope rash two weeks following a COVID-19 infection treated with Paxlovid. An elevated CK was found. CT neck revealed a single cervical lymph node. COVID related or drug-induced dermatomyositis (DM) from Paxlovid was concluded. Improvement was noted on steroids and a short taper was prescribed. One month later, he returned with recurrence of symptoms following the completion of steroids. A deltoid muscle biopsy was performed revealing dermatomyositis with positive P155/P140 and TIF-1 gamma antibodies. Neck, chest, abdomen/pelvis CT showed an unchanged cervical lymph node, no other mass or lymphadenopathy. The cervical lymph node was biopsied, and the patient was sent home on another prednisone taper.

Pathology returned as non-small cell carcinoma. PET scan revealed a mild hypermetabolic foci at the left piriform sinus. Several weeks later, the left piriform sinus was biopsied and sent for pathology which revealed squamous cell carcinoma. A partial laryngopharyngectomy was performed. Final pathology report revealed a poorly differentiated invasive basaloid squamous cell carcinoma. Almost three months from presentation, he was referred for consideration of chemoradiation after surgery. His debilitation progressed during this time to the point of inability to perform ADLs or obtain adequate oral nutrition.

IMPACT/DISCUSSION: DM has been reported as a possible sequela of COVID-19 infection and the side

effect profile of Paxlovid is not fully understood to date. Though lymphadenopathy has been noted with COVID-19, it’s important to remember that DM is associated with a 6-fold higher risk of malignancy. Head and neck cancer has been observed to be the predominant type in several areas of Asia. Myositis-specific antibodies, P155/P140 and TIF-1γ/α antibodies are associated with malignancy.

Our patient, a Vietnamese-born male was found to have head and neck cancer in the form of a rare hypopharyngeal squamous cell carcinoma causing his DM. This case was complicated by the timing of his COVID-infection and Paxlovid treatment which incorrectly led to a diagnosis of drug-induced DM.

CONCLUSION: As we are learning about post-COVID conditions and monitoring the side of effects of Paxlovid, we must continue to be cognizant of other etiologies for illnesses that occur near a COVID infection. Though DM has been associated with COVID, refractory symptoms after steroids should warrant prompt investigation for malignancy. Although lymphadenopathy is common with COVID infection, in certain clinical settings as DM, prompt biopsy may expedite a diagnosis and treatment of malignancy, possibly shortening debilitating symptoms and allowing for quicker return of function.

REFRACTORY HYPERCALCEMIA IN A RENAL TRANSPLANT PATIENT SECONDARY TO PNEUMOCYSTIS JIROVECII PNEUMONIA

Lillian Sangha, Benjamin Ravichander, Irina Mishagina

Internal Medicine, UPMC Central PA, Harrisburg, PA. (Control ID #3875322)

CASE: A 57-year-old male with a history of renal transplant currently on immunosuppressive medication presented to the hospital with fevers and general malaise. Laboratory findings were significant for hypercalcemia (15.6 mg/dL) with suppressed parathyroid hormone (PTH) levels. Infectious investigation including urinalysis, chest x-ray, commuted tomography (CT) of the chest, abdomen, and pelvis, blood cultures, viral panel which included COVID-19, influenza, and respiratory syncytial virus were unremarkable. Due to his severe hypercalcemia, isotonic saline, calcitonin, and bisphosphonates were administered with no improvement. Further laboratory studies to evaluate refractory hypercalcemia were significant for a normal PTH-Related Protein (14 pg/mL), elevated 1,25 dihydroxy vitamin D (133 pg/dL), and normal 25-dihydroxy vitamin D (52 ng/dL). The patient was persistently febrile despite broad spectrum antibiotics in the setting of his immunosuppression. Further infectious investigation was pursued. This workup involved ruling out Ebstein Barr virus, Parvovirus, Lyme, tuberculosis, herpes simplex virus, histoplasma and pneumocystis jirovecii. His pneumocystis jirovecii qualitative PCR returned positive. He was promptly treated with systemic steroids and atovaquone for Pneumocystis jirovecii pneumonia. Serum calcium returned to normal after completion of therapy.

IMPACT/DISCUSSION: Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection that can occur in solid organ transplant recipients. These transplant patients benefit from primary microbial prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) which significantly reduces the incidence of PJP. PJP can be insidious in clinical expression and difficult to diagnose, and thus remains a life-threatening illness that has increased mortality rates in this population. Hypercalcemia is associated with PJP in renal transplant patients and is often the leading clue to aid in diagnosis. The mechanism of hypercalcemia in renal transplant patients infected with PJP is similar to that of granulomatous diseases. Granulomas are formed and consist of macrophages, monocytes, and other cell types. The macrophages produce 1-alpha hydroxylase, which converts calcidiol to calcitriol, which is an active form of vitamin D. Calcitriol stimulates calcium absorption in the intestines and kidneys as well as mobilizes calcium from bone tissue which results in hypercalcemia.

CONCLUSION: Hypercalcemia can originate from pathologies and diseases from many organ systems and requires a thorough work-up to find the root cause. When encountering resistant hypercalcemia in the setting of renal transplant, PJP should be included as a possible diagnosis.

RETURN OF THE KISSING DISEASE CULPRIT: AN ATYPICAL REACTIVATION OF EPSTEIN- BARR VIRUS

Elizabeth Douglas¹; Colin Burnett³; Rohit Das³; Meghna C. Trivedi²; Joshua Lyons¹

¹Internal Medicine, University of Massachusetts Chan Medical School, Worcester, MA; ²Department of Medicine, UMass Memorial Medical Center, Worcester, MA; ³University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #3859437)

CASE: A 63-year-old male presented to the ED for evaluation of two weeks of progressive malaise, tender lymphadenopathy, diarrhea, dyspnea, and decreased urination. Physical exam revealed posterior cervical and axillary lymphadenopathy and abdominal distension. Initial differential diagnosis prioritized hematologic malignant versus infectious etiologies.

In the ED, the patient recieved fluids, supplemental oxygen for hypoxia, and empiric antibiotics. CT showed bulky multistation adenopathy throughout neck, thorax, and peritoneum, raising further concern for lymphoma. He developed thrombocytopenia, leukocytosis; acute kidney injury associated with decreasing urine output; and electrolyte imbalances including hyperuricemia, hypokalemia, and hyponatremia. He received rasburicase and allopurinol for presumed tumor lysis syndrome and a tunneled line was placed for expected chemotherapy.

However, hematologic workup was unremarkable. Immunoglobulin testing did not show monoclonal growth patterns. Both core and excisional lymph node biopsies showed necrotic cells, with some viable immune cells but no evidence of lymphoma. Renal biopsy was consistent with acute interstitial nephritis. Extensive infectious testing was also unremarkable aside from an elevated Epstein-Barr virus (EBV) by quantitative PCR.

Considering decreased lymphadenopathy on repeated imaging and spontaneous symptomatic improvement with conservative management following antibiotic discontinuation, we concluded that the patient experienced an atypical EBV reactivation and he was discharged.

IMPACT/DISCUSSION: While age and bulky diffuse lymphadenopathy were highly concerning for malignancy, this case identifies a severe presentation of EBV reactivation leading to acute renal failure, respiratory failure, and necrotic lymph nodes despite immunocompetent status. EBV viremia in symptomatic young adults is considered a primary infection, but cases of EBV viremia in older adults are considered to be reactivations of the latent virus due to host immunocompromise. Oliguria and renal failure secondary to EBV infection, while rare, is most often manifested as acute interstitial nephritis as was the case for this patient. The patient’s oliguria and fluid retention were believed to be the cause of his respiratory failure and ascites.

CONCLUSION: Over 90% of the global adult population has been infected with EBV and are seropositive upon testing. It is best known for its clinical presentation in young adults as infectious mononucleosis, but most manifestations of primary EBV infections are subclinical. Despite its predominant visibility at a younger ages, EBV viremia must be considered in the differential for lymphadenopathy and vague symptoms of any age, particularly when bacterial and hematologic etiologies remain unsubstantiated. Furthermore, when a patient presents with EBV infection and an elevated creatinine or decreased urine output, acute interstitial nephritis must be considered in addition to pre-renal etiologies.

RHABDOMYOLYSIS IN A PATIENT WITH UNDIAGNOSED SICKLE CELL TRAIT

Ayat Abyad, Jasdeep Bathla, Asim Kagzi

Internal Medicine, Detroit Medical Center, Detroit, MI. (Control ID #3874879)

CASE: A 61-year-old male with past medical history of hypertension, GERD and osteoarthritis presented with severe epigastric pain radiating to the back associated with nausea for two weeks. During this time, he

reported progressive myalgia and decrease in urination. He attributed symptom onset to inadequate hydration while being outdoors in the heat, however, he continued to have poor oral intake due to abdominal pain and nausea. He was immediately started on IV fluids for acute pancreatitis given elevated lipase 461; no obvious etiology of acute pancreatitis was identifiable by history, laboratory tests, and gallbladder ultrasound. Labs were significant for hyperkalemia 8.4 with peaked T-waves on EKG, elevated creatinine 23.25, elevated BUN 288. hypocalcemia 5.6, and metabolic acidosis. Dialysis was initiated for oliguric acute kidney injury (AKI) without clear etiology, but elevated CPK 10604 suggested rhabdomyolysis. Renal biopsy revealed acute tubular necrosis, ruling out any underlying autoimmune. While investigating predisposing conditions for AKI, hemoglobin electrophoresis revealed sickle cell trait (SCT). As kidney function improved, he developed hypercalcemia during polyuric phase however this resolved as kidney function recovered and he was slowly weaned off dialysis.

IMPACT/DISCUSSION: The cause of rhabdomyolysis is divided into three categories: traumatic (or direct muscle injury), nontraumatic exertional, and nontraumatic non-exertional. Dehydration, a nontraumatic exertional process, was the primary factor causing rhabdomyolysis in this patient given reported heat exposure and poor oral intake during acute pancreatitis. Risk factors for rhabdomyolysis identified in this patient include male sex, black race, age >60 years, and dehydration. Several immediate complications of rhabdomyolysis were noted which include fluid and electrolyte abnormalities—hypovolemia, hyperkalemia and hypocalcemia which increases risk for cardiac dysthymias, hyperuricemia, hyperphosphatemia, and metabolic acidosis. Later complications seen in this patient include AKI and hypercalcemia. Later complications to monitor include compartment syndrome after fluid resuscitation and disseminated intravascular coagulation (DIC). Heme pigment rarely causes kidney injury with lower CPK levels at admission (less than 20,000 units/L) without predisposing conditions, including dehydration, acidosis, and sepsis. SCT is a benign carrier condition under normal physiological conditions, but it might predispose to exertional rhabdomyolysis —particularly with dehydration and strenuous physical activity.

CONCLUSION: Trauma, infections, drugs, and surgery are the most common causes of rhabdomyolysis in adults. Most individuals have more than one risk factor, however, less than 10 percent have no identifiable cause. Sickle cell trait is associated with a slightly higher risk of exertional rhabdomyolysis and should be considered in regular individuals, not just athletes and military personnel as commonly suggested.

SCALY BUT NOT SEBORRHEIC: A CASE OF MISDIAGNOSED DERMATOMYOSITIS Aneeqah H. Naeem¹; Zain Chaudry²; Arkadiy Finn¹

¹Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI; ²University of Vermont Larner College of Medicine, Burlington, VT. (Control ID #3876666)

CASE: A 73-year-old man presented to the ED with a 12 day history of rash affecting his face, scalp, ears, and chest with associated swelling. On exam, the rash was noted to be erythematous with greasy scale throughout, with some associated angioedema particularly on his ears. Scattered across the scalp there were a few greasy pink papules, some eroded and some with overlying hemorrhagic crust. There were also noted to be greasy, pink-yellow plaques across his scalp. On the central chest were a few thin, pink plaques with very mild overlying scale. He denied any triggers, such as new shampoos, clothes, lotions or bug bites as he could recall. He initially received a 5 day course of steroids that helped his symptoms. However, as soon as he finished the steroids, his rash re-appeared. On re-evaluation, his ESR was elevated at 81 and CRP at 42.45.

He was seen by dermatology and initially diagnosed with severe seborrheic dermatitis. He was discharged home with ketoconazole cream and hydrocortisone ointment. Two weeks later, he presented again to the ED with worsening angioedema and diffuse muscle weakness. He was found to have transaminitis, a significantly elevated creatine kinase of 5,830 and an ANA of 1:320. Re-examination of his skin lesions showed concern for a heliotrope rash and Gottron papules, rather than seborrheic dermatitis. Elevated alpha fetoprotein of 2,751 and CA-19 of 208 suggested underlying malignancy. A CT abdomen/pelvis showed a liver mass secondary to underlying cholangiocarcinoma versus hepatocellular carcinoma with possible tumor thrombus, which prompted a suspicion for paraneoplastic dermatomyositis. A muscle biopsy was performed and confirmed a diagnosis of dermatomyositis. One week later, he was readmitted to the hospital with worsening angioedema and dysphagia and eventually was transitioned to comfort care measures.

IMPACT/DISCUSSION: A rash can be the initial presentation of dermatomyositis in the absence of any joint or muscle pain. It is important to broaden the differential of a scaly, erythematous rash with angioedema even despite the lack of other systemic symptoms and only mildly elevated inflammatory markers. While both seborrheic dermatitis and a dermatomyositis rash can present with erythema and scale, angioedema and involvement of eyelids, chest, and knuckles, should prompt consideration of a condition such as dermatomyositis. In the case of a paraneoplastic syndrome which occurs in 20% of patients with dermatomyositis, early diagnosis can help accelerate cancer management that can dramatically improve symptoms. While dermatomyositis often has a more prolonged course, the acute decline and subsequent passing of this patient highlights the critical need of correct diagnosis and intervention.

CONCLUSION: Having a clinical suspicion of dermatomyositis is important in a scaly rash with angioedema without any known triggers to help expedite care in conditions like paraneoplastic dermatomyositis.

SCLEROSING MESENTERITIS – A RARE CAUSE OF ACUTE ABDOMEN

Divya Parepalli²; Shreya Uppala³; Barath Rangaswamy¹

¹Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ²Internal medicine, Texas Tech University Health Sciences Center, Permian Basin, TX; ³school of medicine, Texas Tech University Health Sciences Center, Permian Basin, TX. (Control ID #3877152)

CASE: 68-year-old male with an extensive medical history, including sclerosing mesenteritis, type 2 diabetes initially presented to the ED for altered mental status, shortness of breath, diaphoresis, and cold extremities. Patient had abdominal pain and diarrhea for the past month, which was suspected to be due to metformin use and nonobstructive bilateral nephrolithiasis. Metformin had been discontinued a week prior. Initial labs in ED were notable for pH 7.204, lactic acid 16.6mmol/L, bicarbonate of 9.8mmol/L, and creatinine 4.6mg/dl. He was admitted to ICU for suspected DKA and intubated due to unresponsiveness. Abdominal X ray showed multiple dilated central small bowel loops and suspected mucosal thickening of the small bowels. CT image of the mid abdomen showed diffuse haziness and increased heterogeneous fibrofatty density within the root of the mesentery, suggestive of sclerosing mesenteritis. Exploratory laparotomy in the OR revealed widespread ischemia of the small bowel and descending large intestine. Both areas were subsequently resected. Patient continued to have up trending lactic acid levels even after the surgery. He was taken to the OR again for further bowel resection. Despite further removal of affected bowel areas, he deteriorated and was pronounced deceased the following day with the primary cause of cardiac arrest.

IMPACT/DISCUSSION: Sclerosing mesenteritis (SM) is a rare primary idiopathic inflammatory and fibrotic process involving predominantly the small bowel mesentery and usually presents with nonspecific abdominal symptoms. Clinical presentation is diverse ranging from being asymptomatic to acute abdomen due to complications including bowel obstruction and even widespread bowel ischemia as seen in this patient. SM can be associated with various malignancies, tobacco use, or previous history of abdominal surgery or trauma, but the true etiology remains unknown. There is no standardized pharmacological treatment, however reports have shown success with corticosteroids and other anti-inflammatory, immunomodulatory, and antifibrotic agents for nonobstructive cases. Cyclophosphamide, azathioprine, tamoxifen, pentoxifylline are some of the examples. Corticosteroid treatment alone or in combination with above agents in certain reports has provided rapid clinical improvement. In cases where obstruction or ischemia is present, surgical intervention is required.

CONCLUSION: Physicians should consider Sclerosing Mesenteritis in a differential diagnosis of an acute abdomen. Severe or atypical cases of sclerosing mesenteritis without proper initial intervention can increase the risk of developing severe obstruction or bowel ischemia.

While patients with bowel obstruction should undergo surgery, nonobstructive symptoms might benefit from steroid therapy alone or in combination with other drugs. Prompt follow up of the disease progression for further surgical intervention is needed.

SCRATCHING THE SURFACE: CUTANEOUS LEUKOCYTOCLASTIC VASCULITIS AS A RARE HARBINGER FOR SUBACUTE BACTERIAL ENDOCARDITIS

Sujan Badal¹; Federico Fenton Portillo^1,2; Jonathan Salud¹

¹Internal Medicine, Washington State University, Everett, WA; ²Internal Medicine, Providence Regional Medical Center Everett, Everett, WA. (Control ID #3853727)

CASE: A 61-year-old male with history of primary hypertension and prostate cancer in remission presented with 2 weeks of progressive, severely painful bilateral lower extremity rash. The rash began as multiple small red macules on the dorsum of both feet. It spread to involve both lower legs and became larger, raised, and tender. He denied any recent travel, medication change, or acute illness. No prior history of alcohol, tobacco, and recreational drugs. No known drug allergies. He also reported 3 months of intermittent epigastric abdominal pain and 50-pound unintentional weight loss, for which he had recently undergone EGD/colonoscopy and capsule endoscopy that were unremarkable.

On admission, vitals were normal. Exam revealed diffuse, tender, purpuric, non-blanching maculopapular rash on both legs, and a new 2/6 holosystolic murmur at the cardiac apex. Initial labs were notable for hemoglobin of 8 g/dL, MCV 84, WBC 14,000, serum creatinine 1.53 mg/dL, ESR 34, CRP 117 mg/L. Recent outpatient skin biopsy revealed leukocytoclastic vasculitis.

On hospital day #1, the patient became febrile and severely hypotensive. Empiric antibiotics were initiated, and blood cultures showed Streptococcus mitis. Systemic steroids were discontinued.

Transesophageal echocardiogram revealed severe mitral regurgitation and a large, mobile echogenic mass on the mitral valve. ANA, ANCA, HIV, hepatitis panel, COVID-19 PCR were negative. Complements, cryoglobulin, and immunoglobulins were normal. The pattern of findings was most consistent with subacute bacterial endocarditis and secondary cutaneous leukocytoclastic vasculitis. The rash improved following initiation of antibiotics, and he thereafter underwent mitral valve replacement.

IMPACT/DISCUSSION: Leukocytoclastic vasculitis (LCV) is a histopathologic term characterizing a small vessel vasculitis affecting the arterioles, capillaries, and postcapillary venules. The hallmark features are neutrophilic infiltration of the vessel wall, fibrinoid necrosis, and signs of damage to the vessel wall and surrounding tissue.

The differential for LCV includes drug-induced, malignancy, primary autoimmune disease, and infection. It is commonly seen in the setting of chronic infections (e.g. HIV, HCV) and upper respiratory tract infections caused by beta-hemolytic Streptococcus. It is critical to consider infection as a cause of LCV to expedite initiation of antimicrobial therapy. Empiric steroids should then be promptly discontinued. In this case, the confluence of biopsy-proven cutaneous LCV, a new systolic murmur, and distributive shock fueled urgency to pursue endocarditis as a source of infection.

CONCLUSION: Cutaneous LCV is a rare presenting sign of subacute bacterial endocarditis. This case underscores the importance of vigilantly investigating infection as a cause of leukocytoclastic vasculitis, particularly to ensure timely management.

SEARCHING FOR THE RED STAIN: A CASE OF PROGRESSIVE HEART FAILURE

Viviane C. Cahen¹; Craig C. Morris²; Michael J. Hendricks³

¹School of Medicine, Oregon Health & Science University, Portland, OR; ²Internal Medicine, Oregon Health & Science University, Portland, OR; ³Hospital Medicine, Oregon Health & Science University, Portland, OR. (Control ID #3876455)

CASE: A 72 year old man with a history of COPD, HFpEF, and recent transient ischemic attack, presented to the emergency room with acute flank pain and worsening shortness of breath, in the context of months of progressive weight loss and fatigue. One week prior, his PCP had started him on digoxin and furosemide for treatment of presumed decompensated HFpEF. However, despite increased diuretic, his SOB worsened.

On physical exam, he appeared cachectic. JVP was elevated to 10 cm, with crackles at the lung bases, and bilateral lower extremity pitting edema. Labs were notable for normocytic anemia, low serum sodium, and an elevated BNP of 693 with a high sensitivity troponin of 99. Imaging was concerning for new ascites, a small right pleural effusion, and a right kidney infarction. EKG showed an ectopic atrial bradycardia at 48 beats per minute. Echocardiogram showed mild concentric left ventricular hypertrophy, left ventricular ejection fraction of 45%, intra-atrial septal aneurysm, and tricuspid valve regurgitation. Importantly, there was relative apical sparing of contractile function, a pattern concerning for cardiac amyloid.

The patient had sustained bradycardia with tele showing multiple ectopic atrial arrhythmias and junctional rhythms with recurrent sinus pauses of 3-4 seconds and inappropriate chronotropic exercise response, ultimately requiring dual chamber pacemaker placement. Cardiac MRI showed mild asymmetric left ventricular hypertrophy with elevated T1 and T2 signal, late gadolinium enhancement most notably at the bases, and elevated extracellular volume fraction, consistent with cardiac amyloidosis.

He underwent bone marrow biopsy which showed plasma cell proliferation. Fat pad biopsy showed positive congo red staining for lambda light chains confirming the diagnosis of AL amyloidosis. In consultation with the multi-disciplinary amyloid team, rapid initiation of outpatient treatment was arranged with CyBorD, in addition to spironolactone and torsemide therapy for Stage III A AL.

IMPACT/DISCUSSION: AL amyloidosis is a multisystem accumulation of light chain proteins in various organs. When involving the heart, amyloid infiltration can cause hypertrophic cardiomyopathy and conduction abnormalities. Due to its multiorgan involvement, it can prove a challenging diagnostic workup. Subtle signs of the disease may be missed, resulting in diagnostic delays and subsequently, ineffective treatment. Signs that should raise your index of suspicion include rapidly progressive HF, left ventricular wall thickening, and dissociation between short and long axis systolic function; typically, there is much greater restriction of movement at the base compared to the apex.

CONCLUSION: This case illustrates the importance of considering multiorgan conditions such as AL Amyloidosis in the workup for heart failure. Atypical presentations like this one can confound the clinical picture, leading to delays in appropriate treatment. Early detection is important, as more effective therapies now exist.

SECONDARY BACTERIAL PERICARDITIS WITH CARDIAC TAMPONADE AFTER ENDOBRONCHIAL ULTRASOUND WITH TRANSBRONCIAL NEEDLE ASPIRATION Johnathan Stephan¹; Mohamed Ramzi Almajed¹; Austin J. Parsons¹; Samuel Gregerson¹; Benjamin Swanson²

¹Internal Medicine, Henry Ford Hospital, Detroit, MI; ²Cardiology, Henry Ford Hospital, Detroit, MI. (Control ID #3876712)

CASE: A 44-year-old male without signficant past medical history underwent endobronchial ultrasound- guided transbronchial needle aspiration (EBUS-TBNA) for an incidentally identified subcarinal mass. He later presented with pleuritic chest pain and shortness of breath. CT imaging demonstrated enlargement of the subcarinal mass with a trace pericardial effusion. The patient was planned to undergo repeat EBUS-TBNA, however, he quickly developed hemodynamic instability. Echocardiogram revealed a pericardial effusion with evidence of tamponade. Emergent pericardiocentesis was performed with placement of a pericardial drain, purulent fluid was obtained. Video-assisted thoracoscopic surgery (VATS) was performed with mediastinal washout and pericardial window. Fluid cultures returned positive for S. aureus and Capnocytophaga.

IMPACT/DISCUSSION: Bacterial pericarditis is a rare cause of pericarditis; in cases of secondary bacterial pericarditis, Staphylococcus Aureus is the most commonly implicated bacteria. Pericarditis is a known procedural complication of EBUS-TBNA. Given our patient’s hemodynamic instability in the setting of cardiac tamponade, emergent pericardiocentesis was indicated. VATS was selected as the treatment modality of choice over subxiphoid pericardotomy, the standard of care, in order to achieve optimal source control by marsupialization of the bronchogenic cyst and completion of a mediastinal washout. Infectious disease was consulted given the atypical growth of Capnocytophaga and S. Aureus for which he was initially treated with Vancomycin and Piperacillin-Tazobactam then transitioned to Amoxicillin-Clavulanate to complete a 6-week treatment course. It was determined that Capnocytophagia was likely introduced to the patient's respiratory system by his dog licking the patient's face. Colchicine was administered for treatment of pericarditis in line with the current guideline recommendations.

CONCLUSION: We present an uncommon case of Capnocytophaga bacterial pericarditis leading to cardiac tamponade. The occurrence of pericarditis after EBUS-TBNA is well-documented and clinicians should have a high index of suspicion in patients who become hemodynamically unstable within 3 months of the procedure. In cases of post-procedural bacterial pericarditis, it is important to take a multidisciplinary approach to determine the best treatment course.

SEPTIC ARTHRITIS DUE TO NON-TYPEABLE HAEMOPHILUS INFLUENZAE BACTEREMIA IN AN IMMUNOCOMPETENT YOUNG ADULT

Bisrat K. Woldemichael

Internal Medicine, Emory University, Atlanta, GA. (Control ID #3876764)

CASE: A 29 year-old previously healthy male presented to the ED with 3 days of subjective fevers, malaise, polyarticular arthralgias and joint swelling. He had a fever (T 38.3C), blood pressure of 154/83, pulse of 117 bpm, and respiratory rate of 26. His labs were significant for white blood cell count of 39.6 K/mcL (89.2% neutrophils), lactic acid 5.6 mmol/L and elevated ESR and CRP (both >80 mg/L). His exam was remarkable for swelling and redness of the left knee, right great toe, bilateral elbows, wrists, and ankles. Blood cultures were positive for non-typeable Haemophilus influenzae. He was started on IV ceftriaxone. Initial left knee arthrocentesis revealed WBC 27k (85% PMNs) with no bacterial growth; surgical washout was not pursued. However, on day three of admission, he had increasing WBC count and worsening left knee pain and swelling and the joint was re-aspirated. This revealed purulent fluid, WBC 43K (97% PMNs) with no organisms. He was then taken to the OR for irrigation and drainage of his left knee. He was discharged home with PO levofloxacin 750mg daily for a 3-week course on discharge. At follow-up, his symptoms had improved.

IMPACT/DISCUSSION: H flu bacteremia is typically seen in patients with risk factors including asplenia, HIV, autoimmune/immunodeficiency syndromes, complement deficiency, chronic alcohol use, or diabetes. While invasive H. flu infection is rare in immunocompetent adults, a thorough work-up should be pursued to evaluate for underlying conditions. A work-up in this case did not reveal any of the previously documented risk factors.

Prompt initial and subsequent serial joint examinations and arthrocentesis should be performed and inform the decision to pursue surgical management to optimize recovery from this invasive infection. A similar case and clinical course is described by Kim et al (2011) in which serial arthrocentesis ultimately resulted in surgical irrigation and debridement of multiple joints. Initial joint aspirate may not always appear infectious, thus clinical suspicion with consultant support should aid in the decision to pursue surgical management. (2)

CONCLUSION: - Suspect virulent non-typeable Haemophilus influenzae in young patients who present with polyarthralgia and non-specific systemic symptoms (fever, malaise)

- Perform serial joint examinations and arthrocentesis in patients who present with bacteremia and joint symptoms

- Have a low threshold for diagnosis and treatment of septic arthritis in patients with non-typeable Haemophilus influenzae bacteremia

References

Kim, J. H. , Muto, C. A. , Pasculle, A. & Vergis, E. N. (2011). Journal of Clinical Rheumatology, 17 (7), 380-382. doi: 10.1097/RHU.0b013e318236e499.

Tadych AS, Catano DE, Brill AL. Atypical Presentation of Haemophilus influenzae Septic Arthritis: A Case Report. Clin Pract Cases Emerg Med. 2021 Nov;5(4):459-462. doi: 10.5811/cpcem.2021.9.54043. PMID: 34813444; PMCID: PMC8610458.

SERTRALINE-INDUCED ACUTE EOSINOPHILIC PNEUMONIA

Spencer Bonnerup, Bryan T. Hummel-Price, Everett M. Cooper, Kengo Z. Soghoyan, Margaret Beliveau, Christopher Nelson

Internal Medicine, Indiana University School of Medicine, Indianapolis, IN. (Control ID #3877125)

CASE: A 29-year-old female G1P1 with a history of postpartum depression on sertraline experienced a two- day history of progressively worsening shortness of breath with a cough. The cough was occasionally productive with whitish-yellow sputum. While family members had tested positive for COVID, the patient did not. The patient presented to her Primary Care Provider, who provided her with an albuterol inhaler and low-dose prednisone, which helped briefly. However, symptoms persisted, and she presented to Emergency Department complaining of left-sided, pleuritic chest pain and wheezing. In the ED, the patient was tripoding and using accessory muscles of respiration. Her oxygen saturation was 78 % on room air. The patient had significant leukocytosis with WBC 35 k/μL. CT chest was negative for pulmonary embolus but did show bilateral hazy infiltrates without consolidation. The patient was placed on high-flow nasal cannula oxygen at 10 L/min and was given inhaled ipratropium bromide-albuterol and epinephrine, as well as intravenous methylprednisolone, ceftriaxone, and azithromycin. The infectious workup was entirely negative. Bedside bronchoscopy with bronchial alveolar lavage revealed 95 % eosinophils. She responded well to high-dose glucocorticoid therapy and was successfully weaned down to room air. Her dyspnea and chest pain resolved. Her sertraline was safely tapered and discontinued. The patient was discharged on a slow prednisone taper starting at 60 mg daily with close out-patient pulmonary follow-up.

IMPACT/DISCUSSION: Acute eosinophilic pneumonia (AEP) is a rare and heterogeneous syndrome that often presents as a dry cough, fever, chest pain, and dyspnea. Clinical findings may include chest radiographs demonstrating bilateral ground-glass opacities and bronchoalveolar lavage may show >25 % of white blood cells are eosinophils. Case reports have linked over 200 cases of AEP to medications, most commonly mesalamine and daptomycin. However, AEP secondary to selective serotonin reuptake inhibitors, is rare. There are no guidelines for the treatment of AEP, but systemic glucocorticoids are recommended. Severe cases may require mechanical ventilation. Identification and avoidance of triggers is imperative.

CONCLUSION: Our patient did not have a history of atopy or hypersensitivity reactions. No other causes were identified. Therefore, high clinical suspicion for sertraline-induced AEP. A literature review shows the time frame between the initiation of sertraline therapy and the onset of symptoms is typically one to three months. This is consistent with our patient’s presentation. Clinicians should be cognizant of rare etiologies of AEP, including antidepressants, and initiate prompt and appropriate interventions, given the acute and life- threatening presentation of this disease process. Literature reports varying dosing and duration of therapy, but oral glucocorticoids therapy with taper for at least four to eight weeks with reevaluation is effective without rebound of symptoms.

SEVERE ACQUIRED APLASTIC ANEMIA IN A 28-YEAR-OLD MALE ASSOCIATED WITH SARS-COV-2

Mithin Mathew¹; Jawairia Sahar Mirza²; Murali Ranjani Behara³; Mital Patel⁴

¹Internal Medicine, Creighton University School of Medicine, Omaha, NE; ²Internal Medicine, Creighton University School of Medicine Phoenix Regional Campus, Phoenix, AZ; ³Internal Medicine, Creighton School District 14, Phoenix, AZ; ⁴Oncology, University of Arizona Cancer Center, Phoenix, AZ. (Control ID #3877002)

CASE: A 28-year-old Hispanic, uninsured male with no PMH presented to the ED with shortness of breath and fatigue for a three-week duration. He had associated chest pain, dyspnea, and hemoptysis. He also noted bruising of his upper extremities and abdomen without significant trauma. He tested positive for COVID-19 at the onset of symptoms. He reported recent travel to Mexico. He denied tobacco, alcohol, and drug use. Physical exam was remarkable for ecchymosis on his right upper extremity. Lab findings were significant for WBC 1.9K/uL, Hgb 4g/dL, PLT 8K/uL, ALT 168 U/L and AST 70 u/l. CT angiogram of the chest revealed generalized ground-glass opacities. He was admitted to the ICU for worsening hypoxic respiratory failure secondary to COVID-19 infection. He underwent bronchoscopy which had no significant findings. He was started on high dose steroids to suppress the cytokine storm from the COVID-19 infection, with improvement in his respiratory function, downtrending of IL-6 levels and was extubated. A bone marrow biopsy during this hospital course revealed markedly hypocellular bone marrow with decreased trilineage hematopoiesis, less than ten percent cellularity. Subsequent tests for HIV, hepatitis, parvovirus, CMV, EBV, vitamin deficiencies, iron deficiency, TB, and coccidioidomycosis were negative. The patient continued to be profoundly pancytopenic, requiring transfusions to keep levels above standard thresholds. Differential diagnosis at this time included idiopathic primary severe aplastic anemia versus aplastic anemia secondary to COVID-19. He was safely discharged after obtaining charity approval for evaluation for bone marrow transplant. He followed-up in the hematology clinic to discuss the treatment for aplastic anemia, including immunosuppressive therapy with horse anti-thymocyte globulin (ATG) and cyclosporine (CSA) and eventual evaluation for allogenic stem cell bone marrow transplant.

IMPACT/DISCUSSION: This case demonstrates a patient developing severe aplastic anemia with an association to an episode of COVID-19 infection. While the suspicion remains high that the culprit for this severe aplastic anemia is COVID-19, there are very few cases presented in the literature, in spite ofCOVID-19 affecting a large population at a global scale. The exact pathophysiology is not well understood but thought to be related to marrow suppression by the cytokine storm induced by COVID-19 infection. This case further discusses treatment options for the uninsured patient population, including obtaining charity approval to pursue immunomodulator therapy initially, and an evaluation for hematopoietic bone marrow transplant.

CONCLUSION: Aplastic anemia is a disorder of bone marrow failure that is clinically observed with presentation of pancytopenia and bone marrow hypoplasia.

Severe aplastic anemia can be a severe sequelae of SARS-CoV-2 infection and hematopoietic cell transplantation is definitive treatment.

SEVERE HEMAPHAGOCYTIC LYMPHOHISTIOCYTOSIS SECONDARY TO EBV INFECTION

Juhi Gor, Keri Maher

Internal Medicine, Virginia Commonwealth University, Richmond, VA. (Control ID #3868954)

CASE: A 42-year-old male with no significant past medical history presents with several weeks of intermittent fevers, fatigue, 40-pound weight loss, decreased appetite, and bilateral lower extremity swelling. Positron emission tomography (PET) scan imaging showed diffuse hypermetabolic lymph node activity, hypermetabolic activity in the spleen, and a soft tissue prominence in the right T6-T7 paraspinal region. Computerized tomography (CT)-guided supraclavicular lymph node biopsy was concerning for giant cells, histiocytes, and noncaseating granulomatous formation without evidence of lymphoma. Labs were notable for pancytopenia, hypofibrinogenemia, and hyperferritinemia with elevated Interleukin (IL)-6 and IL-2. He developed neutropenic fevers and progressive acute hypoxic respiratory failure. Extensive infectious workup was performed which showed a positive EBV PCR. He required intermittent treatment in the medical intensive care unit due to progression of respiratory failure, along with the development of septic shock, requiring vasopressor support and broad-spectrum antibiotics. After meeting six of the eight criteria for hemagophagocytic lymphohistiocytosis (HLH), likely secondary from EBV infection, the patient was started on HLH-94 protocol with caution to the severe, life-threatening side effects from the aggressive chemotherapy that was involved in the protocol. Even with appropriate treatment, this patient continued to further decompensate and ultimately succumbed to his disease at day 20 of treatment with HLH-94.

IMPACT/DISCUSSION: Hemagophagocytic lymphohistiocytosis (HLH) is a life-threatening condition characterized by increased cytokine levels and immune mediated damage leading to multi-organ system failure. This disorder can be either primary (related to genetic causes) or secondary (often related to underlying malignancy or infection). Diagnosis is often difficult and can be delayed due to lack of distinct pathognomonic findings, however, diagnostic criteria have been well established and treatment protocols have been well studied. HLH-94 and HLH-2004 are two well-known protocols as first line treatment for HLH. HLH-94 treatment consists of etoposide, dexamethasone, cyclosporine, and rituximab. Rituximab is also crucial in the treatment of EBV, allowing for increased benefit in this patient. Of note, the use of etoposide has been shown to improve prognosis, especially in adults who are considered to be high risk.

CONCLUSION: This case report focuses on the diagnosis of HLH, along with interdisciplinary approach to treatment of the condition. Our patient had multiple care teams involved throughout the hospital course, including critical care, hematology/oncology, infectious disease, and general internal medicine. We also focus on the importance of ruling out other causes of the clinical presentation as early diagnosis is crucial to outcomes, along with determining primary versus secondary to help guide treatment options.

SEVERE PANCYTOPENIA FROM NEPAL

Alexandra L. Coritsidis¹; Kenneth M. Fifer²

¹Internal Medicine, Mount Sinai Health System, New York, NY; ²Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3876166)

CASE: A 42 year old man with no past medical history presented to the emergency room with two months of progressive fatigue and two weeks of headache, dizziness, intractable nausea and vomiting, and significant dyspnea on exertion. The patient resides in Nepal and was visiting family in New York at the time of presentation. He denied abdominal pain, weight loss, night sweats, or fevers. Social history was notable for 4-5 alcoholic drinks weekly and no tobacco or drug use. On physical exam the patient was notably pale, diaphoretic and ill-appearing. He had no abdominal tenderness or lymphadenopathy. The remainder of the physical exam was unremarkable. Initial labs were significant for marked pancytopenia with a white blood cell count of 1.12, hemoglobin of 3.6 with mean corpuscular volume 107.3, and platelet count of 34. Reticulocyte index was 1.4, demonstrating hypoproliferation. Diagnostic work up revealed an undetectable vitamin B12 level with normal folate. Flow cytometry was negative. Autoimmune pernicious anemia labs were sent and were notable for an intrinsic antibody level of 11. During hospitalization, he received a packed red blood cell transfusion which was stopped early due to a transfusion related fever. He was given B12 injections and discharged home with close follow up. Within approximately 10 days from initial presentation, the patient’s hemoglobin improved to 8.1 and white blood cell count normalized to 7.1.

IMPACT/DISCUSSION: Pernicious anemia is caused by autoantibodies that interfere with vitamin B12 absorption by targeting intrinsic factor (IF), gastric parietal cells, or both. Vitamin B12 is an important cofactor in DNA and RNA synthesis. While production of all hematopoietic cell lines can be affected by B12 deficiency, the impact on erythrocytes is greatest. Other common causes of macrocytic anemia include folate deficiency, hypothyroidism, or drug-induced. Typical symptoms of pernicious anemia include jaundice and neurologic abnormalities such as cognitive slowing and neuropathy from demyelination of the dorsal and lateral columns of the spinal cord. Pancytopenia is rare and indicates a prolonged period of deficiency. This patient’s significant dyspnea can be attributed to the severity of his anemia. His gastrointestinal manifestations are also a rare presentation and thought to be due to the effect of B12 deficiency on the rapidly dividing cells of the gastrointestinal mucosa. Treatment includes parenteral B12 weekly until deficiency is corrected. Blood transfusion is indicated in cases of severe, symptomatic anemia because improvements in red blood cell production with B12 take several days to take effect.

CONCLUSION: This case is an important reminder that B12 deficiency can manifest with severe symptoms if left untreated. B12 deficiency should be considered in any patient presenting with cytopenia in order to avoid unnecessary and invasive medical work up, especially considering the concern for malignancy in patients presenting with severe pancytopenia.

SEVERE REFRACTORY LACTIC ACIDOSIS: A CASE OF ACUTE THIAMINE DEFICIENCY AND METFORMIN ASSOCIATED LACTIC ACIDOSIS

Cecilia Peterson¹; Elizabeth McDonald²; Blair Lenhan²

¹The University of Utah School of Medicine, Salt Lake City, UT; ²Internal Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #3876906)

CASE: A 58-year-old male with a history of type 2 diabetes mellitus (T2DM) on metformin and alcohol use disorder was transferred from a rural emergency department for hypotension and lactic acidosis. On arrival to our medical ICU, he required three vasopressors to maintain a MAP > 65; physical exam was notable for an intubated man with a GCS of 3. Lab work showed severe anion gap metabolic acidosis with pH 6.6, lactate 23, and anion gap >33. Creatinine was 1.78 (baseline ~1.0) with negative toxicology and toxic alcohols except for ethanol level of 157. Antibiotics were started. Blood and respiratory cultures were negative. Given his persistent acidosis and shock, CRRT was started. The patient was empirically given 400 mg of thiamine due to his alcohol use disorder. Within 24 hours of administration, lactate rapidly dropped, and thiamine levels from admission returned as undetectable. On hospital day five, lactic acidosis had improved and hemodialysis was stopped. The patient was later discharged home with full cognitive and renal recovery.

IMPACT/DISCUSSION: While the neurological effects of thiamine deficiency are well recognized, the role of thiamine in aerobic metabolism and severe lactic acidosis is underappreciated. Prompt identification and appropriate treatment of thiamine deficiency can rapidly improve lactic acidosis and shock as was seen in our patient and previous case reports. While rare in developing countries, thiamine deficiency should be considered in patients with a history of bariatric surgery, alcoholism, and malnutrition. It is now recognized that metformin can induce thiamine deficiency.

Our patient had multiple risk factors for thiamine deficiency including chronic alcoholism and metformin use. While his lactic acidosis did rapidly improve from 23 to 7.6 with thiamine, the patient continued to have significant lactic acidosis for several days suggesting a secondary etiology. While we were unable to obtain levels, given lack of an alternative source, we strongly suspect the patient developed metformin associated lactic acidosis (MALA) in the setting of his renal impairment. MALA is associated with a mortality rate over 30% and treatment is primarily supportive with a possible role for hemodialysis.

While not fully understood, metformin shares the same hepatic transporter as thiamine and can lead to severe thiamine deficiency. It is theorized that acute thiamine deficiency may be a possible mechanism for the profound acidosis seen with metformin toxicity. Thus we are reporting on a case of a patient with severe thiamine deficiency likely driven by his chronic alcoholism and metformin use. The combination of MALA and thiamine deficiency can cause profound lactic acidosis.

CONCLUSION: Here, we present a patient with refractory lactic acidosis in the setting of severe thiamine deficiency and suspected MALA. Our case highlights the importance of identifying causes of type B lactic acidosis, prompt treatment, and the possible relationship between thiamine and metformin.

SEVERE THROMBOCYTOPENIA AND NEUTROPENIA IN A PATIENT WITH CHRONIC HEPATITIS C

Jared Schattenkerk¹; Anne L. Cravero¹; Lauren Beste²

¹Department of Medicine, University of Washington, Seattle, WA; ²General Internal Medicine, University of Washington/ VA Puget Sound, Seattle, WA. (Control ID #3871015)

CASE: A 64-year-old man with diabetes on oral medications presented with four months of oral ulcerations, easy bruising, and unintended weight loss. Physical exam was notable for diffuse ecchymoses, petechiae, and two oral mucosal ulcerations. Labs revealed hemoglobin of 9.5g, platelet count of 2k, white blood cell count of 1.25k and absolute neutrophil count (ANC) of 200. Peripheral flow cytometry showed no blasts or evidence of hematolymphoid neoplasm. A bone marrow biopsy identified hypercellular marrow without blasts or dysplastic cells. Platelet specific antibodies were positive. Viral serologies were newly positive for hepatitis C virus (HCV) antibody and HCV viremia, presumed to reflect chronic HCV infection due to lack of recent intravenous drug use or other blood exposure. Abdominal ultrasound showed normal liver parenchyma without evidence of cirrhosis.

He was initially transfused with platelets, but his platelet count remained <5k after 5 units. Given suspicion for immune thrombocytopenic purpura (ITP), he was started on intravenous immunoglobulin and dexamethasone. He ultimately responded to platelet transfusions after 2 days and his neutropenia resolved. He was discharged home with a plan to complete a course of dexamethasone and pursue treatment for HCV.

IMPACT/DISCUSSION: This case of severe thrombocytopenia and neutropenia was initially suspected to be a primary hematologic disorder, but was ultimately linked to undiagnosed chronic HCV. HCV infection can cause a range of hematologic abnormalities. The most common, thrombocytopenia, often results from advanced liver fibrosis with splenic sequestration. HCV is the most common infectious cause of secondary ITP with up to 30% prevalence of HCV-positivity in chronic ITP.

Conversely, HCV-associated neutropenia is rare. Severe neutropenia (i.e., ANC <500) in non-cirrhotic, viremic patients not on interferon has been described in limited case reports and series. In a retrospective review of 685 patients with active HCV at one Veteran Affairs Medical Center, 6 patients had severe neutropenia not associated with interferon or underlying hematologic cancer. These patients were no more likely than HCV-positive controls to have severe liver disease or splenomegaly.

Our patient presented with profound, transfusion-refractory thrombocytopenia and severe neutropenia without cirrhosis and with normal bone marrow cellularity. This clinical picture suggests immune-mediated peripheral destruction as the underlying mechanism, rather than sequestration or impaired production. Our patient was found to have detectable platelet-specific antibodies, which are implicated in immune-mediated peripheral destruction but have low specificity in the diagnosis of ITP.

CONCLUSION: HCV testing should be performed in patients presenting with any new cytopenia given the relatively high prevalence of undiagnosed HCV and the virus’s association with immune-related blood cell destruction.

SHAKE A LEG! EXPANDING THE DIFFERENTIAL FOR ACUTE ON CHRONIC LIMB ISCHEMIA

Grace L. Lisius

Department of Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #3877293)

CASE: A 77-year-old seamstress with hypertension, former 50-pack-year smoking history, rheumatoid arthritis (RA) on methotrexate, and polycythemia vera presents with acute on chronic left foot pain and pallor. For a year, she had stable left foot and great toe pain on walking several blocks. Over two months, though compliant with aspirin and statin, the pain worsened, now present at rest with skin whitening and tingling of her left great and second toes. She had no foot wounds, or worsening RA pains. She hadn’t needed her usual polycythemia phlebotomy and had unintentional weight loss. She was told she had an 8cm necrotic pelvic mass several months ago but didn’t know what “mass” meant so had not followed up. She was mildly hypertensive and thin, BMI 17. Exam showed right lower quadrant palpable mass, and pallor of left great and second toes, and severe pain to lightest touch. Left dorsalis pedis and posterior pedis pulses were intermittently detectable. Her labs were showed thrombocytosis to 1.2 million, normal hemoglobin, lactate and INR. Her abdominal CT angiogram showed occlusion of her left tibial, peroneal, and dorsalis pedis arteries. She underwent platelet-phoresis and anticoagulation with heparin. Angiogram revealed small but patent vessels and severely sluggish flow that did not improve with thrombolytic. Normalizing her platelet count, determined to be due to new myelodysplastic syndrome, did not improve her ischemic symptoms. Biopsy of her pelvic mass given the concern for malignancy and hypercoagulability driving her limb ischemia, revealed invasive gastrointestinal carcinoma. Given her declining clinical status, she chose to return home with hospice.

IMPACT/DISCUSSION: Acute on chronic limb ischemia is overwhelmingly caused by peripheral artery disease, either progression of an existing atherosclerotic plaque or rupture of a plaque. The well-trodden risk factors of smoking, hypertension, hyperlipidemia, and diabetes construct cognitive tunnel-vision (availability heuristic), obscuring other crucial processes for arterial occlusion in this case: hypercoagulability and severe thrombocytosis. She was also at risk for RA hypercoagulability and vasculitis, both of which could have mirrored her presentation. Given her chronic clinical picture, she was at risk for premature closure and anchoring on a primary atherosclerotic cause. Her severe thrombocytosis, crucial initial discordant information, created diagnostic momentum and risk for search satisfaction bias. Navigating these biases in diagnosis and management empowered her to make an informed decision on her remaining time.

CONCLUSION: Acute on chronic limb ischemia is an unfortunately common presentation and requires cognitive vigilance to maintain a thorough differential, especially in unexpected worsening or discordant data. Guarding against numerous biases in this acute-on-chronic case protects patients’ safety and strives for most appropriate diagnosis, management, and procedures (or lack-thereof).

SHOCK AND AWE: INAPPROPRIATE ICD SHOCK IN THE SETTING OF ATRIAL FIBRILLATION

Anna C. Jameson¹; Pranav Shah^1,2

¹Internal Medicine, Medical University of South Carolina, Charleston, SC; ²Internal Medicine, VA Medical Center Ralph H Johnson, Charleston, SC. (Control ID #3876335)

CASE: A 51-year old male with a history of hypertension, hyperlipidemia, and coronary artery disease status post coronary artery bypass graft and percutaneous coronary intervention complicated by heart failure with reduced ejection fraction (HFrEF) of 26% status post cardiac resynchronization therapy defibrillator (CRT-D) presented to the Emergency Department (ED) following 13 Implantable Cardioverter Defibrillator (ICD) discharges. The first shock occurred early that morning after getting up to use the restroom. At the time he was fatigued and diaphoretic, but otherwise reported feeling at his baseline. His ICD had been recently implanted less than 2 days prior for sudden cardiac death prophylaxis in the setting of his reduced EF. Vitals were significant for tachycardia to 185 with a BP of 130/87. Labs were unremarkable with a high sensitivity troponin of 35 (reference range <=27). His initial electrocardiogram (ECG) revealed a regular and wide complex tachyarrhythmia concerning for Ventricular Tachycardia (VT) and he was started on an Amiodarone and Lidocaine drip. Device interrogation demonstrated multiple inappropriate ICD shocks for Atrial Fibrillation (AF) with rapid ventricular response (RVR). On review of prior ECGs, he had a known Left Bundle Branch Block (LBBB), making differentiating his rhythm difficult. Given that he was in AF and not VT, the Lidocaine drip was discontinued. He was continued on Amiodarone and his Metoprolol Succinate dose was increased. His ICD was reprogrammed with VT discrimination and right to left ventricular activation delay considering his LBBB pattern. Of note, he did not carry a prior diagnosis of AF. It was suspected that this new onset AF was due to acute irritation from atrial lead placement.

IMPACT/DISCUSSION: AF is the most commonly treated cardiac arrhythmia. AF is generally associated with an irregularly irregular ventricular rhythm and absence of distinct P waves. However, as this patient had a preexisting LBBB, the rhythm on his ECG appeared wide and regular, concerning instead for VT. Only after device interrogation was AF recognized as the underlying rhythm. Review of telemetry also revealed p-waves and increased atrial firing. A common etiology of QRS widening during AF is aberrant conduction. This aberrant conduction in AF is a rate-related change that is more commonly seen in right bundle branch blocks as opposed to LBBB. Though, aberrancy with LBBB morphology can occur, as in this patient, though it is less common.

CONCLUSION: As Internists, we often encounter AF. This case highlights an unusual presentation of AF with RVR that was misunderstood as VT due to its wide complex tachyarrhythmia. This may occur in patients with LBBB or RBBB. ICD interrogation and telemetry strips may helpful in distinguishing between these arrhythmias.

SLOW DOWN AND THINK ABOUT IT: DIFFERENTIATING CAUSES OF GASTROPARESIS IN PATIENTS WITH DIABETES

Nikhita Chahal, Jabra Zarka, Michael Simonson

Department of Medicine, UPMC Presbyterian-Shadyside, Pittsburgh, PA. (Control ID #3874930)

CASE: A 66-year-old man with a 10-year history of type 2 diabetes mellitus presented with subacute progressive abdominal distension, nausea, and vomiting. At the time of presentation, his medications included atorvastatin, fluvoxamine, losartan, metformin, pantoprazole, and semaglutide.

Six months prior, his diabetes medications were metformin 1000mg daily and linagliptin 5mg; his hemoglobin (Hb) A1c was 8.3%. After three months, glycemic control remained suboptimal, so the linagliptin was switched to semaglutide 3mg daily and his metformin increased to 1500mg. With semaglutide, he noted a decrease in appetite and early satiety but no other side effects. Since the medications were well-tolerated, semaglutide was increased to 7mg daily. After this change, he reported worsening abdominal distension, reflux symptoms, nausea, and vomiting. He was decreased his metformin dose but remained on the 7mg semaglutide. His oral intake remained limited with worsening nausea, vomiting, and distension.

On exam, he was mildly tachycardic with dry mucus membranes. Labs were notable for lipase 34, glucose 150, and urinalysis showing ketonuria. A recent HbA1c was 7.2%. Abdominal CT showed a distended stomach with food and fluid contents. The tachycardia resolved with intravenous fluids. Semaglutide was held and metoclopramide was initiated. His symptoms resolved within 24 hours, and he was discharged home on metoclopramide. One month later, his HbA1c was 6.1%. He remained symptom-free and was started back on linagliptin.

IMPACT/DISCUSSION: This case illustrates the potential for gastroparesis with semaglutide, a GLP-1 RA.

GLP-1 RAs bind to and activate GLP-1 receptors in pancreatic beta cells, enhancing glucose-dependent insulin secretion and slowing gastric emptying. Patients with medication-associated gastroparesis experience symptoms within 4-6 weeks of drug initiation and resolution within the same timeframe of stopping the medication.

In contrast, diabetes-related gastroparesis develops over years, as with the development of associated microvascular complications. Prolonged hyperglycemia can lead to irreversible neuronal damage, unlike in medication-associated gastroparesis. Endogenous GLP-1 concentrations are decreased given higher circulating glucose levels seen with insulin resistance. Glycemic control and concomitant depression or anxiety can cause fluctuations in symptoms.

A clinical history of time-course and symptom-onset since disease diagnosis and drug initiation is most valuable for differentiating the two types of gastroparesis.

CONCLUSION: Gastroparesis is a disorder of stomach and intestinal motility. It can present with non- specific gastrointestinal symptoms including abdominal pain, fullness, nausea, and vomiting. Gastroparesis is a common complication of prolonged diabetes attributed to acquired autonomic neuropathy. Paradoxically, some medications used to treat diabetes can also cause gastroparesis. It is important to recognize these different etiologies; as the latter reversible.

SOMETHING TO CHEW ON: DENTURE ADHESIVE-INDUCED COPPER DEFICIENCY MYELONEUROPATHY IN A PATIENT WITH SUSPECTED MS

Vijay Shimoga²; Matthew Westfall^2,1; Victoria Stoffers^2,1

¹Department of Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ²University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #3872711)

CASE: A 60-year-old male presented with 18 months of steadily worsening balance, inability to locate his feet beneath him, and lack of coordination in his hands, with an associated 75-pound weight loss during this time period. Physical examination revealed symmetrical deficits in vibration, proprioception, and temperature sensation in the extremities and absent Achilles tendon reflexes bilaterally. Examination of the oropharynx revealed an absence of teeth requiring the use of poorly fitting dentures affixed with large amounts of denture adhesive. CSF studies from the outside hospital prior to admission showed oligoclonal bands, which, in the setting of the patient’s subacute neurologic findings, suggested a diagnosis of Multiple Sclerosis (MS). However, further workup revealed no enhancing lesions on brain MRI to support this diagnosis, prompting additional investigation into other etiologies of sensory deficits including tabes dorsalis, transverse myelitis, and micronutrient deficiencies. Subsequently serology showed critically low serum copper and ceruloplasmin levels, which helped confirm the diagnosis of copper deficiency myeloneuropathy.

IMPACT/DISCUSSION: Copper deficiency classically presents with a length-dependent distribution of impaired proprioception, pain, and temperature sensation, and subacute gait disorder with sensory ataxia^[1]. Although this presentation with abnormal CSF findings raised initial concern for MS, this diagnosis proved to be a red herring given the absence of supportive findings on MRI. Avoiding anchoring bias ultimately led to the correct diagnosis of copper deficiency due to toxic zinc ingestion from denture adhesive overuse. Zinc- containing denture adhesive is a documented causative agent in copper deficiency^[2-6], and risk is especially high among patients with poorly fitting dentures in whom excess adhesive is often inadvertently ingested^[5]. Zinc and copper bind competitively for absorption in the jejunum^[2,7,8]; with the patient’s zinc intake exceeding the threshold for toxicity of 150mg/day^[9], elevated zinc levels in the gut likely resulted in copper malabsorption leading to peripheral neuropathy. As in this patient, copper deficiency can be treated by discontinuing zinc-containing agents and replacing copper intravenously^[3,8], coupled with long-term care for ongoing rehabilitation.

CONCLUSION: Copper deficiency myeloneuropathy is a rare but well-described cause of sensory neuropathy that can mimic more common presentations like MS, often leading to delays in diagnosis. As such, copper deficiency should be considered when other more common etiologies have been ruled out. Index of suspicion should remain high among patients using zinc-containing denture adhesive, in whom risk of copper deficiency is particularly high. Appropriate diagnosis and timely treatment may help minimize further loss of sensory function and improve quality of life for patients.

SPHINCTER OF ODDI DYSFUNCTION: MORPHINE, AN UNLIKELY CAUSE OF TRANSAMINITIS AND PANCREATITIS

Samah H. Syed, Takele Demesilassie, G. W. Garriss

Internal Medicine, WellStar Kennestone Hospital, Marietta, GA. (Control ID #3877054)

CASE: A 40-year-old female with a history of diverticulitis and prior cholecystectomy presented with sharp, constant left lower quadrant abdominal pain following a cross fit class. Vitals were stable and exam findings significant for normoactive bowel sounds and moderate left lower quadrant tenderness. Labs revealed mild leukocytosis and unremarkable liver function tests (LFTs). Imaging confirmed diverticulitis with colonic microperforation. She received morphine which slightly improved her symptoms, but then she began to have sharp epigastric pain radiating to the mid back. Follow up labs revealed a marked elevation in her LFTs and lipase. Within 6 hours, her alkaline phosphatase increased from 79 to 193 IU/L, AST from 34 to 784 IU/L, ALT from 32 to 583 IU/L, bilirubin from 0.3 to 1.6 mg/dL, and lipase from 28 to 939 U/L.

A right upper quadrant doppler ultrasound revealed a surgically absent gallbladder, no evidence of biliary duct dilation, and appropriate hepatic blood flow. MRI abdomen/MRCP showed no evidence of choledocholithiasis, biliary stenosis, or hepatic lesions. The only medications she received between the two lab draws were morphine and Piperacillin/Tazobactam (Pip/Tazo). Though Pip/Tazo can cause LFT elevation, one dose is unlikely to cause such a significant change. Labs were followed every four hours and began to improve within 24 hours.

IMPACT/DISCUSSION: Morphine is the most frequently used analgesic in the inpatient setting. Morphine is a largely benign drug with a half-life of 2-4 hours. Side effects include sedation, nausea, and mild respiratory depression. A rather uncommon side effect is biliary spasm, which can mimic, or reveal, SOD.

SOD, also known as post-cholecystectomy syndrome, is theorized to be related to damaged nerve fibers resulting in altered sphincter motility. This results in an acalculous, functional or mechanical, biliary obstruction. Type I dysfunction describes sphincter of Oddi stenosis, while type II dysfunction describes sphincter of Oddi dyskinesia. Both types can clinically present as biliary or epigastric pain mimicking cholelithiasis or acute pancreatitis. Our patient presented with type II SOD, resulting in a rare combination of both biliary and pancreatic symptoms with associated lab findings.

SOD is definitively diagnosed with sphincter manometry, but can also be a diagnosis of exclusion. Our patient’s extensive negative workup and transient abnormalities led to the diagnosis of SOD. SOD can be treated with sphincterotomy, and symptoms can be managed with calcium channel blockers.

CONCLUSION: The paradoxical effect of morphine in our patient resulted in significant transaminitis and acute pancreatitis, thus incidentally precipitating SOD. It is important to be aware of the side effects of commonly used medications in the inpatient setting, such as morphine. Recognizing SOD can help allay fears with unexpected lab findings. The normalization of labs confirms the benign nature of SOD and can help explain recurrence.

SPLENIC INFARCTION, A RARE PRESENTATION AND COMPLICATION OF INFECTIOUS MONONUCLEOSIS

Mahrukh Majeed¹; Atene S. Poskute²; Nida Rizvi¹

¹Internal Medicine, WellSpan Health, York, PA; ²Drexel University College of Medicine, Philadelphia, PA. (Control ID #3873996)

CASE: An 18 year old female with no significant past medical history presented with 3 days of left upper quadrant cramping abdominal pain, fatigue and nausea. She also reported nasal congestion, intermittent dyspnea, fever and diarrhea. She denied any sick contacts, recent travel, outdoor activities, or trauma. There was no personal or family history of thrombophilic disorders. Physical exam revealed tachycardia and left upper quadrant tenderness. The spleen was palpable below the coastal margin. She had a leukocytosis of 27.7 K/mcL, AST 120 IU/L, ALT 220 IU/L and alkaline phosphatase 568 IU/L. HIV antibody and hepatitis panel were unremarkable. Serological and polymerase chain reaction tests for Epstein Barr virus were positive and confirmed the diagnosis of infectious mononucleosis. CT scan of the abdomen was done to evaluate for her pain and revealed hepatomegaly of 23 cm,splenomegaly of 16 cm and 2 wedge shaped segmental splenic infarcts. CT angiography of the abdomen did not reveal any arterial or venous thrombosis. Thrombophilic workup, including prothrombin time, INR, partial thromboplastin time, anti-cardiolipin antibodies, beta 2 glycoprotein antibodies, factor 5 leiden and protein C activity was unremarkable. Since no evidence of thrombophilic disease was found, she was diagnosed with infectious mononucleosis complicated by splenic infarction. She was managed conservatively in the hospital and was discharged without any complication, with strict instructions to avoid any contact sports for at least 8 weeks. Approximately 2 months later, repeat imaging of her abdomen was obtained which showed resolution of splenomegaly and infarcts.

IMPACT/DISCUSSION: Spontaneous splenic infarctions have been described as a rare complication of infectious mononucleosis due to EBV infection.The exact incidence is not known, and only 34 cases have been reported in medical literature since 1961. Up to thirty percent of patients can be asymptomatic, whereas those with symptoms can present with left upper quadrant pain, nausea, vomiting and/or fever. Computed tomography scan is the diagnostic imaging modality of choice. The exact pathology is unknown, but the most common explanation is demand ischemia, due to increasing spleen size, which may result in a supply- demand mismatch and cause infarcts. Another explanation could be a relative hypercoagulable state in the setting of active infection and inflammation. Conservative management and follow up imaging is recommended to ensure resolution of splenomegaly and infarcts.

CONCLUSION: Infectious mononucleosis can cause spontaneous splenic infarction, which may be the initial presentation of the disease. It is important to obtain imaging with CT scan. Conservative management generally leads to improvement in symptoms, however, follow up imaging in 4-6 weeks is recommended to ensure resolution.

SPONTANEOUS HEMATOMAS: THE CASE OF ACQUIRED HEMOPHILIA

Hyeon Jeong Park¹; Michael Lankiewicz²

¹Internal Medicine, Christiana Care Health Services Inc, Wilmington, DE; ²Hematology Oncology, Christiana Care Health Services Inc, Newark, DE. (Control ID #3877160)

CASE: Acquired hemophilia A (AHA) is a rare and potentially fatal autoimmune disorder characterized by bleeding due to autoantibodies against coagulation factor VIII. We present the case of a elderly female with no personal or family history of a bleeding disorder presenting with hematoma found to have acquired hemophilia.

The patient is a 75-year-old female with a medical history of rheumatoid arthritis, gastrointestinal bleed, hypertension, hyperlipidemia presenting with acute onset of left forearm pain and swelling. Edema and ecchymosis were noted from the elbow to wrist with a hematoma present. Labs showed hemoglobin 9.2 G/DL, platelets 292 nl, white blood count 19.2 nl, prothrombin time 12.77s, and activated partial thromboplastin time (aPTT) 83s.

The patient was initially started on cefazolin for concerns of cellulitis due to edema and elevated white blood count. Compartment syndrome was excluded, and ultrasound was negative for DVT. Overnight the patient developed swelling of the contralateral forearm with hematoma. Hematology was consulted due to elevated aPTT with ecchymosis and spontaneous hematoma formation.

Mixing study demonstrated incomplete correction of the aPTT. The factor VIII level was 3% and the Bethesda inhibitor titer was high at 68.3 Bu, consistent with the diagnosis of AHA. The patient was started on a recombinant activated Factor VII for hemostasis and prednisone and rituximab for immunosuppression of the inhibitor. Active bleeding was stabilized prior to discharge with close hematology follow up for continued administration of immunosuppression and clinical monitoring. At last lab check, factor VIII level was now 13% and the Bethesda inhibitor titer was decreased to 3.0 Bu.

IMPACT/DISCUSSION: The clinical manifestation of AHA includes spontaneous hemorrhages into skin, muscles, soft tissues and mucous membranes. Hemarthrosis typical of inherited Hemophilia A are uncommon. AHA should be suspected when a patient with no previous history presents with bleeding and an unexplained prolonged aPTT. Associated diagnoses include autoimmune disorders (systemic lupus erythematosus, rheumatoid arthritis), the postpartum state and malignancy, although half of the cases are idiopathic and presenting bimodally in the young or old. Our patient was an elderly female with underlying rheumatoid arthritis.

CONCLUSION: AHA has a high mortality risk, making prompt diagnosis and treatment critical. Treatment is twofold. Hemostasis is achieved with bypassing agents such as activated factor VII or the novel bispecific agent Emicizumab, while some combination of immunosuppressive agents such as corticosteroids, Cytoxan or rituximab are employed to suppress the culprit antibody. Our patient achieved hemostasis with factor VIIa and subsequently remission with prednisone and Rituxan. Although rare, AHA should be considered in the setting of unexplained bleeding and a prolonged aPTT.

SPONTANEOUS INTRACRANIAL HYPOTENSION LEADING TO IRREVERSIBLE TETRAPLEGIA

Corinne P. Camp¹; Catherine Gilligan²

¹Internal Medicine, University of Colorado, Denver, CO; ²University of Colorado, Denver, CO. (Control ID #3847930)

CASE: A 23-year-old female was brought in by ambulance after being found obtunded at home. She was noted to be hypoxic with no motor activity and was intubated en route. Brainstem reflexes were absent on the initial neurologic examination. CT head demonstrated diffuse cerebral edema and downwards cerebellar herniation causing brainstem compression. Brain MRI was notable for cerebellar tonsils 1.9 cm below the level of the foramen magnum and mild retroversion of the dens, compatible with Chiari I malformation. Subsequent MRI T-spine findings and low opening pressure on lumbar puncture were consistent with CSF leak. With these findings, treatment for intracranial hypotension was initiated with discontinuation of sedation, placement in Trendelenburg position, and administration of intrathecal saline. Following these interventions mental status improved and she was able to communicate via eye and mouth movements, but was otherwise locked in with tetraplegia resulting from brainstem and upper spinal cord injury due to tonsillar herniation. After nearly a month-long stay in the ICU with ongoing ventilator dependence this patient unequivocally expressed her wishes to end all supportive care including ventilator support. With the expertise of palliative care, psychiatry, neurosurgery, and the ICU medical team she was transitioned to comfort care and compassionately removed from the ventilator.

IMPACT/DISCUSSION: Spontaneous intracranial hypotension (SIH) is a rare condition that occurs in about 5 cases per 100,000 person-years. It is most commonly caused by cerebrospinal fluid (CSF) leakage through ventral dural tears or nerve root diverticula. The term “Spontaneous” differentiates this diagnosis from intracranial hypotension caused by accidental or iatrogenic spinal trauma. The most common symptom of this is an orthostatic headache. In rare cases, it can cause encephalopathy, stupor, obtundation, and coma. There have been prior case reports of transient paraplegia and tetraplegia in patients with SIH. We describe the first case of severe irreversible tetraplegia due to SIH. Cerebellar tonsillar ectopia, also known as brain sagging, is a common imaging finding in SIH which can appear similarly to a Chiari I malformation. The degree of downward herniation in this case and the catastrophic progression of her neurologic deficits raised the possibility of a pre-existing Chiari I malformation, which may have led to a more rare constellation of signs and symptoms of SIH. This case exemplifies the need for a multi-disciplinary approach to identification of patients' values and medical wishes in situations with devastating medical complications. It acknowledges the patients' understanding and ability to communicate their own wellbeing despite any physical limitations.

CONCLUSION: This case presents a rapidly progressive and severe presentation of neurologic impairment caused by SIH resulting in permanent tetraplegia with no evidence of recovery despite appropriate management of SIH.

SPONTANEOUS RESOLUTION OF RECURRENT PANCREATITIS AFTER SPLENIC ARTERY PSEUDOANEURYSM STENT PLACEMENT - A CASE REPORT

W. F. Bohler¹; John D. Bohler²

¹School of Medicine, Oakland University William Beaumont School of Medicine, Rochester, MI; ²Marcus Daly Memorial Hospital, Hamilton, MT. (Control ID #3874678)

CASE: A 72-year-old male was admitted to the Emergency Department (ED) presenting with intermittent mid-epigastric pain that began 24 hours prior. Computerized tomography (CT) scan revealed acute pancreatitis (AP) with extensive portal vein thrombosis (PVT) that was believed to be secondary to his AP. The patient denied alcohol/recreational drug abuse, recent abdominal trauma, or any previous episodes of AP. Additionally, he was not taking any medications known to significantly cause pancreatitis. Lab reports showed unremarkable triglyceride and calcium levels but indicated elevated levels of lipase. To investigate potential autoimmune pancreatitis, IgG4 levels were checked but were unremarkable. Appropriate

anticoagulation for PVT was initiated. A magnetic resonance cholangiopancreatography (MRCP) revealed some atrophy of the tail of the pancreas but no ductal anomalies or gallstones. Over the following 3.5 months, the patient continued to experience episodes of epigastric pain and elevated lipase levels. An upper endoscopic ultrasound (EUS) revealed a 49X29 mm fluid collection around the pancreatic body initially thought to be a pancreatic pseudocyst. Two weeks later, the patient presented again to the ED with emesis and severe epigastric pain that now radiated to his back. A CT scan revealed 2 cm from its origin a ruptured splenic artery pseudoaneurysm (SAP) measuring 3.6 cm with a large retrogastric hematoma. An emergency arteriogram was conducted and a fully covered endovascular stent was successfully placed at the origin of the SAP. Subsequent lab results indicated normal lipase levels and resolved pancreatitis. Over the following 6 months, the patient denied any further epigastric pain.

IMPACT/DISCUSSION: The exact etiology of the patient’s AP remains unknown. While AP is the most common cause of SAP, we believe this case represents an etiology in which the proximal location of the SAP to the pancreas allowed for its compression causing intermittent episodes of AP. Upon further reflection, we believe the SAP was visualized during the patient’s EUS but was mistakenly identified as a pancreatic pseudocyst. The spontaneous resolution of the patient’s recurrent AP after the splenic artery stent placement further supports our theory.

CONCLUSION: SAPs are by nature rare conditions, but we believe this case represents the first of its kind to be reported in the literature. We hope that the findings from this case will be of use to physicians in the future and that SAP will be considered in cases of recurrent AP with no apparent etiology.

SPONTANEOUS TUMOR LYSIS SYNDROME IN ACUTE LEUKEMIA BEFORE INITIATION OF CHEMOTHERAPY

Garima Gautam¹; Manne Madhuri²

¹Internal Medicine, UConn Health, Farmington, CT; ²Internal Medicine, Saint Francis Hospital and Medical Center, Hartford, CT. (Control ID #3864633)

CASE: A 74-year-old male presented with shortness of breath on exertion. He complained of generalized weakness, fatigue, and dizziness that started 10 days ago and had gradually worsened. He also had an unintentional weight loss of 12 pounds in the past 10 days. Vital signs and Physical exam were normal. His white blood cell count was 144.1 K/uL, Hemoglobin 5.5 g/dL, Hematocrit 18%, platelet 7000 L, Potassium was 5.0, Bicarbonate 15 mmol/L, BUN 48, creatinine 3.1, Uric acid 24, PT 17.6, INR 1. 5, fibrinogen 300, LDH 330, Lactic acid 3.2 mmol/L.

Peripheral blood flow cytometry revealed monocytes CD56 positive with about 7% to 8% blasts consistent with acute monocytic leukemia. Bone marrow biopsy showed markedly hypercellular marrow (greater than 95%) with sheets of monocytic cells of varying maturation, including many monoblasts and promonocytes (90% by manual differential). The patient was initiated on hydroxyurea 2g twice daily, rasburicase, sevelamer 800mg three times daily, and prophylactic antibiotics levofloxacin, posaconazole, and acyclovir. He was initiated on IV Lactated ringer at 150 mL/hour and received 3 units of PRBC and 3 units of platelet transfusion. He was not initiated on chemotherapy since his labs were consistent with tumor lysis syndrome.

24 hours later the patient became hypoxic with Spo2 85%, the rhythm was atrial fibrillation in the 150s, and temperature 101.5. He was placed on a BiPAP machine, discontinued IV fluids, and initiated on a diltiazem drip. His chest x-ray showed Pulmonary edema and developing pneumonia and CT chest without IV contrast was consistent with pulmonary edema. His kidney injury worsened with BUN 110 mg/dL, Creatinine 4.2 mg/dL, phosphate 13.4 mg/dL, and lactic acid 6.6 mmol/L. Despite a dose of Lasix, increasing the dosage of sevelamer to 1600 mg three times daily, his urine output was minimal and his labs did not improve. He was also hypotensive so he was upgraded to ICU level of care and initiated on continuous venous hemofiltration to manage refractory tumor lysis syndrome. His labs improved and arrhythmia resolved and he was eventually initiated on chemotherapy.

IMPACT/DISCUSSION: Spontaneous tumor lysis syndrome is a rare oncological emergency associated with multiorgan failure and unrelated to chemotherapy. AML with WBC above 100,000/uL or LDH two times above baseline like in our case, imposes high risk. The available data are limited to reports of individual cases and a few series of cases, so quantifying the real incidence is difficult. Treatment includes rasburicase, intravenous hydration, electrolyte correction, and dialysis for refractory cases.

CONCLUSION: This case emphasizes that TLS can be a complication of AML even prior to initiation of chemotherapy. Physicians should be aware of this complication and start treatment promptly. Quick and early recognition of the renal and metabolic derangement associated with tumor lysis syndrome and initiation of treatment can save a patient's life.

STATIN-INDUCED NECROTIZING MYOPATHY: A RARE CONSEQUENCE TO A COMMON MEDICATION

Harrison C. McMinn, Jennifer Schmidt

Internal Medicine, Washington University in St Louis School of Medicine, St Louis, MO. (Control ID #3872243)

CASE: A 67-year-old male with a past medical history of hypertension, coronary artery disease, and hyperlipidemia presents to his primary care office for evaluation of proximal muscle weakness and fatigue after recent initiation of statin medication. Patient endorsed a one month history of fatigue, shoulder pain, inability to lift his arms above his head, and brown/tea-colored urine. Neurologic exam demonstrated 3/5 strength in upper and lower extremity. Initial laboratory evaluation showed AST 1090, ALT 1553, CK 44,040, Aldolase 303. He was admitted to Barnes-Jewish hospital for management and treatment of rhabdomyolysis and statin-induced myopathy. The patient was initially treated with intravenous fluid replacement and statin discontinuation and discharged following improvement of his CK and liver enzymes towards baseline. Following this hospitalization he presented again with a worsening of his symptoms and new dysphagia. During his second hospitalization he was evaluated by the rheumatology and neurology services. Muscle biopsy of his deltoid muscle showed epimysial and interstitial perivascular lymphocytic infiltration. A myositis panel (which was sent during first admission) demonstrated anti-HMGCR and anti-SRP autoantibodies. Following a prolonged hospitalization during which he was treated with IVIG inpatient, the patient was ultimately treated with IV steroids and weekly intravenous immunoglobulin (IVIG) infusions. Patient was discharged to an inpatient rehab facility with gradual improvement of his symptoms over the next 9 months with weekly steroid and IVIG infusions.

IMPACT/DISCUSSION: Statin medications are one of the most common medications in the primary care setting, serving an important role in reducing cardiovascular risk and treating hyperlipidemia.

Although generally well tolerated, the most common side effect associated with statin use is myopathy. Muscle-related complications from statin use exist across a spectrum ranging from myalgias to myonecrosis. Although the incidence of true myonecrosis is less than 1%, muscle related symptoms are the leading reason for discontinuation by patients. Autoimmune necrotizing myositis differs from statin-induced myopathy by several key components, chief of which is the formation of autoantibodies against muscle tissue. Anti-HMGCR is the most common form and is characterized by autoantibody formation after exposure to a statin in genetically susceptible individuals. Treatment is usually with IVIG and high-dose intravenous steroids. Creatine kinase levels are used as a marker to monitor response to treatment.

CONCLUSION: It is important for Internists to be aware of and able to promptly recognize rare complications associated with statin medications in order to prevent irreversible muscle damage and loss of function in affected patients.

STEELY-EYED MISSILE MAN: WHEN UNEVEN BLOOD PRESSURES ARE NOT AN AORTIC DISSECTION

Jacob Khoury¹; Celeste M. Newby²

¹Internal Medicine, Tulane University School of Medicine, New Orleans, LA; ²John W Deming School of Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #3873473)

CASE: A 74-year-old woman presented with a left open tibial fracture following a motor vehicle accident. She was initially triaged and stabilized by orthopedics who performed external fixation of her leg. Internal medicine was consulted due to asymptomatic hypotension noted post-op day one. On initial interview, the patient reported pain in her left lower extremity but otherwise had no complaints. She reported no pain, numbness, cramping, or weakness in the upper extremities. Blood pressure in the left arm was 55/41, and in the right arm was 120/55. Physical exam disclosed a significantly stronger radial pulse in the right arm compared to the left arm, and the left hand appeared intermittently dusky. Doppler pulses were obtained in bilateral upper extremities, with right pulses louder and more dynamic than in the left. CT angiography of the chest was notable for occlusion of the left subclavian artery with reconstitution of distal blood flow near the origin of the left vertebral artery, suggestive of subclavian steal syndrome. Vascular surgery was consulted and recommended medical management with aspirin and statin, as the patient was asymptomatic.

IMPACT/DISCUSSION: Subclavian steal syndrome occurs when a stenosis or occlusion of the subclavian artery proximal to the origin of the vertebral artery results in retrograde flow from the ipsilateral vertebral artery to supply distal arteries.<span style="font-size:10.8333px"> </span>A blood pressure differential between arms is one of the most telling physical exam findings for subclavian steal syndrome. One ultrasound study noted an increase in sensitivity for subclavian steal syndrome in patients who had a blood pressure differential > 20 mmHg between arms. In fact, if proximal subclavian stenosis is > 50%, over 90% of patients will have intermittent or continuous reversal of flow.

The differential diagnosis for blood pressure differential between arms includes subclavian steal syndrome, aortic dissection, ischemic limb due to arterial occlusion, large artery vasculitis, thoracic outlet syndrome, and congenital cardiovascular malformations. Subclavian steal syndrome can often be the most likely diagnosis based on history and exam, as patients often have no symptoms or specific symptoms related to physical exertion of the affected arm. Medical management can be pursued in most cases with aspirin and statin therapy.

CONCLUSION: Subclavian steal syndrome is a common cause of asymptomatic blood pressure differential between the arms. The differential diagnosis for blood pressure differential between arms is broad; further history and physical can help hone the differential and diagnose subclavian steal syndrome.

STRAINED FOR A DIAGNOSIS: A ROGUE CLOT MASQUERADING AS SEPTIC SHOCK

Isabel M. Lopez, Tyler J. Kristoff, Dheepa Sekar

Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #3872076)

CASE: Patient is a 68-year-old female with dementia and chronic systolic heart failure who was brought to the emergency department (ED) after found down with confusion and right lower extremity pain. There was no bystander information, but prior ED visits showed baseline orientation to person and place. On exam, she was afebrile, tachycardic to 120s, and hypotensive in 90s/70s, without hypoxia on room air. She was noted to be lethargic but arousable, with cool extremities, suprapubic tenderness, and right ankle deformity. Labs were significant for white blood count 10 K/mcl, bicarbonate 20 meq/L, lactic acid 3.7 mmol/L, creatinine 2.3 mg/dL, high-sensitivity troponin 1,830, BNP 480, and urinalysis with bacteriuria and pyuria. Imaging was notable for right ankle fracture on x-ray and an unremarkable head CT. Given these findings, there was concern for both septic and cardiogenic shock. She was initially treated for urinary tract infection with antibiotics and gentle intravenous fluids with improvement in hemodynamics and warming of extremities. However, lack of continued improvement in mentation, tachycardia remaining in the 110s, elevated cardiac enzymes in the setting of initially cool extremities and history of systolic heart failure raised concern for cardiogenic shock. Echocardiography performed to evaluate cardiac function instead revealed a newly flattened ventricular septum. A CT PE was pursued, which ultimately showed extensive bilateral pulmonary emboli extending from main to subsegmental pulmonary arteries suggesting a component of obstructive shock. Hemodynamics improved after starting anticoagulation. The patient had high clot burden, but was not a surgical candidate for thrombectomy due to her dementia and overall clinical improvement with anticoagulation.

IMPACT/DISCUSSION: In the United States, pulmonary embolism (PE) accounts for approximately 100,000 annual deaths. Etiology of hemodynamic instability can be difficult to differentiate, especially in cases with limited history, when clinicians must rely on objective data. In this case, lab data suggested sepsis, but exam suggested poor cardiac output. The component of obstructive shock in initial presentation was obscured by sepsis and the patient’s moderate, but not complete clinical improvement. Additionally, while the Well’s score is often cited as a clinical decision-making tool, its applicability is limited in cases who present with a mixed clinical picture, as the highest weighted feature depends on the likelihood of an alternative diagnosis. The most challenging aspect of diagnosing PE is recognizing when to initiate further testing; perhaps a lack of clinical improvement is a clinician’s cue to re-evaluate for additional components of shock.

CONCLUSION: This case demonstrates the importance of considering all forms of shock in critically ill patients who do not fully improve with treatment of the initial suspected diagnosis.

STREPTOCOCCUS ANGINOSUS LUNG ABSCESS WITH COMPLICATED PARAPNEUMONIC EMPYEMA

Laura Gonzalez¹; Raghavendra Sanivarapu²; Lutfor Nessa³

¹Internal Medicine, Texas Tech University System, Lubbock, TX; ²Pulmonary Critical Care, Texas Tech University Health Sciences Center, Lubbock, TX; ³Internal Medicine, Texas Tech University Health Sciences Center Permian Basin, Odessa, TX. (Control ID #3875543)

CASE: A 55-year-old female with history of hypertension was transferred to our hospital for complicated pneumonia. She had been treated for an upper respiratory tract infection with antibiotics a month prior. However, she complained of progressive shortness of breath and right pleuritic chest pain for 2 days. On admission, she was febril 101.2°F, O₂ saturation 87% on room air; heart rate was 118 bpm. Laboratories showed leukocytosis up to 17x10³/mcL with 47% bands. CT chest demonstrated near complete opacification of the right lung, cavitation with fluid level in the right middle lobe, and moderate to large effusion. Vancomycin, Azithromycin, and Zosyn were started. Sputum culture was later positive for methicillin- resistant Staphylococcus aureus, which prompted antibiotic de-escalation to Vancomycin. A chest tube was placed into the right pleural space. Fluid analysis showed WBC 175, LDH 2240 IU/L, glucose <2mg/dL, and culture grew Streptococcus anginosus group (SAG) bacteria. Due to not resolving respiratory distress and residual effusion, two rounds of tPA with dornase were administered through the chest tube. Repeated CT chest showed multiloculated right-sided empyema. We proceeded with right thoracotomy and decortication.

A thick visceral pleural peel covering the entire right lung was found. As well as an abscess in the right upper lobe ruptured into the pleural space, consisting of necrotic tissue per pathology, with negative microbiology. The patient clinically improved post-operatory and was discharged home with oral Linezolid to complete 30 days.

IMPACT/DISCUSSION: Members of the SAG are facultative anaerobic colonizers of the upper airways, very rarely pathogenic. It is thought that it has the ability to release a toxin with leukocidin effect. It has been reported most commonly as a causative pathogen of brain abscesses. However, in very few occasions has been related to lung abscess. Proceeding respiratory tract infection can be seen in some cases. This group has the unique ability to extend beyond fascial planes and interlobar fissures. Lung abscesses that develop from necrotizing pneumonia communicate with the airway, undergo auto-drainage, and usually only require long- term antibiotics. But due to the SAG’s ability to cross fascial planes, the lung abscess is often complicated by empyema due to its rupture into the pleural cavity. In these patients, antibiotic therapy often fails and requires surgical intervention. The typical treatment for these infections is ampicillin or vancomycin plus drainage of any concomitant abscess. Timely treatment for lung abscesses is essential to hinder infection dissemination and prevent the grave complications of overwhelming sepsis and multiorgan failure.

CONCLUSION: Lung abscess is a severe complication of pneumonia. Moreover, when accompanied by empyema raises its complexity.

Individual cultures and sensitivities are essential to successfully tailor the treatment in cases of lung abscess; either for medical or operative management.

STREPTOCOCCUS PYOGENES SPINAL EPIDURAL ABSCESS AND MSSA BACTEREMIA IN A 54 YEAR OLD MAN—CONCOMITANT CONTIGUOUS COINFECTION OR INDEPENDENT EVENT?

Fulei Peng, Edward A. Cantos, Nathan Robertson

Internal Medicine Residency, Mercy Health, St Louis, MO. (Control ID #3859410)

CASE: We present a 54 yo man admitted for 7 days of LBP, constipation, and urinary retention after a motor vehicle accident (MVA). He was evaluated at an ER but left AMA and subsequently developed progressive LBP. He was given Decadron and Percocet at an Urgent Care without relief. Symptoms progressed to constipation and urinary retention, prompting another presentation to the ER. A foley was placed with drainage of 1.8 liters of urine, relieving his abdominal pain. He initially denied sensory changes or weakness but later noted weakness.

Physical exam revealed poor dentition and intact sensation but reduced strength in both legs. His skin was notable for a diffuse scaly rash with excoriations on his bilateral arms. An MRI spine revealed an extensive spinal epidural abscess (SEA) from C5-L5. The patient underwent emergent abscess drainage with improvement in all his symptoms. The culture from the SEA grew Group A Strep, while his admission blood culture grew MSSA. The patient was discharged home with a total of 6-week-course of IV Ceftriaxone and has made a near full recovery.

IMPACT/DISCUSSION: This case illustrates the importance of knowing the risk factors for SEA. These include DM, IVD use, alcoholism, HIV, recent trauma/surgery, and local or systemic infection.^1–5 This patient had alcoholism, MVA injury, poor dentition, skin rash laceration, and immunosuppression from steroids. All of which made him high risk for SEA. It is clear that SEA patients may not present with systemic symptoms that would raise immediate suspicion for an epidural abscess. Therefore, it is vital to be aware of these SEA risk factors to promote prompt suspicion and diagnosis.

This case highlights an unusual bacterial pathogen pattern for a patient with concomitant SEA and bacteremia. Among patients with SEA, contiguous bacteremia is reported in approximately 63% of cases.⁶ Hematogenous spread of pathogens to the epidural space is the most frequent cause of SEA⁴, thus the culprit pathogens for bacteremia and SEA are usually the same. Staph aureus accounts for 2/3 of cases⁴, while less

common pathogens include Strep species, coagulase-negative Staph, and gram-negative species like E. coli and Pseudomonas.^4,7 We suspect that our patient’s SEA (Group A Strep) was caused by oral flora, while the bacteremia (MSSA) was likely related to skin breakdown. Therefore, it is crucial to culture both the blood and abscess from patients with SEA to tailor therapy that covers the culprit organism(s).

CONCLUSION: Here we present a case of a patient presenting with progressive neurologic symptoms and risk factors typical for SEA that allowed for prompt recognition and intervention. Like many with SEA, this patient was also found to have concomitant bacteremia. However, this presentation is atypical in that different organisms were isolated from the SEA and bloodstream, highlighting the importance of assessing the possibility of multiple sources of infection at the same time.

STRESS-INDUCED CARDIOMYOPATHY IN THE SETTING OF ACUTE ADRENAL CRISIS

Sadia A. Tanami²; Basheer Mohammed²; Muhammad Ali Anees²; David Brabham¹; Kelly Mcmaster²

¹Cardiology, Texas Tech University, Amarillo, TX; ²Internal Medicine, Texas Tech University Health

Sciences Center, Amarillo, TX. (Control ID #3858725)

CASE: A 59-year-old female with a history of hypertension, hypothyroidism, and secondary adrenal insufficiency (AI) presented to the emergency department with 1 hour of constant, severe retrosternal chest pain that radiated to the right shoulder. The patient’s AI was secondary to a remote history of pituitary gland removal, and she was on chronic hydrocortisone and fludrocortisone at home. On admission, blood pressure (BP) was 126/56 mm Hg, Heart Rate (HR) was 84 beats/min, troponin (TR) 57 ng/L, blood glucose 89, sodium 124, potassium 3.6, and ECG showed T-wave inversions in the inferior leads. The patient was diagnosed with a non-STEMI and acute coronary syndrome (ACS) protocol was initiated. On the following day, the patient's BP was 62/36 mm Hg, HR was 112 beats/min, TR 3998.2 ng/L, and ECG showed anterior lead T-wave inversions (inferior T-wave inversions had resolved). Transthoracic echocardiography showed an ejection fraction (EF) of 35-40%, with apical segment akinesis without thrombi or trabeculations. The patient was taken for cardiac catheterization and her coronary angiography showed no vessel occlusion but ventriculography showed hypokinesis of the basal segment and akinesis of the mid and apical segments.

These findings were most compatible with stress-induced cardiomyopathy (SIC). Due to hemodynamic instability, electrolyte imbalance, and a history of chronic AI, the patient was also diagnosed with acute adrenal crisis. She was started on Lactated Ringer’s solution, high dose IV hydrocortisone 50 mg twice daily, and fludrocortisone 0.1 mg daily, and ACS protocol was stopped. The patient clinically improved, and her laboratory abnormalities returned to normal. Due to low EF, she was discharged with a wearable defibrillator and advised to follow up with her endocrinologist and cardiologist as an outpatient.

IMPACT/DISCUSSION: SIC, also known as Takotsubo cardiomyopathy and left ventricular apical ballooning syndrome, is characterized by transient systolic dysfunction of the apical and mid segments of the left ventricle with the absence of coronary occlusion. It is much more common in women than men and occurs predominantly in older adults. SIC due to AI is very rare in the adult population, only 4 cases have been reported. The pathogenesis of this disorder is not well understood. Postulated mechanisms include catecholamine excess, microvascular dysfunction, and coronary artery spasm. In a SIC, left ventricular function returns to normal within a few weeks; however, several complications like shock and acute heart failure may occur before the systolic function returns to normal and in-hospital mortality is approximately 3%-4%.

CONCLUSION: Our case report describes the rare finding of SIC in the setting of acute adrenal crisis. In all cases of SIC, treatment of underlying etiology along with careful monitoring of cardiac function and appropriate guideline-directed medical treatment of cardiomyopathy can reverse the left ventricular dysfunction.

SUBCLAVIAN STE-NO-IT’S MY BREATH: CORONARY STEAL IN A PATIENT WITH CORONARY ARTERY BYPASS GRAFTING (CABG)

Alan Amedi¹; Maaz Ahmed¹; Maan Jokhadar²; David Krakow¹

¹Hospital Medicine, Emory University School of Medicine, Atlanta, GA; ²Cardiology, Emory University, Atlanta, GA. (Control ID #3834759)

CASE: A 67-year-old female with hypertension, diabetes mellitus, and coronary artery disease status post CABG (left internal mammary (LIMA) to left anterior descending (LAD)) presented with two weeks of progressive shortness of breath and bilateral lower extremity swelling. She reported orthopnea, paroxysmal nocturnal dyspnea, and early satiety. On admission, temperature was 36 degrees Celsius, blood pressure was 177/99 mmHg, heart rate was 102 beats per minute, respiratory rate was 22 breaths per minute, and oxygen saturation was 95% on room air. Her heart rhythm was regular and jugular venous pressure was 12 cm H2O.

Her upper extremity pulses were diminished bilaterally. She had trace pretibial edema bilaterally. Her breathing was unlabored with faint bibasilar crackles. Her abdomen was soft and non-distended. Electrocardiogram was notable for T-wave inversions in inferior and anterolateral leads. Chest radiography was consistent with pulmonary edema. Her brain natriuretic peptide was 892pg/mL and high sensitivity troponin was 17ng/L. Echocardiography was notable for an ejection fraction of 35-40% with no valvular or wall motion abnormalities. Computed tomography with contrast was notable for bibasilar atelectasis, moderate atherosclerosis, and no pulmonary embolism. She was started on intravenous diuretics. She developed periodic asymptomatic hypotension. Repeat blood pressure was taken in both arms. Blood pressure in the right arm was 118/75 mmHg and 92/65mmHg in the left arm. A left subclavian bruit was appreciated on further auscultation. Coronary catheterization revealed 99% stenosis of her proximal left subclavian artery with retrograde flow from her LAD to a patent LIMA just distal to the proximal subclavian stenosis, known as coronary steal. Left subclavian artery balloon angioplasty and stent placement was performed, correcting coronary flow. The patient clinically improved, and her shortness of breath resolved. IMPACT/DISCUSSION: Atherosclerosis of the subclavian can occur in patients referred for CABG, with coronary steal occurring rarely in patients post CABG involving the LIMA. Coronary steal is a very rare cause of new ischemic cardiomyopathy. In this patient, her reported stress, high-salt diet, and secondhand smoke exposure was not enough to explain her acute heart failure symptoms. When suspected, left heart catheterization can confirm the diagnosis of coronary steal. This case should serve to demonstrate the importance of a thorough physical exam, particularly assessing blood pressure in both arms, and the need to work up and determine the etiology of symptoms rather than treatment alone.

CONCLUSION: This presentation of new heart failure symptoms in a patient with CABG of the LIMA to LAD should prompt a thorough work up that includes careful consideration of subclavian artery stenosis. Ultrasound of the subclavian, along with auscultation and bilateral blood pressure measurements are simple, fast, and minimally invasive techniques to assess for the syndrome.

SUCCESSFUL DEFIBRILLATION AFTER SUDDEN CARDIAC ARREST FROM ARRHYTHMIC MITRAL VALVE PROLAPSE WITH MITRAL ANNULAR DISJUNCTION

Nicholas S. Faraci, Anisha Reddy, Gregory M. Olenginski

Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #3876918)

CASE: A 55-year-old man without significant past medical history presented after suffering an out-of- hospital cardiac arrest. Near-immediate bystander CPR was initiated, automated external defibrillator (AED) was placed and administered 4 shocks, and return of spontaneous circulation was achieved after 10 minutes. In the preceding weeks, the patient was asymptomatic.

The patient was admitted to the cardiac ICU. Exam notable for a grade 3/6 systolic murmur most prominent at the cardiac apex and grossly normal neurological exam. Rhythm strips from AED demonstrated ventricular fibrillation (VF). Current ECG demonstrated normal sinus rhythm, normal QT interval, and non-specific ST- segment changes. Coronary angiogram demonstrated clean coronary arteries. Transthoracic echocardiogram (TTE) demonstrated non-dilated LV size, LVEF 55-60%, mild prolapse of both mitral leaflets with mild mitral regurgitation (MR), and mitral annular disjunction (MAD) of 10 mm. Cardiac MRI (CMR) demonstrated dilated LV with LVEF 62%, severe mitral valve prolapse (MVP) and severe MR, but no MI, scarring, fibrosis, or infiltrative disease noted on late-gadolinium enhancement. Transesophageal echocardiogram (TEE) demonstrated non-dilated LV, LVEF 60-65%, MV with appearance of Barlow valve with degenerative MVP of both mitral leaflets, severe MR, MAD of 13 mm.

The patient had subcutaneous ICD placed on hospital day 6 and was discharged home on metoprolol- succinate 25 mg daily with plan for outpatient CT surgery follow-up for consideration of mitral valve replacement.

IMPACT/DISCUSSION: This case highlights the most feared complication of MAD – sudden cardiac arrest.

MAD is defined as an atrial displacement of the posterior mitral leaflet and is associated with MVP. MAD with MVP is independently associated with increased clinical arrhythmias, yet the causal link remains unknown. It has been hypothesized that the systolic curling of the myocardial wall in MVP exerts stress on the MV apparatus and adjacent structures causing myocardial injury and fibrosis. More recently, it has been shown that the location, specifically inferolateral MAD, is linked to MVP, systolic curling, fibrosis, and arrhythmias.

The two class I indications in for MV repair per the AHA 2020 guidelines are: (1) symptomatic severe primary MR (stage D) and (2) asymptomatic severe primary MR with LV systolic dysfunction (LVEF < 60%, LVESD > 40 mm) (stage C2). Our patient's LV appeared non-dilated by linear measurements on TTE, borderline by TEE, and dilated by CMR so there was discrepancy whether MR stage C1 or C2, but notably valve guidelines do not use MR-derived volumes in their definition of dilation. Furthermore, MR consistently overestimates EDV relative to echocardiography by ~55 mL.

CONCLUSION: MAD is associated with MVP, and is an independent risk factor for an arrhythmic phenotype, specifically when located in the inferolateral LV wall. MV repair has a class I indication in severe MR when symptomatic or in the presence of LV dysfunction.

SUCCESSFUL OUTCOME FROM THE RAPID INITIATION OF ANTIVIRAL THERAPY IN A CASE OF VARICELLA ZOSTER VIRUS (VZV) PNEUMONIA

Hillary G. Meeker, Loura Khallouf, Nicole Rodis

Internal Medicine, UMass Memorial Medical Center, Worcester, MA. (Control ID #3875425)

CASE: A 62-year-old female presented to the Emergency Department with shortness of breath, tachypnea, and a diffuse, vesicular rash. She had a history of IgA/lambda Multiple Myeloma (MM) status post two autologous stem cell transplants (SCT) in 1999 and 2013 on Lenalidomide maintenance therapy. A chest x-ray showed diffuse, indistinct interstitial opacities. A CT demonstrated bilateral infiltrates and mediastinal lymphadenopathy concerning for infection. A presumptive diagnosis of disseminated VZV was made and the patient was started on Valacyclovir. Biopsies of her vesicular rash were positive for VZV by nucleic acid analysis. The patient became increasingly tachypneic and required admission to the ICU. The patient was intubated and found to have esophageal thickening indicative of VZV esophagitis. Subsequently, her respiratory status stabilized, she was transitioned to oral Acyclovir, and she was successfully discharged from the hospital 3 weeks after admission.

IMPACT/DISCUSSION: VZV is a human herpes virus responsible for varicella (chickenpox) as the primary infection and zoster (shingles) as the latent reactivation in the sensory ganglia. Disseminated VZV is a rare, life-threatening infection. It is defined as greater than 20 lesions outside the affected dermatome and can occur in 15-30% of immunocompromised patients. It has a mortality rate of 50%, with multiple complications including Varicella Pneumonia and Esophagitis. Identifying Varicella Pneumonia by characteristic clinical and radiographic features is crucial to early initiation of therapy and prevention of mortality. Typical manifestations on a radiograph include diffuse pulmonary nodules, which can mimic other diseases, making it difficult to distinguish in the early stage. Clinically, patients may present with shortness of breath, chest pain, fatigue, and symptoms indicative of infection even before vesicular rash formation

CONCLUSION: We report a case of successfully managed severe disseminated VZV infection in a multiple myeloma patient with two autologous SCTs on Lenalidomide therapy. In this case, the patient presented 9 years after her second transplant. Prior cases of disseminated VZV in SCT patients occurred within 9-12 months, although cases of herpes zoster have been reported as late as 3 years post-transplant. This case illustrates multiple important issues:

1. The importance of considering VZV pneumonia in the differential diagnosis of respiratory failure, especially in immunocompromised individuals. In this patient, it is likely that suspecting VZV pneumonia led to the timely institution of appropriate antiviral therapy and a good outcome.

2. MM can be associated with long survivals using contemporary therapeutic approaches.

3. For disease prevention, there may be value in exploring intensive VZV vaccination strategies in at-risk patients.

SUCCESSFUL TREATMENT OF ACUTE INTERSTITIAL NEPHRITIS INDUCED BY IMMUNE CHECKPOINT INHIBITOR RECHALLENGE

Mark Hanna¹; Swarna Nalluru²; Kostas Papamarkakis³; John McCann²

¹Internal Medicine, Baystate Medical Center, Springfield, MA; ²Hematology/Oncology, Baystate Medical Center, Springfield, MA; ³Nephrology, Baystate Medical Center, Springfield, MA. (Control ID #3869821)

CASE: 53 year old woman with metastatic melanoma presented to the hospital 6 days after receiving her first treatment of Nivolumab and Ipilmumab with chief complaints of high grade fever, nausea, right upper quadrant pain, and generalized weakness. Her other past medical history included GERD. Home medications included pantoprazole and as needed zofran. Vitals were significant for mild tachycardia and high-grade fever. Lab work significant for elevated creatinine of 1.4 mg/dL. CT abdomen showed perinephric stranding with no hydronephrosis. Urine analysis showed mild pyuria, positive leukocyte esterase and moderate bacteriuria. She was started on cefepime for concern of sepsis in the setting of a urinary tract infection. Her creatinine uptrended to 2.5 mg/dL despite continuing antibiotics for 3 days. Final urine and blood cultures were negative. Given the concern for ICI mediated grade 3 nephritis, intravenous solumedrol was started.

Kidney biopsy showed findings of heavy inflammation of tubulointerstitium. Pantoprazole was discontinued. As she progressed to grade 4 nephritis despite a solumedrol trial for 3 days, dialysis was started and infliximab was added. She was then discharged home with a plan of oral steroid taper and dialysis outpatient. Within five weeks after receiving infliximab, she was noted to have normalization of kidney function. Since her treatments were on hold due to the complications, she had disease progression with new lesions in the brain, lungs, and liver. Since she did not have targetable mutations to recommend alternate treatments, pembrolizumab monotherapy was started. Two weeks after receiving pembrolizumab, she again was noted to have grade 2 nephritis. She was started on steroids but continued to have worsening nephritis. Rebiopsy confirmed the same. Given that this was a steroid refractory grade 2 nephritis currently and in the past, she received a dose of infliximab and her kidney function improved within one week.

IMPACT/DISCUSSION: Incidence of renal toxicity with ICIs is <5% and typically appears 6 to 47 weeks after treatment initiation. Our patient presented with steroid refractory grade 4 nephritis in less than one week after starting treatment and rapidly worsened to grade 4 steroid refractory nephritis requiring dialysis. Within 5 weeks with infliximab, she had a rapid recovery with return of kidney function. One study showed 23% incidence of AKI upon rechallenging with ICI and only 3% did not recover kidney function. Rechallenging with ICI requires a multidisciplinary approach, avoiding other agents that cause AIN and close monitoring for reemergence of similar adverse effects. Our patient again developed steroid refractory grade 2 nephritis even with monotherapy and warranted permanent discontinuation of any ICI use.

CONCLUSION:Recognize ICI induced AIN early in cancer patients receiving immunotherapy

Recognize medications that can contribute to ICI induced AIN such as concomitant use of PPIs

SUL-BACT(AM) TO THE DRAWING BOARD: A CURIOUS CASE OF BETA-LACTAMASE INHIBITOR HYPERSENSITIVITY

Alicia Liu²; Morgan Ferrell¹; Emily Min¹; Alfred Shoukry¹

¹Internal Medicine, UPMC, Pittsburgh, PA;²University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #3875969)

CASE: A 78-year-old man was admitted to General Medicine for confusion and generalized weakness. A CT of his chest showed a new right-sided loculated pleural effusion with adjacent consolidation. He had been treated two weeks prior with a course of amoxicillin-clavulanate for pneumonia. He had no known history of medication allergies. During his admission, he was febrile and was treated with vancomycin and piperacillin- tazobactam for parapneumonic effusion versus empyema. Thoracentesis showed an exudative effusion and antibiotics were de-escalated to ampicillin-sulbactam. One hour after his first dose of ampicillin-sulbactam, the patient developed tachycardia, rigors, and developed an elevated lactate of 3.3 mmol/L. He was given acetaminophen and IV fluids, and his antibiotics were broadened back to piperacillin-tazobactam with resolution of symptoms. After discussion with infectious disease, another dose of ampicillin-sulbactam was attempted the next day eliciting a similar reaction which again improved with IV fluids. There was a high suspicion for a sulbactam allergy, and he was de-escalated to amoxicillin-clavulanate for a 3-week treatment of complicated parapneumonic infection, which he tolerated well.

IMPACT/DISCUSSION: The initial differential diagnosis for this patient’s new rigors and tachycardia after sulbactam exposure included bacterial seeding after his recent thoracentesis or a new primary infectious process. However, his rapid improvement and similar episode upon re-trialing sulbactam increased suspicion for a primary beta-lactamase inhibitor allergy. While beta-lactam allergies are well described in the literature, less information is available regarding reactions to beta-lactamase inhibitors, especially sulbactam allergies. These have mostly been described in isolated case reports, with a scant minority proving specific sulbactam allergy, ie contact dermatitis with a scratch test. This patient experienced hypersensitivity to sulbactam in the absence of clavulanate or prior penicillin allergy. This is anomalous as both clavulanate and sulbactam are beta lactam-based with a penicillanic sulfone structure. Furthermore, sulbactam’s structure is more similar to the penicillin nucleus increasing risk of cross-reactivity with beta-lactams. A physician utilizing premature closure bias may not have included sulbactam reaction in their differential for this patient’s abnormal response to sulbactam; yet stopping this medication caused rapid improvement of symptoms. This case highlights the importance of including drug reactions in the differential for vital sign abnormalities when evaluating patients with infections.

CONCLUSION: While less commonly documented than beta-lactam allergies, reactions to beta-lactamase inhibitors have been proven and may be specific to one agent as opposed to a class effect. It is important for the general internist to avoid premature closure bias when evaluating acutely ill patients.

SUMATRIPTAN INDUCED ISCHEMIC COLITIS A CASE REPORT

Waldo J. Santiago Colberg¹; Sameer Khan¹; Claire Goode²; Nathan Douthit³

¹Internal Medicine, East Alabama Medical Center, Opelika, AL; ²Student, Edward Via College of Osteopathic Medicine - Auburn Campus, Auburn, AL; ³Internal Medicine Residency, East Alabama Medical Center, Opelika, AL. (Control ID #3875426)

CASE: A 38-year-old female with a medical history of migraines presented to the ED with a one-day history of diarrhea that quickly progressed to hematochezia, hematemesis and 10/10 burning abdominal pain that radiated to her back. Four days prior to onset of hematochezia, she states she had a migraine, for which she took sumatriptan along with NSAIDs. Vitals were within normal limits. Physical exam was generally benign, with abdominal exam showing normoactive bowel sound and generalized tenderness to palpation without guarding, rigidity, or rebound tenderness. Labs in the ED were significant for WBC at 14,000/mcL, CRP was elevated at 4.0 mg/dL, and Lactic acid was normal. Repeat labs were significant for a decrease in hemoglobin from 14.0 g/dL to 11.1 g/dL and a decrease in WBC and CRP. Calprotectin level was 365.0 mcg/g. CT scan of abdomen and pelvis with contrast showed diffuse wall thickening in the descending colon and proximal sigmoid with a small amount of free fluid likely related to inflammatory changes in the colon. She was admitted for further treatment and evaluation. EGD showed no abnormalities. Colonoscopy showed erythematous lesions in the mid-sigmoid colon with a segment of ulceration near the splenic flexure that measured approximately 4-5cm. She was diagnosed with ischemic colitis (IC) secondary to chronic sumatriptan use. Raskin protocol was initiated for her migraine with Fioricet instead of dihydroergotamine (DHE) due to the risk of DHE induced IC. She was also started on divalproex sodium. The patient was discharged home and referred to outpatient neurology and gastroenterology for further follow up. IMPACT/DISCUSSION: IC is the result of tissue injury and inflammation of the large intestines due to a reduction in blood flow and is a rare occurrence before the fifth decade of life. Triptan-induced ischemia is traditionally reported with effects in the cardiovascular system and more common in patients with predisposing comorbidities; however, vasoconstriction of other arterial beds resulting in IC is possible particularly when associated with chronic or excessive use, as seen in our patient. A 2014 literature review of the FDA Adverse Event Reporting System identified five published reports with a total of seven patients indicating IC in patients taking sumatriptan over a five-year period.

CONCLUSION: Recognition of uncommon medication side effects is critical in order to commence appropriate therapy and prevention.

This case should prompt patient assessment for potential risk factors and promote thorough counseling on the appropriate use of triptans and concomitant use with other medications.

SUPERIOR VENA CAVA SYNDROME: A NEAR MISS

Raihan El-Naas^1,2

¹Internal medicine, Weill Cornell Medicine, New York, NY; ²Internal medicine, New york-Presbyterian hospital cornell, New York, NY. (Control ID #3849403)

CASE: 30 year old man former smoker w/ no significant PMH p/w a cough for 1 month. A week after the cough began, he also noted some neck and bilateral shoulder swelling along w/ some hoarseness and dysphagia. Denied any fevers, chills, weight loss, CP or SOB at the time. He then had a video visit with his PCP who diagnosed him with a COPD exacerbation 2/2 a likely viral URTI and prescribed a 5-day course of steroids with some benzonatate for the cough. He then started developing dyspnea on exertion prompting him to go to the ED. In the ED, he was tachycardic to 120s but otherwise afebrile, normotensive and satting well on RA. His physical exam was only notable for mild neck, bilateral shoulder & R arm swelling with no erythema or TTP (swelling difficult to note given his overweight body habitus). EKG showed sinus tachycardia and CXR showed a widened mediastinum but otherwise clear lungs.

A CT neck & chest was obtained to further evaluate the neck & bilateral shoulder swelling which revealed the following:

1.A large anterior mediastinal mass measuring 11.4cm compressing the superior vena cava resulting in thrombosis of bilateral internal jugular veins, brachiocephalic veins and R subclavian veins 2. Mild cervical, mediastinal and retroperitoneal lymph nodes 3. Moderate pericardial effusion w/ mild flattening of the R ventricular free wall TTE showed no e/o tamponade. Pericardial drain was placed and 500cc serosanguinous fluid was removed and sent for cytology. Interventional radiology performed a percutaneous CT guided core needle biopsy of the mass. Pathology and cytology were both consistent with diffuse large B cell lymphoma. Pt was transferred to the lymphoma service and started on DA-EPOCH-R chemo regimen as well as apixaban for the diffuse venous thrombosis.

IMPACT/DISCUSSION: Meticulous history taking and a careful physical exam are paramount! On admission, the patient complained mostly of the cough and SOB and those were the symptoms that he mentioned on the video visit with his PCP making him anchor on the COPD diagnosis given his former smoking history. Upon further questioning in the hospital, the patient slowly began to disclose other symptoms including the neck/shoulder/arm swelling (concerning for disruption of venous return possibly from compression of SVC) and dysphagia & hoarseness of voice (concerning for compression of mediastinal structures such as esophagus and larynx/recurrent laryngeal nerve). On exam, the neck, bilateral shoulder and R arm edema were also notable though subtle given his overweight body habitus. Given the alarming history and exam findings, a CT neck and chest was performed which established the diagnosis of SVC syndrome.

CONCLUSION: 1. Eliciting a comprehensive Review of Systems is critical especially when the chief complaint is non-specific

2. Performing a thorough physical exam and paying close attention to salient features can be key in diagnosis

SUPPLEMENTING THE DIFFERENTIAL: A CASE OF DRUG-INDUCED AND AUTOIMMUNE LIVER INJURY

Hannah Archibald

Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #3876805)

CASE: A 55 year old woman with diet-controlled hyperlipidemia presented via video visit with pruritus and fatigue for two weeks, preceded by a subjective fever. She had not noticed a rash and tried topical steroid cream without improvement. She took no prescribed medication and had been taking Herbalife vitamin supplements or 10 months prior to presentation. She did not drink alcohol or use recreational drugs. Her PCP checked CBC, BMP, and LFTs. These revealed AST 1,074, ALT 887, alkaline phosphatase 213 and total bilirubin 1.2. Her BMP, CBC, and INR were normal. An in-person exam revealed normal vital signs, normal mental status and no bruising, bleeding, or rash. Serologies showed hepatitis A Ab IgM negative, immunity to hepatitis B with hepatitis B DNA <10 international units/mL, Hepatitis C Ab negative, and negative EBV and CMV serologies. Further workup revealed normal ceruloplasmin, ANA titer 1:320, elevated smooth muscle antibodies (ASMA), and IgG 1980 (elevated). Ultrasound of the abdomen showed normal-appearing liver with patent vasculature. The patient stopped taking the supplements and subsequently her liver enzymes normalized and her symptoms resolved. During the next year she had one episode of modestly elevated liver enzymes (AST and ALT in the 100s) that resolved spontaneously.

The patient was diagnosed with drug-induced liver injury caused by supplements. The recurrent enzyme elevation along with positive ASMA and ANA are also suggestive of autoimmune hepatitis, potentially triggered by drug-induced injury.

IMPACT/DISCUSSION: The differential diagnosis for liver enzyme elevation >1000 includes drug-induced liver injury (acetaminophen as a common culprit), acute viral hepatitis, and ischemic liver damage most commonly; other considerations include Wilson’s disease, autoimmune hepatitis, and Budd-Chiari syndrome. Initial workup should include viral hepatitis serologies, acetaminophen level, toxicology screen, autoimmune markers, and abdominal ultrasound. Patients should also be evaluated for signs of acute liver failure.

In this case, the patient was taking a supplement that has been associated with liver injury. The NIH LiverTox website is a helpful repository of substances known to cause liver injury, and this patient’s supplement had more than 50 reports. A complicating factor in this case is the patient’s subsequent fluctuating liver enzyme elevation and positive ASMA, ANA, and elevated IgG, which are suggestive of autoimmune hepatitis. One hypothesis is that she had drug-induced liver injury from the supplements that then triggered the development of autoimmune hepatitis, a phenomenon that has been seen with other drugs. Liver biopsy could provide a definitive diagnosis.

CONCLUSION: - Consider systemic etiologies such a liver and kidney dysfunction in a differential for pruritus.

- Clinicians should thoroughly review medications patients are taking, including over-the-counter medications and supplements, and consider these as potential causes of liver injury.

SUSPECTING TUMOR LYSIS WHEN YOU SEE NUMEROUS SMALL CELLS

Toru Yoshino¹; Sae X. Morita²; Hirotaka Kato³

¹Internal Medicine, US Naval Hospital Okinawa, Okinawa, Japan; ²Department of Medicine, SBH Health System, Bronx, NY; ³Internal Medicine, University of Kentucky College of Medicine, Lexington, KY. (Control ID #3875627)

CASE: A 70-year-old woman with a history of chronic obstructive lung disease and left small cell lung cancer (SCLC) presented with four days of right upper quadrant pain and vomiting. A left lower lobe mass was incidentally detected on CT 3 months prior, and the limited-stage SCLC was diagnosed by the biopsy and PET-CT 2 weeks prior. The associated symptoms were fatigue and weight loss. Upon arrival, her vitals were notable for tachycardia (113 beats per minute). Her physical exam revealed tenderness associated with hepatomegaly. The further workup confirmed new hepatomegaly with innumerable masses on the CT and MR of the abdomen as well as serum creatinine of 2.18 mg/dL (baseline 1.4), aspartate aminotransferase 323 U/L, alanine aminotransferase 99 U/L, alkaline phosphatase 642 U/L, and total bilirubin 2.4 mg/dL. After the admission, serum creatinine initially responded to intravenous fluids (1.98 mg/dL on day 2), however, it started rising to 2.69 mg/dL by day 4. Given the rapid progression with innumerable liver lesions, tumor lysis syndrome (TLS) was suspected and confirmed by elevated lactate dehydrogenase (1502U/L) and hyperuricemia (21.4 mg/dL). Intravenous rasburicase and oral allopurinol were initiated. A liver biopsy showed a high-grade neuroendocrine tumor which confirmed extensive-stage SCLC. Renally dosed carboplatin and etoposide were started on day 5. Serum creatinine improved to the normal range after the first cycle. The patient was discharged on day 32 after two cycles of chemotherapy. Atezolizumab was subsequently started following the fourth cycle.

IMPACT/DISCUSSION: TLS is a life-threatening emergency with high mortality and morbidity rates. Cell lysis releases intracellular contents, such as DNA (uric acid), phosphates, and potassium, leading to acute kidney injury, seizure, fetal arrhythmia, and death. While it most frequently occurs in patients with aggressive hematologic malignancies such as acute myeloid leukemia, pre-treatment (spontaneous) TLS in solid tumors is extremely rare. Handful cases have been reported, including SCLC, breast cancer, germ cell tumor, and malignant melanoma.

A high mortality rate was reported among spontaneous TLS cases with SCLC as only 2 out of 8 patients survived per a review in 2020. Their commonalities were high tumor burdens from metastatic lesions (e.g., liver, bone) and renal failure. Even though only a few cases in treatment-naïve SCLC develop spontaneous TLS, it is critical to keep a high index of suspicion for early diagnosis. In our case, innumerable liver metastases in about 3 weeks raised concern for TLS once serum creatinine started rising despite intravenous fluids. Even with ongoing tumor lysis and renal failure, urgent chemotherapy should be considered to achieve renal recovery and survival.

CONCLUSION: This case highlights the importance of recognizing TLS in aggressive solid tumors with high tumor burdens before cancer treatment. Prompt treatment can contribute to clinical improvement.

SUSTAINED VENTRICULAR TACHYCARDIA PRESENTING AS GASTROINTESTINAL (GI) SYMPTOMS

Ijeoma C. Orabueze^1,2; Ovie Okorare²; Olushola Ogunleye²; Sanjaya Jha²

¹Medicine, Debreceni Egyetem, Debrecen, Hajdú-Bihar, Hungary; ²Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #3875001)

CASE: Patient is a 53-year-old male with a medical history of hypertension, hyperlipidemia, ischemic cardiomyopathy with ejection fraction < 20%, and coronary artery disease (status post myocardial infarction requiring percutaneous coronary intervention with left anterior descending stent placed 10 years earlier, then lost to follow up). He presented with a 2-day history of shortness of breath, nausea, vomiting and diarrhea. On presentation, he was hypotensive (82/69 mmHg), tachycardic (211 bpm), tachypneic (30 breaths/min) with electrocardiogram findings of monomorphic ventricular tachycardia with heart rate in the 200s. He underwent emergent electrical cardioversion with conversion back to sinus rhythm and maintained in sinus rhythm with intravenous amiodarone. Transthoracic echocardiogram revealed a large thrombus in the apex of the left ventricle. Left cardiac catheterization revealed a discrete 100% proximal lesion in the LAD with collateral flow from proximal LAD to distal LAD; so, no stents were placed. Prior to discharge, he underwent implantable cardioverter defibrillator (ICD) placement and was commenced on warfarin.

IMPACT/DISCUSSION: Coronary artery disease (CAD) with a history of myocardial infarction (MI) is the most common underlying heart disease associated with development of sustained monomorphic ventricular tachycardia (SMVT) and ventricular fibrillation (VF). Like in our patient, the most common underlying mechanism is generation of a reentry circuit within the scar tissue formed at the site of prior MI. Sustained monomorphic VT is the most common arrhythmic cause of out of hospital cardiac arrest. Due to the lethality of the condition, brief immediate assessment of symptoms, vital signs, and level of consciousness is essential. Hence, the objective of this case report is to educate on rare ways monomorphic VT can present and facilitate quick patient assessment and cardioversion as indicated. During episodes of VT, common symptoms include palpitations, chest tightness, chest pain, dyspnea, dizziness, syncope. Moreover, GI symptoms like nausea and vomiting could be indicative of a VT, even in the absence of electrolyte derangements like in our patient, adding to the quality of history taking. However, to our knowledge, there are no previous reports in adults describing an association between VT and GI symptoms except when related to electrolyte derangement. In the setting of hemodynamic instability, our patient received emergent cardioversion and an ICD was subsequently placed to reduce the risk of sudden cardiac death, treat any recurring VTs and reduce the overall mortality risk.

CONCLUSION: Sustained ventricular tachycardia remains an important cause of sudden cardiac deaths. Rare symptomatology can include nausea, vomiting and diarrhea. Depending on the hemodynamic status, therapy ranges from pharmacologic to electrical cardioversion, while interventions such as ICD placement have been shown to reduce mortality.

TAKE MY BREATH AWAY: NASAL CONGESTION AS THE PRIMARY SYMPTOM OF EGPA Jacob Khoury¹; Celeste M. Newby²

¹Internal Medicine, Tulane University School of Medicine, New Orleans, LA; ²John W Deming School of Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #3873478)

CASE: A 56-year-old woman presented with two weeks of worsening shortness of breath and intractable cough. The patient reported increasing nasal congestion over the same time period, leading to difficulty breathing through her nose. The patient’s past medical history was notable for adult-onset asthma, and chronic kidney disease stage 3b. The patient’s asthma symptoms had been worsening, and the diagnostic workup during several recent admissions was unrevealing. Head and neck exam revealed swollen nasal turbinates bilaterally. Pulmonary exam was positive for diffuse inspiratory wheezes. Labs on admission revealed normal white blood cell count but elevated absolute eosinophil count to 0.70 x 10³ cells/μL (normal 0.00-0.60 x 10³ cells/μL). CT chest revealed interval development of multiple nodules within the left lung, patchy ground glass opacities, and bilateral hilar lymphadenopathy. Throughout the admission, eosinophils continued to rise, peaking at 2.70 x 10³ cells/μL. ANCA IgG titer was sent and ultimately was positive at 1:320 with cytoplasmic (c-ANCA) staining pattern observed. The patient was started on oral steroids with significant improvement in symptoms and eosinophil count became undetectable by discharge.

IMPACT/DISCUSSION: Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare autoimmune systemic vasculitis. The typical clinical presentation can be characterized as a prodrome, beginning with asthma and rhino-sinusitis, followed by peripheral eosinophilia, and culminating in generalized small to medium vessel vasculitis.

Clinically, EGPA has a strong association with asthma; however, unlike patients with asthma, patients with EGPA often develop pulmonary nodules and infiltrates, as well as associated rhino-sinusitis.

Classically, EGPA is associated with ANCA positivity, particularly anti-MPO antibodies. However, ANCA positivity can range greatly from 30-70%, and often can be negative in patients with the appropriate clinical picture. ANCA positivity is reported less frequently for EGPA than other autoimmune vasculitides, and ANCA negativity does not rule out the diagnosis of EGPA. Ultimately, biopsy showing eosinophilic vasculitis and granulomas is the gold standard for diagnosis. A biopsy can be difficult to obtain as vasculitis is often the last phase of the disease.

CONCLUSION: EGPA is a disease that can be difficult to diagnose due to a prolonged prodrome and antibody variability; therefore, an accurate diagnosis can be quite challenging and requires high clinical suspicion. The constellation of asthma, eosinophilia, pulmonary infiltrates, and sinus disease is highly suggestive of EGPA and should prompt further workup.

THE "OTHER" SALMONELLA INFECTION

Connor Murakami²; Anjul Moon¹; Kuo-Chiang Lian^1,2

¹The Queen's Health Systems, Honolulu, HI; ²University of Hawai'i at Manoa John A Burns School of Medicine, Honolulu, HI. (Control ID #3874462)

CASE: A 22-year-old male presented to the ED with a prolonged fever for two weeks while at sea with body aches, arthralgia, nausea, vomiting, and diarrhea. The patient was originally from India and was working on a ship traveling from Panama to Japan. Before boarding the ship, he stayed in Panama for a few days.

However, a week later, he developed a fever, with a maximum temperature of 40°C, chills, myalgias, arthralgias, vomiting, and diarrhea. The fever was intermittent throughout the day with no apparent pattern. Neither his family nor crewmates reported illness. On the ship, he was treated with Augmentin, Metronidazole, Mebendazole, Azithromycin, and Coartem without improvement.

On presentation, he was afebrile, but soon developed a fever of 38.3°C and tachycardia. The physical exam was significant for hepatomegaly. Labs showed elevated AST of 352 U/L, ALT of 321 U/L, elevated procalcitonin at 1.05 μg/mL, low platelets at 138x10⁹/L, but normal WBC. Abdominal CT confirmed hepatosplenomegaly with nonspecific mesenteric adenopathy. Ceftriaxone and Ondansetron were initiated and Infectious Diseases consultation was obtained.

A few days later, blood cultures returned positive for Salmonella resistant to Ciprofloxacin and Amoxicillin, susceptible to Ceftriaxone and Bactrim, confirming the diagnosis of Salmonella typhi bacteremia: typhoid fever. The patient improved significantly with treatment and was discharged on a 10-day course of Cefdinir.

IMPACT/DISCUSSION: Merely a century ago, typhoid fever was a virulent disease in the U.S., due to poor sewage disposal combined with S. typhi’s fecal-oral transmission. Although uncommon in the U.S. today, typhoid fever continues to be an important cause of morbidity and mortality in developing countries, such as those in Asia, Central and South America, and Africa. Its rarity in the U.S. makes it a challenging diagnosis.

This case illustrates the importance of obtaining a comprehensive history, including recent travel and contact, when dealing with infections. Typhoid fever must always be considered in patients with a fever of unknown origin and recent travel to an endemic region due to S. typhi’s fairly long incubation period of 7-14 days and nonspecific symptoms of GI disturbance and headache. Its pathognomonic features occur over 3 weeks, starting with a pulse-temperature dissociation, then rose spots on the chest and trunk, and finally hepatosplenomegaly and intestinal perforation.

The patient exhibited only a few symptoms upon presentation: diarrhea and hepatosplenomegaly. Thus, the diagnosis was influenced more by his travel history to a region where S. typhi was endemic. Recognition of these details is vital to the timely treatment and prevention of chronic carriers.

CONCLUSION: ● Travel history to endemic regions is a key detail when considering a typhoid fever diagnosis

● Symptoms include fever with pulse-temperature dissociation, rose spots, and GI ulceration

● Patients may become chronic carriers when the gallbladder is colonized

THE ABSENCE OF CHEST PAIN IS NOT THE ABSENCE OF ACUTE CORONARY SYNDROME Oluwatomi O. Adeoti, Brittany M. Hansen

Internal Medicine, Boston Medical Center, Boston, MA. (Control ID #3876899)

CASE: A 65-year-old woman with a history of hypertension, type 2 diabetes, and obesity presented to the emergency department with shortness of breath (SOB) of one-week duration. She denied fever, chest pain, nausea/vomiting, palpitations, calf pain, and recent travel history. The patient reported she had a similar episode in the past. She denied history of heart failure, acute coronary syndrome (ACS), diagnosed chronic obstructive pulmonary disease (COPD). She was found to be afebrile, tachycardic, with normal blood pressure, respiratory rate, oxygen saturation on room air. Her physical examination was significant for increased work of breath, decreased breath sounds without crackles or wheezes in all lung zones, and no peripheral edema. The initial impression was COPD exacerbation, she received stacked albuterol/ipratropium nebules. Her labs were notable for mild anemia, normal white cell count, creatinine of 1.3, A1c 5.7%. Initial troponin (trop) was high at 1.194. EKG showed sinus tachycardia, T-wave inversions (TWI) in leads I/aVL. Chest x-ray showed mild pulmonary edema, CT pulmonary angiogram showed no pulmonary embolism. Given EKG findings, elevated trop, her persistent SOB and absence of chest pain, Type 2 NSTEMI due to demand ischemia was suspected. Repeat EKG showed TWI in leads I/aVL, new ST segment elevations in leads V1-V3, interval trop increased to 1.748. She underwent cardiac catheterization, was found to have multivessel coronary artery disease, 4 drug-eluting stents were placed.

IMPACT/DISCUSSION: Chest pain (CP) is a classic presentation of ACS that is well-established and emphasized at all levels of clinical training. The likelihood of missed or delayed diagnosis of ACS is high in patients without this classic symptom. Atypical symptoms of ACS include dyspnea, weakness/malaise, nausea/vomiting, epigastric pain/discomfort, and palpitations. These occur more often in the elderly (>75 years), women, and patients with diabetes (possibly due to diabetic neuropathy). Data from the National Registry of Myocardial Infarction (MI) II showed that up to one-third of patients with confirmed acute MI had no chest pain at presentation. Accurate diagnosis of acute MI occurred in 22 versus 50% of patients without and with CP respectively. Inappropriate/delayed management and in-hospital mortality increased in patients without CP. This female patient with a history of diabetes who presented with SOB without CP had a high pre-test probability of having acute MI. Given low suspicion, initiation of treatment for acute MI was delayed because she continued to deny chest pain throughout the encounter. Providers should consider MI as a high differential in the absence of CP in patients with the highlighted risk factors.

CONCLUSION: Atypical presentation of ACS is common in the elderly, women, and patients with diabetes. Providers should have a high index of suspicion for ACS in these patients at initial presentation, especially in the absence of prior known significant cardiac morbidity.

THE CONFABULATION CONUNDRUM: A CASE REPORT AND REVIEW OF VARIED THERAPEUTIC RESPONSE TO ATYPICAL WERNICKE'S-KORSAKOFF SYNDROME Udit Asija, Mashu Shrivastava, Ali Shah

Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA. (Control ID #3871857)

CASE: A 23-year-old female with medical termination of pregnancy(MTP) 2 months ago due to hyperemesis gravidarum presented with worsening balance issues, confusion, and memory deficits worsening for 3 weeks with 45 lbs weight loss. The patient gradually regained her appetite over the past month after MTP. Vitals were remarkable for sinus tachycardia. The examination was significant for disorientation to time and place, subdued mood, avoidant affect, tangential thought process, memory deficits for recent events, confabulations with childhood memories, horizontal nystagmus, positive hypometric finger-to-nose test, and ataxic gait. Muscle strength was preserved. Laboratory investigations revealed electrolytes, metabolic panel, TSH, Vitamin B12, and CBC in normal range with negative urine drug screen, pregnancy test, and blood alcohol concentration. MRI Brain showed medial bilateral thalamic and mammillary body T2/FLAIR hyperintensity. Intense parenteral thiamine(B1) therapy for 1 week followed by daily oral thiamine led to the resolution of nystagmus first and then memory deficits but ataxia remains even on 6-month follow-up outpatient.

IMPACT/DISCUSSION: Wernicke's-Korsakoff Syndrome(WKS) is a rare neurological sequela of severe B1 deficiency and is almost always correlated with chronic alcohol use. Non-alcohol use etiologies including hyperemesis gravidarum, starvation, anorexia nervosa, systemic malignancies, post-bariatric surgery, dialysis patients, and post-transplant patients are under-recognized, misdiagnosed, and undertreated with prevalence varying from 0.04% to 0.13%. It is a clinical diagnosis with a triad of Nystagmus, Ataxia, and memory deficits (all 3 present in less than 33% of patients) along with confabulations in later stages. MRI is sensitive and specific for diagnosis. Memory impairment correlates better with anterior thalamic lesions rather than mammillary bodies. Nonetheless, mamillary body atrophy is a relatively specific sign of WKS. Administration of glucose before B1 can precipitate/worsen WKS. Treatment is often empirical and consists of parenteral B1 repletion with 500 mg of IV B1 infused three times daily for 2-7 days followed by 250 mg IV or IM once daily for an additional 5-7 days but can be continued further until improvement plateaus. Abnormal T2 signal on MRI usually resolves within as little as 48 hrs after treatment with B1. Improvement of nystagmus occurs within hours to days. Recovery in gait ataxia usually starts during the second week of treatment. Confusion subsides over days and weeks, that's when memory deficits become more apparent. Residual deficits are the rule. While gaze palsies recovered completely in most cases, remaining mobility deficits range from the inability to walk to a wide-based, slow, shuffling gait.

CONCLUSION: A high degree of clinical suspicion of WKS is essential with a low threshold to administer high-dose empirical parenteral thiamine in the inpatient setting and oral thiamine supplementation in an outpatient setting.

THE CURIOUS CASE OF IMATINIB TOXICITY

Daniela Arango Isaza, Daniele Olveczky

Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #3874467)

CASE: A 40-year-old female with a past medical history of chronic myeloid leukemia on imatinib, Roux- en-Y gastric bypass, appendectomy, and cholecystectomy presented to the emergency department with abdominal pain and bright red blood per rectum. She reported significant diarrhea since starting imatinib that progressed to severe abdominal pain which worsened with eating. Of note, the patient had held her imatinib a couple of weeks earlier due to covid 19 infection and the interaction of this medication with Nirmatrelvir/Ritonavir. At that time, her gastrointestinal symptoms completely resolved, but once Imatinib was restarted, she noticed that her diarrhea and abdominal pain returned. She presented to an outside emergency room prior to the presentation. A CT scan demonstrated mesenteric panniculitis. She was discharged on methylprednisolone with partial resolution of her symptoms.

On admission labs, her hemoglobin was normal at 13 g/dl but then dropped to 11 g/d. She had a normal lipase and liver function tests, with an elevated CRP of 13.5, calprotectin of 661, negative stool cultures, clostridium difficile, and Anti-Tissue Transglutaminase Antibody. Other diagnostic studies included an unremarkable endoscopy, colonoscopy, and abdominal CT scan. After discussions with the outpatient oncology team, Imatinib was held and the patient's symptoms slowly resolved on a steroid taper.

IMPACT/DISCUSSION: While tyrosine kinase inhibitors are typically well tolerated in patients with chronic myeloid leukemia, they have numerous toxicities typically overlooked in inpatient settings. For example, Imatinib-induced gastrointestinal toxicities are seen in up to 50% of patients and usually occur within the first 2 years of therapy initiation. Prompt recognition and treatment are necessary for adequate symptom resolution and planning alternative cancer-targeted therapies. Common symptoms include nausea, vomiting, and diarrhea but gastrointestinal bleeding can happen in up to 3.5%. In patients with a history of major gastrointestinal surgeries, such as the patient above, levels must be drawn often and dosing is reduced due to a higher risk of toxicity. Optimal patient care consists of a multidisciplinary team including hospital medicine, gastrointestinal medicine, and oncology as well as prompt initiation of steroids and stopping imatinib.

CONCLUSION: This case highlights the importance of imatinib gastrointestinal toxicity such as bleeding and abdominal pain, especially in patient populations with significant gastrointestinal surgery.

THE DIAGNOSIS AND TREATMENT OF TONSILLAR KAPOSI’S SARCOMA IN A YOUNG ADULT WITH HIV.

Jacob T. Howshar¹; Stefania del Rosario²

¹University of Arizona College of Medicine - Phoenix, Phoenix, AZ; ²Creighton University School of Medicine, Omaha, NE. (Control ID #3873359)

CASE: A 20-year-old homeless male with a past medical history of untreated HIV and polysubstance abuse presented to the emergency department after 4 months of worsening sore throat with associated dysphagia, dysarthria, and difficulty breathing. At presentation his adenoid, palatine, and lingual tonsils were extremely enlarged with cryptic exudate and erythema. Bilateral cervical lymphadenopathy and oral thrush were present. Rapid Strep A PCR test was positive and empiric treatment with ampicillin/sulbactam was begun. He was admitted to medicine and ENT was consulted. He initially responded to treatment, but on hospital day 5, he experienced acute respiratory distress secondary to obstruction from worsening tonsillitis. He was emergently taken to the operating room for awake tracheostomy and tonsillectomy. Diffuse lymphoid hyperplasia involving the entirety of Waldeyer’s ring with areas of tissue necrosis was noted. The palatine tonsils were debulked and pathology demonstrated Kaposi’s sarcoma. Treatment with complete surgical resection was not recommended because of the extent of disease, so in collaboration with infectious disease and oncology specialists, plans for outpatient chemotherapy and highly active antiretroviral therapy (HAART) were established.

IMPACT/DISCUSSION: Kaposi’s sarcoma is a malignant endothelial tumor caused by human herpesvirus 8 infection in the setting of immunosuppression. It is the most common cancer in patients with untreated HIV and is considered an AIDS-defining illness. It most commonly presents as multifocal cutaneous macules or nodules that are violaceous or brown in color, with a predilection for the lower extremities. However, oral involvement may also be seen, most commonly affecting the hard palate, gingiva, and tongue. Early oral lesions are usually asymptomatic, but later-stage lesions can be excruciatingly painful, ulcerate, or cause functional impairments in speech and swallowing. The diagnosis is confirmed with tissue biopsy. Localized lesions can be surgically excised. In HIV-positive patients, the mainstay of treatment is HAART, which both reduces the incidence of Kaposi’s sarcoma and treats existing lesions. If the disease is widespread, rapidly progressive, or involves visceral organs, systemic chemotherapy is added. Kaposi’s sarcoma of the tonsils is extremely rare with only a handful of cases reported in the literature. This is the first reported case of tonsillar Kaposi’s sarcoma involving the entirety of Waldeyer’s ring and thus unable to be treated with complete surgical resection.

CONCLUSION: In immunocompromised patients presenting with signs and symptoms of oropharyngeal infection, Kaposi’s sarcoma is a rare, but important, component of the differential diagnoses. In HIV-positive patients with visceral involvement, the best treatment is a combination of HAART, chemotherapy, and surgical excision when possible. Collaboration between internal medicine, ENT, oncology, and infectious disease physicians is essential in its management.

THE EVOLUTION OF SEROTONIN SYNDROME

Cristina Fischer¹; Moksha Patel²

¹Internal Medicine, University of Colorado, Denver, CO; ²Internal Medicine, University of Colorado, Denver, CO. (Control ID #3874532)

CASE: Serotonin syndrome is a life-threatening condition caused by serotonergic drugs. Considered a rare diagnosis, though the true incidence is unknown as the diagnosis is challenging to make. The most widely used diagnostic criteria is the Hunter Criteria, which requires an exposure to a serotonergic drug and one or more of the following: spontaneous clonus, inducible clonus with agitation and diaphoresis, tremor and hyperreflexia, hypertonia, or temperature over 38C with ocular or inducible clonus¹. We present a case of a 66-year-old female who presented with acute encephalopathy who ultimately was diagnosed and treated for Serotonin Syndrome.

A 66-year-old female presented with acute encephalopathy from a living facility. Initial physical exam revealed normal vitals, oriented to self, drowsy but arousable, intermittently responding, and moving all extremities. Overnight evaluation was notable for sodium 147, potassium 2.9, creatinine 2.31, calcium 11.8, TSH 0.06, and T4 1.45. Chest x-ray with atelectasis. Her confusion was initially attributed to hypercalcemia and fluids were started. Exam the following morning was unchanged besides new akathisia. An hour later she was found to be diaphoretic, rigid, tremulous, and with clonus. Serotonin Syndrome was diagnosed given her presentation and exposure to serotonergic medications. Diazepam administration resulted in rapid resolution of her symptoms. Review of records revealed she had prescriptions for fluoxetine, duloxetine, mirtazapine, as well as baclofen and gabapentin. In the setting of her kidney injury, it is likely she had higher concentrations of these serotonergic medications in her system during her presentation.

IMPACT/DISCUSSION: Several important learning points regarding bias and diagnosing rare syndromes are emphasized in this case. On admission, it was believed that hypercalcemia was the etiology for her confusion. However, mild hypercalcemia often causes constipation, fatigue, and depression. It isn’t until calcium is >14, where symptoms of lethargy, confusion, stupor, and coma arise. This patient’s calcium of 11.8 wouldn’t have caused her profound confusion. Due to anchoring bias and premature closure, additional evaluation for encephalopathy was not performed and her serotonergic medications were continued overnight.

Additionally, this case highlights the spectrum of symptoms displayed within serotonin syndrome, symptoms that are not completely encompassed within the Hunter Criteria. It wasn’t until the final evaluation when she met Hunter Criteria with hypertonia, clonus, agitation, and diaphoresis. Prior to this, she experienced other important symptoms including confusion, restlessness, and akathisia.² It is important to note that she never developed hyperthermia, but this often presents late.³

CONCLUSION: In conclusion, this case exemplifies the importance of avoiding anchoring bias and premature closure and highlights the dynamic presentation of serotonin syndrome.

THE FIRST CASE OF GROUP B STREPTOCOCCAL MENINGITIS IN A YOUNG ADULT WITH MENINGOCELE

Azeem Arastu¹; Pratiksha Moliya¹; Farshad Bagheri²

¹Internal Medicine, Jamaica Hospital Medical Center, Jamaica, NY; ²Medicine, Jamaica Hospital Medical Center, Jamaica, NY. (Control ID #3874083)

CASE: A 30-year-old male presented with headaches and otalgia for 3 weeks and altered mental status for 2 days. He had normal development and no significant family history. Upon arrival, he was febrile, oriented only to himself, and had neck stiffness. He was immediately started with IV dexamethasone, ceftriaxone, vancomycin, acyclovir, and ampicillin for suspected meningitis. CT scan of the head showed a congenital transsphenoidal meningocele projecting into the nasopharynx. Lumbar puncture revealed cloudy CSF with findings consistent with bacterial meningitis (CSF WBC: 17721/mm 3, 99% neutrophils, glucose: 20 mg/dL, protein: >900 mg/dL). Blood cultures grew Group B Streptococcus (GBS) and the antibiotics were de- escalated to IV penicillin G. The CSF cultures were negative, likely because the first dose of antibiotics was given 2 hours before the lumbar puncture. No acute intervention was recommended by the neurology team for the meningocele. However, he was placed on oral levetiracetam for seizure prophylaxis. His mental status improved and he was later discharged on a 21-day course of IV Penicillin G. At the follow-up after one month, he was in his usual state of health and did not suffer any neurologic sequelae.

IMPACT/DISCUSSION: Group B Streptococcus (GBS) is one of the leading causes of bacterial meningitis in neonates but is extremely rare in adults. GBS meningitis in adults occurs primarily in those with traditional risk factors such as older age, diabetes mellitus, obesity, liver disease, malignancy, an immunocompromised state, or endocarditis. This patient had none of these conditions. The congenital meningocele likely led to a CSF leak which served as a source of GBS infection via the nasopharynx. Patients with altered mental status, focal neurologic deficits, new onset seizures, immunocompromised state, a history of central nervous system (CNS) disease, or papilledema require a head CT before lumbar puncture (LP) to rule out space-occupying lesions. Since the CT scan can delay treatment, such patients must first receive empiric antibiotics and adjuvant dexamethasone even though this might reduce the yield of CSF cultures.

CONCLUSION: To our knowledge, no case of GBS meningitis has been described in a patient with meningocele. Although rare, GBS meningitis has a higher case fatality rate and higher mortality. This case highlights the importance of early and appropriate treatment in any patient with meningitis. The timely initiation of appropriate antibiotics, CT scan, and lumbar puncture can be life-saving and prevent long-term neurologic sequelae.

THE GREAT IMITATOR

Jonathan Blackmon¹; Shannon Hart²

¹Internal Medicine Residency, East Alabama Medical Center, Opelika, AL; ²Edward Via College of Osteopathic Medicine - Auburn Campus, Auburn, AL. (Control ID #3873041)

CASE: A 71-year-old female, with a history of hypertension, presented with a history of genital sores 3 years prior, several months of worsening rash, nausea, ataxia, and vision complaints. Her sister, who sees her daily, substantiated several months of changes in her memory and noted that the patient has difficulty recognizing familiar objects and forgetfulness. The patient explains that 3 months prior to current presentation, she developed a generalized rash sparing the palms, which later became pruritic and eventually progressed to the palms, prompting evaluation by a dermatologist. She reports being prescribed hydrocortisone cream, which provided relief. She admits to falling without head injury along with noticeable gait changes. Physical exam included being aox3, no oral or genital ulcers, generalized light remnant of previous rash, cranial nerve 2-12 intact bilaterally, patellar and biceps reflexes 2/4 bilaterally. MRI of the brain demonstrated hippocampal atrophy with an MTA score of 3 and prominent microvascular changes of the white matter. She was then assessed by ophthalmology with findings suspicious for ocular syphilis. Infectious disease was consulted and CSF VDRL was reactive 1:2. CSF HSV 1 and 2 DNA were not detected and culture of CSF was negative. CSF protein was elevated at 55 mg/dL with CSF glucose of 50 mg/dL and WBC 4/mcL.

IMPACT/DISCUSSION: For proper diagnosis, it is important to note serum nontreponemal tests (VDRL and RPR) may be nonreactive in late neurosyphilis while the treponemal tests (FTA-ABS) remain reactive making it essential to order if suspicion for late neurosyphilis. The CSF VDRL is specific but not sensitive for diagnosis of neurosyphilis while FTA-ABS is sensitive but not specific.. If neurologic, otologic,or ocular symptoms are present, lumbar puncture with CSF evaluation is recommended as was completed in this

patient. The mainstay of treatment for neurosyphilis is IV penicillin for 10-14 days. Our patient received the preferred regimen, IV penicillin G 4 million units every 4 hours and was able to complete her 10-14 day course with IV antibiotics at home. For patients with a mild penicillin allergy, ceftriaxone 2 g IV qd for 10-14 days can be completed with close observation. A third line alternative if penicillin or ceftriaxone cannot be used is doxycycline PO 200 mg BID for 21 to 28 days. To be sure retreatment is not needed, treatments are to be monitored with lumbar puncture three to six months after treatment and every six months until the CSF WBC count is normal and VDRL nonreactive.

CONCLUSION: Clinical manifestations of neurosypilis fall into the categories of early (asymptomatic, symptomatic meningitis, ocular, otosyphilis, meningovascular) and late (general paresis, tabes dorsalis).

Diagnostic workup includes laboratory confirmation of syphilis infection as well as lumbar puncture which may be indicated in certain situations including the presence of opthalmic findings.

First line treatment consists of IV penicillin for 10-14 days.

THE HEART OF THE MATTER: CARDIOVASCULAR MANIFESTATIONS OF CUSHING’S SYNDROME

Kathryn M. Welp, Yash Pershad, Sarah E. Myers, Michael E. May, Todd Hulgan. Medicine, Vanderbilt

University Medical Center, Nashville, TN. (Control ID #3877019)

CASE: A 61-year-old female with recently diagnosed diabetes presented with acute onset intermittent exertional chest pain and dyspnea. One week prior, she had dysuria, polyuria, and blurred vision. After initial workup revealed a serum glucose of 570mg/dL, metformin was started. Her symptoms persisted along with substernal chest pain, dyspnea on exertion, and lower extremity edema. On admission, the patient was hypertensive and labs were notable for hypokalemia (2.7mmol/L), hyperglycemia (498mg/dL), acute kidney injury (1.2mg/dL), and elevated troponin (0.05ng/mL). ECG demonstrated sinus rhythm with down-sloping ST depressions and T-wave inversions in the inferolateral leads and ST elevations in aVR. Transthoracic echocardiogram showed a hyperdynamic ejection fraction (70%), asymmetric septal hypertrophy, and dynamic left ventricular outflow tract gradient (12mmHg at rest, 33mmHg with Valsalva). Abdominal MRI showed bilateral adrenal hyperplasia. Further work-up demonstrated elevated serum cortisol (78mcg/dL) after 2mg dexamethasone suppression test, elevated 24-hour urine cortisol (12,000 mcg/day), and elevated serum ACTH (517 pg/mL). Pituitary MRI demonstrated a 7x7mm mass. She was ultimately discharged on aggressive insulin therapy and potassium repletion until transsphenoidal resection.

IMPACT/DISCUSSION: This case demonstrates the cardiac complications of Cushing’s syndrome (CS). Approximately 10% of patients with CS develop cardiomyopathies: 80% are dilated and 20% are hypertrophic. The determinants of hypertrophic versus dilated phenotypes are not fully understood. Elevated cortisol can cause myocardial hypertrophy via arterial hypertension, beta-adrenergic receptor expression, and enhanced responsiveness to angiotensin-II. Glucocorticoids also can cause myocardial fibrosis and dilation via expression of atrogin-1. Both phenotypes of cardiomyopathy have a favorable prognosis, as they are reversible after treatment. This patient presented with chest pain and dyspnea, but was ultimately diagnosed with CS complicated by hypertrophic cardiomyopathy. This case demonstrates the importance of considering a broad differential diagnosis, recent clinical diagnoses, and symptoms outside of the primary organ system of the chief concern.

CONCLUSION: 1. Diagnosing CS is challenging given its non-specific symptoms; however, multiple symptoms with severe electrolyte derangements increases the pretest probability.

2. Patients with CS have increased risk of cardiovascular complications including cardiomyopathy, myocardial infarction, stroke, thromboembolism, hypertension, dyslipidemia, and subclinical atherosclerosis.

THE HIGHS AND LOWS OF HYPEREOSINOPHILIC SYNDROMES AND THE USE OF DIAGNOSTIC FRAMEWORKS

Pearl Ugwu-Dike^1,2; Daniele Olveczky^1,2

¹Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Harvard Medical School, Boston, MA. (Control ID #3877212)

CASE: A 79-year-old man with a history of chronic kidney disease, heart failure with preserved ejection fraction, and aortic stenosis presented with several days of dyspnea, cough, and pruritic rash. Vitals were unremarkable. Physical exam was notable for fine rales in all lung fields, erythroderma, bilateral hand edema and no lower extremity edema. Laboratory evaluation demonstrated peripheral eosinophilia to 2.6 x 10⁹/L, thrombocytopenia, acute kidney injury and azotemia. Hematology was consulted, and further workup revealed elevated tryptase, B12, immunoglobulin A and E levels, positive T cell receptor rearrangement studies, and a negative ANCA. Immunophenotyping demonstrated a T cell predominant lymphoid profile expressing an uncommon CD3+/CD4-/CD8- immunophenotype. FISH was negative for rearrangement of PDGFRA, PDGFRB, and FGFR1. Chest CT revealed multifocal ground-glass and nodular opacities and inflammatory bronchiolar nodulation. Locations of the nodules were not amenable to biopsy. Skin biopsy showed no evidence of vasculitis. He was started on steroids with a prolonged taper for lymphocytic hyper- eosinophilia and initiated on mepolizumab in the outpatient setting with sustained remission of symptoms.

IMPACT/DISCUSSION: Hypereosinophilic syndrome (HES) is defined by peripheral eosinophilia (absolute eosinophil count >1.5 x 10⁹/) with organ dysfunction in absence of an alternative etiology¹. HES has several subtypes and may be challenging to distinguish from other eosinophil-associated organ specific disorders. Here we present a phenotypically complex case of HES to highlight the importance of cytogenetics in guiding diagnosis and treatment.

HES most commonly presents with dermatologic, pulmonary, or cutaneous involvement. Clinically relevant variants of HES include myeloproliferative (MHES), T lymphocytic (LHES), and idiopathic HES (IHES)¹. Diagnostic algorithms are critical in determining the subtype--which has implications on prognosis and treatment response. Our patient met 3/4 diagnostic criteria for MHES: elevated tryptase, B12, and thrombocytopenia. However, MHES is associated with the FIP1L1/PDGFRA gene, negative in our patient. He presented with T-cell receptor rearrangement, a rare CD3+/CD4-/CD8 T-cell clonality, and hypergammaglobulinemia, characteristic of LHES. IHES is rare with unknown prevalence. It is a diagnosis of exclusion, when criteria for LHES/MHES are not met. Given our patient’s favorable response to mepolizumab, his T cell clonality and elevated hypergammaglobulinemia, he was thought to have LHES or IHES.

CONCLUSION: Initial assessment of eosinophilic syndromes should aim to identify the etiology of eosinophilia and evaluate for extent of organ involvement. Clinically relevant subtypes of HES include MHES, LHES, and IHES. Cytogenetics and biomarkers can be used to distinguish one variant from another.

1.Roufosse, F., Klion, A. D., & Weller, P. F. Hypereosinophilic syndromes: clinical manifestations, pathophysiology, and diagnosis. UpToDate. Waltham.

THE HYPERKALEMIA RAFFLE

Navjot Rai¹; Aakash R. Goyal¹; Karen Avgush²

¹Internal medicine, Crozer-Chester Medical Center, Upland, PA; ²Internal Medicine, Crozer-Chester Medical Center, Upland, PA. (Control ID #3876691)

CASE: An 83-year-old female with past medical history of hypertension, type 2 diabetes, bilateral lower extremity chronic venous insufficiency, presented with worsening swelling of her lower extremities along with tenderness and warmth. Vital signs were stable. Labs were significant for white cell count of 11,000, potassium 6.5 and creatinine 2.7 (baseline 0.8). No hyperkalemic changes were observed on the EKG. Patient was diagnosed with cellulitis and acute kidney injury(AKI). Appropriate treatment was started with antibiotics and IV fluids. Home medications included losartan, potassium supplements and lasix among many others. Further evaluation revealed an am cortisol level of 5.

ACTH stimulation test was done and cortisol levels at 30 and 60 min were 10 ( rise <7) and 12.90 (<18) respectively. Patient was diagnosed with primary adrenal insufficiency. She was started on hydrocortisone. This along with resolution of her AKI by fluid resuscitation and holding possible culprit medications resulted in her potassium levels normalising at discharge.

IMPACT/DISCUSSION: Hyperkalemia is a relatively common, and sometimes life threatening, electrolyte disorder. Although precise therapeutic algorithms make the treatment an easy bet, it can be quite challenging to identify the exact cause at the same time. A carefully obtained and detailed history is imperative to establish the differential diagnoses of hyperkalemia.

Diagnostic thought for hyperkalemia should be guided towards the three main causes: increased potassium intake, potassium release from cells and impaired renal potassium excretion. It should also be kept in mind that multiple factors could be contributing, like in our patient. Increased intake due to oral potassium supplementation; impaired renal K+ excretion likely due to the acute kidney injury and use of losartan; and primary adrenal insufficiency. Moreover, in patients presenting with infection, due consideration should be given to possible acidosis due to sepsis resulting in hyperkalemia.

CONCLUSION: Hyperkalemia has a myriad of causes. It's essential to evaluate and unveil concealed causes that might be masqueraded by the causes that are apparent. Not doing so can lead to under- diagnosis and may result in jeopardising patient safety.

THE IMPORTANCE OF PROMPT INITIATION OF THERAPY IN SEVERE ULCERATIVE COLITIS

Benjamin Ravichander¹; Lillian Sangha²; Irina Mishagina²

¹Internal Medicine, UPMC, Pittsburgh, PA; ²Internal Medicine, UPMC Central PA, Harrisburg, PA. (Control ID #3875301)

CASE: A 33-year-old male with a history of hepatitis C, heroin abuse, and hypertension presents to the hospital with a three-month history of abdominal pain and hematochezia. He recently received antibiotics for colitis which resulted in mild improvement in symptoms but had a quick relapse. He was discharged back to prison with an outpatient colonoscopy scheduled for the following month. The gastroenterology office attempted to reschedule this to be done earlier but was not able to coordinate this with his prison. Commuted tomography (CT) of the abdomen and pelvis this admission showed mild pancolitis and colonic distension concerning for a potential to develop into toxic megacolon. He met sepsis criteria and had a significant anemia of 7.2 g/dL (baseline 13.5 g/dL). He was treated with high-dose hydrocortisone, vasopressors, and broad-spectrum antibiotics in the intensive care unit. Colonoscopy was deferred at this time due to his colonic distention. ASCA IgG levels were elevated at 25, and IgA was negative. He underwent a flexible sigmoidoscopy six days after presentation which showed multiple crated ulcers from the rectum to the splenic flexure. Biopsies were consistent with ulcerative colitis (UC), and he started infliximab therapy. He received two doses of infliximab over the next month but showed no improvement. A subsequent flexible sigmoidoscopy was significant for moderately active disease despite therapy. He was discharged back to prison on the same regimen. In three weeks, he presented to the hospital again, prior to receiving his third infliximab dose. CT of the abdomen showed extensive free air and fluid concerning for a perforated viscus.

He underwent emergent exploratory laparotomy in the operating room resulting in a total abdominal colectomy and end ileostomy. His hospital course was complicated further by wound dehiscence, pneumonia, and a second exploratory laparotomy prior to eventual discharge

IMPACT/DISCUSSION: UC is diagnosed by symptoms, physical exam, imaging, and endoscopic evaluation. Laboratory studies that can assist diagnosis are p-ANCA, ASCA, and fecal calprotectin. It is important to establish a diagnosis early so appropriate pharmacological therapy may be initiated. Complications such as surgery, infection, or sepsis increase the mortality in UC patients, and increase in poorly controlled UC. There is a known correlation between delay in diagnosis of inflammatory bowel disease (IBD) and increased risk of intestinal surgery. Incarcerated individuals carry a higher risk of certain medical conditions compared to the general population. These individuals also suffer from delayed routine screening and access to timely healthcare.

CONCLUSION: Incarcerated individuals are at risk of healthcare disparities, and systemic steps should be taken to achieve prompt diagnosis and initiation of therapy to decrease the risk of complications.

THE INTRIGUING PATIENT WITH UNEXPLAINED ABDOMINAL PAIN

Daichi Agetsuma, Masakatsu Yoshikawa, Kazuo Komamura, Mitsunori Iwase

Internal Medicine, Toyota Kinen Byoin, Toyota, Aichi, Japan. (Control ID #3874659)

CASE: A 17-year-old male developed pain in his right hypochondrium five days ago and visited several hospitals, but the cause was not determined. He was referred to our gastroenterology department due to difficulty in pain management. The pain site had gradually migrated from the right hypochondrium to the right lower quadrant over the past few days, and the duration of the pain varied from 5 to 20 minutes. The pain was prickling with waves of intensity (NRS 1-9), sometimes with nausea, but no other gastrointestinal symptoms. There was no remission or exacerbating factors. Physical examination revealed tenderness from the right side of the umbilicus to the right lower quadrant, no rebound tenderness, and no Murphy’s sign. Still, McBurney’s point, Lanz point, Rovsing sign, Rosenstein sign, and Psoas sign were positive. These findings highly suggested appendicitis. However, inflammatory markers such as WBC and CRP were within normal limits, and plain and contrast-enhanced CT showed no evidence of appendiceal swelling, abscess, or other abnormalities that could cause abdominal pain. A second abdominal examination revealed pinpoint tenderness in several areas of the right hypochondrium and a positive Carnett's sign in the same area. When Xylocaine was injected locally into the most tender spot, the pain improved drastically. The patient was definitively diagnosed with ACNES(anterior cutaneous nerve entrapment syndrome) and has had no recurrence of symptoms since then to date.

IMPACT/DISCUSSION: Perception of the abdominal wall consists of the anterior and lateral cutaneous branches of the Th7-12 spinal nerves. Entrapment of the anterior cutaneous branch at the site of the abdominal rectus muscle results in ACNES. In an emergency department, approximately 2% of patients presenting with acute abdominal pain caused by ACNES. In the general population, it develops in 1 in 1,800 people. Factors in the development of ACNES include idiopathic (57%), recent abdominal surgery (28%), sports trauma, and pregnancy. Suspect ACNES when blood tests and imaging findings are normal, and there is localized tenderness within 2 cm2 of the outer edge of the abdominal rectus muscle and a positive Carnett's sign (pain exacerbated by strained abdominal wall muscles). Treatment is trigger point injection (TPI) or rectus sheath block (RSB). The pain improves with TPI (one to several times) in 24-33% of cases. In this case, the diagnosis was difficult because the patient had multiple tender points, and the course and physical examination mimicked appendicitis, but a single TPI produced improvement.

CONCLUSION: We experienced an interesting case that reminded us of the importance of recalling ACNES and checking Carnett's sign in patients with abdominal pain without any abnormality on blood tests or imaging findings. This disease needs to be widely recognized by surgeons and physicians who examine abdominal pain.

THE PATCH THAT BLEW THE PANCREAS

Danielle T. Tran, Lucy Z. Shi

Internal Medicine, University of California Davis Department of Internal Medicine, Sacramento, CA. (Control ID #3877087)

CASE: A 31 year old female presented with acute onset of epigastric pain. The epigastric pain was constant, severe, and radiated to her back with associated nausea and bloating. She denied alcohol use, recent illness, trauma, diarrhea, or constipation. Past medical history included pregnancy 2 months prior complicated by gestational diabetes, hypertriglyceridemia, and cholecystectomy several years ago. One month prior to presentation, she started an estrogen-progestin contraceptive patch.

She had epigastric tenderness to palpation without abdominal distension, rebound or guarding. Calcium was 6.6 mg/dL, lipase was 197 U/L and triglycerides were >10,000 mg/dL. Computed tomography imaging of her abdomen showed acute focal pancreatitis. She was provided aggressive intravenous hydration and an insulin infusion. During her hospitalization, she developed a retroperitoneal hematoma and her gastroduodenal artery was embolized. Her contraceptive patch was discontinued due to potential contribution to her hypertriglyceridemia and she started gemfibrozil. Three weeks later, her triglyceride level was 157 mg/dL. She was readmitted twice for complications related to initial pancreatitis including for gastric outlet obstruction caused by external compression from the retroperitoneal hematoma and complex pseudocysts.

IMPACT/DISCUSSION: Hypertriglyceridemia is the third most common cause of acute pancreatitis.

Several studies show that the degree of elevation is associated with severity of pancreatitis. Common causes of secondary hypertriglyceridemia include obesity, diabetes mellitus, pregnancy, and medications (i.e., estrogen, tamoxifen). Pregnancy, diabetes, and contraceptives are associated with mild increases in triglyceride levels, but typically do not have a significant effect. However, these risk factors may have an additive effect and multiple case reports suggest that some patients may have exaggerated responses to contraception with severe adverse outcomes. This patient had a history of untreated hypertriglyceridemia and was in a peripartum state complicated by gestational diabetes. The addition of estrogen-releasing contraception may have further elevated her triglyceride level to precipitate her acute pancreatitis with multiple complications.

CONCLUSION: While routine lipid screening is not recommended for patients starting estrogen-based contraception, there may be a subset of patients who should be screened prior to initiation and monitored closely given the potentially severe complications that can arise. Patients with 2 or more risk factors for hypertriglyceridemia should be evaluated and those at highest risk may benefit from using progestin only or non-hormonal contraceptives as first line options.

THE PIMPLE THAT WON’T STOP POPPING - A CASE OF PEMPHIGUS VULGARIS IN A YOUNG FEMALE

Aminata Soumare¹; Allison Samuel²

¹Internal Medicine, The Mount Sinai Hospital, New York, NY; ²General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3877717)

CASE: A 35 year-old female with no medical history presented to clinic with painful lesions in her mouth. She initially developed gingival pain 2 months prior which progressed into a single white ulcer on her soft palate, and then into multiple painful ulcers in her bucca. She also reported dysphagia and odynophagia. She was seen in the emergency room and was diagnosed with gingivitis and Coxsackie Virus Infection. Her symptoms did not improve with prescribed anesthetic mouthwashes.

She denied fevers, chills, shortness of breath, or joint pain. She was only sexually active with her husband, and had no history of sexually transmitted infections and no recent sick contacts. Physical exam was notable for difficulty with opening her mouth due to pain, and superficial erosions with white scabbing on the hairline and lip. Oral exam showed white ulcerative lesions of various healing stages located on the soft palate adjacent to the uvula, the buccal mucosa and at the base of the tongue next to the frenulum.

Her infectious workup for Coxsackievirus, Chlamydia, Gonorrhea and Herpes Simplex were negative. She underwent a biopsy of her oral lesions and immunostaining was positive for C3 and IgG in the epithelial intercellular junctions in areas of acantholysis. She was started on prednisone for the treatment of pemphigus vulgaris.

IMPACT/DISCUSSION: Pemphigus is a rare autoimmune disorder characterized by spontaneous flaccid blister formation on cutaneous and mucosal surfaces. Pemphigus Vulgaris, the most common subtype, is a type II IgG-mediated hypersensitivity reaction against desmoglein 1 and 3 proteins in the desmosome, leading to intraepidermal acantholysis of keratinocytes (disruption of intercellular adhesions). It most commonly presents with painful friable flaccid lesions in the oral mucosa, which then progresses to involvement of cutaneous areas exposed to pressure such as intertriginous folds. Diagnosis mostly involves identifying desmoglein 1 and 3 antibodies on a mucocutaneous biopsy or in serologies. Management involves systemic glucocorticoids and immunosuppressants.

CONCLUSION: - Pemphigus Vulgaris is an autoimmune blistering disease which most commonly presents with oral lesions.

- Diagnosis involves identifying anti-desmoglein antibodies in the epidermal layer of a biopsy. Management includes systemic gluccocorticoids and immunosuppressants.

- Internists should think about auto-immune etiologies when formulating a differential for oral lesions.

THE PITFALLS OF VERTEBRAL OSTEOMYELITIS DIAGNOSIS

Michelle Lee. Medicine, Emory University, Atlanta, GA. (Control ID #3875542)

CASE: A 63-year-old male with past medical history significant for type 2 diabetes presented with 3-week history of lower back pain. The patient reported that he had pain on and off for years, but worsened 3 weeks ago after lifting a TV stand. He denied any fever, chills, recent surgeries, injection drug use or any recent/recurrent infections. He also noted a 2-day history of diarrhea. Vitals were within normal limits. Exam was notable for tenderness of the right paraspinal muscle. There was no spinal tenderness or neurologic deficits. Initial labs were notable only for a slightly elevated CRP to 4.6 mg/L. In the ED, a CT of the abdomen was done which incidentally revealed prevertebral edema at T11/12. MRI was then pursued which was suspicious for osteomyelitis with a possible phlegmon centered at T11/12. While these imaging findings were concerning for osteomyelitis, the patient’s overall clinical picture was not. Because of the risks associated with a bone biopsy, a triple phase bone scan was pursued instead. This study revealed focal radiotracer uptake along anterior osteophytes in T11-L1, which was determined to be most consistent with degenerative changes. The patient’s lumbar back sprain was managed symptomatically and he was discharged home after 7 days in the hospital.

IMPACT/DISCUSSION: Despite osteomyelitis being a common diagnosis encountered among general internists working in the inpatient setting, it can be a difficult diagnosis to make. While bone biopsy is the gold standard for diagnosis, osteomyelitis is usually diagnosed with a combination of clinical and radiographic findings, without invasive testing. MRI is the most common imaging modality used for diagnosis of osteomyelitis. Specifically for vertebral osteomyelitis, MRI has a reported sensitivity between 53-100% and specificity of 42-100%. In cases with severe degenerative arthritis, nuclear imaging may be a better alternative. As shown in this case, degenerative changes of the spine can result in a false positive read for osteomyelitis on MRI because these changes can appear similar to infectious endplate abnormalities. Other mimics for osteomyelitis on MRI include neuropathy, malignancy, vasculopathy and inflammation. Scintigraphy with SPECT using technetium or gallium tracers can be used to rule out vertebral osteomyelitis given sensitivity of ~90%. Specificity is moderate but can be increased by combining both techniques. PET/CT can also be used in cases where mimics are suspected to be present. Overall accuracy of PET/CT for vertebral osteomyelitis is estimated to be similar to MRI.

CONCLUSION: Osteomyelitis is a commonly encountered entity in general internal medicine, and the diagnosis is often made from clinical context in conjunction with corresponding imaging. MRI is often the best initial imaging modality when suspecting osteomyelitis, but degenerative spine disease can mimic MRI findings usually seen with vertebral osteomyelitis. In these cases, nuclear studies may be helpful in diagnosis.

THE PLOT THICKENS: A 72-YEAR-OLD MAN WITH HEADACHE AND RASH

Christopher R. Calkins¹; Robert Atkind²

¹Medicine, Brigham and Women's Hospital, Boston, MA; ²Atrius Health, Newton, MA. (Control ID #3875219)

CASE: A 72-year-old male presented with two weeks of headache. It was primarily occipital with some temporal involvement. It was worsened by occipital pressure but was not otherwise positional, exertional, or worse at a particular time. It was responsive to acetaminophen which he was taking once per day. He reported two episodes of chills. He denied trauma, phonophobia, photophobia, fever, vomiting, travel, time outdoors, or sick contacts. He did endorse significant stress.

Medical history was notable for obesity, hyperlipidemia, HTN, OSA, and thoracic aortic aneurysm. He drank one drink per week and never smoked.

His medications were notable for HCTZ, losartan, metoprolol, atorvastatin, and dutasteride.

On exam, he was afebrile, BP 136/74, HR 90 bpm, and SpO2 98%. The occiput was tender but there was no tenderness of the temples. He had full neck ROM and did not have any tenderness of the paraspinals. Cranial nerves were normal.

A head CT and SARS-CoV-2 PCR were ordered and were negative. The patient was advised that he could increase acetaminophen for suspected tension headache.

Two weeks later, the patient represented with four days of pruritic rash. He had taken no new medications but he had increased his acetaminophen to 3500mg daily from 500mg. Exam revealed an erythematous, maculopapular rash on the chest, axillae, groin, gluteal cleft, and bilateral arms. Labs were notable for WBCs 17, absolute eosinophils 1260, platelets 643, and ESR 130. He was sent to the hospital.

On admission, a workup was sent and he was started on prednisone. A temporal artery biopsy was obtained showing arteritis. Skin biopsy was consistent with a diagnosis of symmetrical drug-related intertriginous and flexural exanthema (SDRIFE). The remainder of the laboratory evaluation was unrevealing. He experienced a resolution of his headache with steroid therapy and his rash resolved with the discontinuation of acetaminophen.

IMPACT/DISCUSSION: This case highlights that the presentation of GCA can be varied and can include occipital headache. Despite being called temporal arteritis, it can affect any of the arteries of the scalp. This also demonstrates how anchoring bias, an overreliance on the first piece of information received, can lead to misdiagnosis. In fact, were it not for the patient’s rash, the diagnosis could have been further delayed.

SDRIFE was initially described in 1984 as “baboon syndrome” for its sharply-demarcated, erythematous appearance. Common offending medications include antibiotics, allopurinol, and some cancer drugs. There are isolated reports of acetaminophen-induced SDRIFE. This patient took acetaminophen in the past, suggesting dose-dependency and supporting one hypothesis about why SDRIFE has its defining distribution: the high density of eccrine sweat glands leads to higher levels of drug excretion.

CONCLUSION: - Occipital headache can be a presenting symptom of GCA

- Anchoring bias can lead to misdiagnosis

-SDRIFE is a lesser-known drug rash that can be caused by many common medications

THE RAPIDLY EVOLVING AND FATAL FAT EMBOLISM SYNDROME

Hyeon Jeong Park¹; Scott Hall²

¹Internal Medicine, Christiana Care Health Services Inc, Wilmington, DE; ²Hematology Oncology, Christiana Care Health Services Inc, Newark, DE. (Control ID #3877115)

CASE: Fat embolism syndrome is a rare complication of sickle cell disease resulting from bone marrow necrosis associated with severe pulmonary and neurological sequalae with a high mortality rate. It affects those with mild forms of sickle cell disease, predominantly HbSC and HbSβ⁺. We present the case of a patient presenting with diffuse back pain who developed fatal fat embolism syndrome.

Patient was a 33-year-old African American male presenting with back pain of one week. He reported a history of sickle cell trait. His pain was not responsive to over-the-counter pain medications. He had taken amoxicillin for cough and muscle aches nine days prior to admission.

In the emergency department, he had fever, tachycardia, and hypoxia concerning for infection. Labs showed a white blood count 14.2x10⁹/L with a hemoglobin of 8.8g/dl. CTA demonstrated atelectatic changes at the bases without evidence of pulmonary emboli or infiltrates.

Within 24 hours the patient had acute decompensation in his respiratory and neurologic status, prompting transfer to the medical ICU. On exam, the patient was diffusely diaphoretic, tachypneic and not following commands. The patient was placed on BiPAP, and started on empirical antibiotics with vancomycin, ceftriaxone, and azithromycin. Chest x-ray showed bilateral diffuse infiltrates. Lumbar puncture was unremarkable. Limited MRI without contrast showed no acute abnormalities.

Hematology was consulted due to concerns for a primary hematologic malignancy as his labs showed progressive pancytopenia with a lactate dehydrogenase 11,108 unit/L and ferritin 32,584 ng/mL. He developed acute renal failure with a creatinine of 5.4 mg/dL, transaminitis concerning for shock liver, a drop in his hemoglobin to 5.5 g/dl with platelet count of 35 nl. Blood smear showed numerous nucleated red blood cells and target cells, raising concern for hemoglobin SC disease rather than sickle cell trait. The rapid onset of respiratory failure and mental status changes raised concerns for fat embolism syndrome. He was intubated and underwent emergent red cell exchange. He became hypotensive and was started on vasopressors along with hemodialysis. Hemoglobin electrophoresis subsequently confirmed SC disease.

Forty-eight hours after red cell exchange, the patient was found to have bilateral fixed and dilated pupils. CT head showed complete effacement of the bilateral cerebral sulci, marked cerebral edema, effacement of basilar and suprasellar cisterns corresponding to focal herniation and infarct of the right temporal lobe. Nuclear brain study showed no flow leading to pronouncement of brain death.

IMPACT/DISCUSSION: This case illustrates the speed of evolvement of fat embolism syndrome in sickle cell disease, with the tragic neurologic consequences that can be seen in patients with otherwise mild disease.

CONCLUSION: Review of the peripheral smear was key in making a prompt diagnosis. Despite emergent red cell exchange, this entity still carries a high mortality rate.

THE ROLE OF FRESH FROZEN PLASMA IN TREATMENT REFRACTORY ANGIOEDEMA SECONDARY TO ANGIOTENSIN CONVERTING ENZYME INHIBITOR

Benjamin Ravichander¹; Lillian Sangha¹; Adalberto Guzman¹; Maria Ibarra²; Irina Mishagina¹

¹Internal Medicine, UPMC Central PA, Harrisburg, PA; ²Pediatrics, Woodhull Medical Center, Brooklyn, NY. (Control ID #3873750)

CASE: A 50-year-old female with history of recently diagnosed hypertension, anxiety, and gastroesophageal reflux disease presented to the hospital due to significant tongue swelling. She had recently initiated lisinopril therapy for her new-onset hypertension in the outpatient setting. On presentation, the patient was diaphoretic, in visible distress, and unable to maintain or clear her oral secretions. Due to the concern for life-threatening angioedema, intramuscular (IM) epinephrine 0.3 mg, intravenous (IV) methylprednisolone 125mg, IV ondansetron, and tranexamic acid were sequentially administered without any improvement in her clinical status. She was subsequently intubated due to concern of an impending airway compromise. She was transferred to the intensive care unit and further therapy of anti-histaminergic and anti-inflammatory medications were administered without improvement. The decision was made to administer fresh frozen plasma (FFP). After four units of FFP, the patient showed significant improvement, with reversal of her edema, and was successfully extubated.

IMPACT/DISCUSSION: Angioedema occurs via two pathways: histamine-mediated and bradykinin- mediated. It is a rapidly developing and potentially fatal swelling of the lips, oropharynx, tongue, and larynx.

Angiotensin converting enzyme inhibitors (ACEI), a commonly used anti-hypertensive medication, is the leading cause of drug-induced angioedema in the United States. ACEI therapy can result in elevated levels of bradykinin and inflammatory vasoactive peptide that causes blood vessel vasodilation which results in angioedema. ACEI blocks the effects of angiotensin converting enzyme (ACE), which is the primary peptidase that degrades bradykinin, a potent vasodilator. Increased circulating bradykinin levels increase the permeability of capillaries. This pathway can result in life-threatening angioedema and airway obstruction of the oropharynx and larynx. Angioedema is treated with antihistamines, epinephrine, and steroids. However, if the bradykinin-mediated angioedema caused by ACEI is refractory to standard therapies, fresh frozen plasma (FFP) has been shown to have success and reduce mortality. The important enzyme in FFP that contributes to its utility in this clinical scenario is Kininase–II. This enzyme degrades bradykinin, thus proving useful in refractory cases of angioedema.

CONCLUSION: Guideline directed therapy for angioedema involves steroids, antihistamines, and epinephrine as first line agents. However, there have been studies and clinical data suggesting that FFP can improve outcomes in refractory angioedema and therefore should be considered.

THE SPIROCHETE THAT WAS CAUGHT IN THE ANCHOR: A TALE OF DARK FIELD BIAS

Maria Tsikala Vafea¹; Anna K. Donovan²

¹Internal Medicine, UPMC, Pittsburgh, PA; ²Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #3873892)

CASE: A 59 year old male with a history of granulomatosis with polyangiitis (GPA) on methotrexate, hypertension, diabetes, and ulcerative pancolitis presented to the hospital with a week of progressive ankle arthralgias. Prior to admission, rheumatology initiated treatment with low dose prednisone and escalated the dose to 40 mg daily, without symptomatic improvement. His exam on admission was significant for mild tachycardia, a bilateral erythematous macular ankle rash, and bilateral ankle synovitis.

Lab results were notable for creatinine 2.0mg/dL (baseline 1.2-1.4), white blood cells 13,400 with neutrophilic predominance (92%), C-reactive protein 5.1 mg/dL, Erythrocyte Sedimentation Rate 48 mm/hr, urinalysis with ketones and glucose. C3, C4, anti-SM, anti-dsDNA, anti-Ro, anti-La, anti-smooth muscle, ANCA anti-PR3, and anti-MPO serologies were all negative. Imaging revealed mild arthrosis of the right foot and ankle. Septic arthritis was deemed less likely, so arthrocentesis was not warranted. The patient was diagnosed with a GPA flare and methylprednisolone 500 mg IV daily was initiated. A skin biopsy of the ankle ultimately showed "multiple spirochetes along the dermo-epidermal junction and the superficial dermis highlighted with treponema stain". By then, the rash had progressed to involve the palms and soles supporting a diagnosis of secondary syphilis. Rapid plasma regain was reactive and the patient received penicillin G 2.4 million Units intramuscularly.

IMPACT/DISCUSSION: Syphilis is a sexually transmitted disease caused by Treponema pallidum, with different stages occurring over time in untreated infection. Skin rashes appear in secondary syphilis and are diverse; macular, papular, maculopapular, papulo-squamous, lichenoid, nodular, and pustular lesions may be observed. The rash on the palms and soles is not always presents, and may develop after other initial skin findings present.

Anchoring bias is a pervasive cognitive bias that occurs when physicians rely too heavily on information they receive early on in the decision-making process, and do not adjust their thinking when new information becomes available. This skews judgment and can delay proper diagnosis and treatment. Anchoring can be reduced by thinking of reasons why the hypothesis could be incorrect and by applying consider-the-opposite strategies. This case reminded us to employ bias reduction strategies when forming differential diagnoses.

CONCLUSION: - Consider secondary syphilis in patients presenting with a new rash.

- Form a broad differential based on presenting symptoms and signs, keeping anchoring bias in mind.

THE SYLLABUS ON SALMONELLA SEPSIS: HOW TRAVEL FOR SCHOOL LED TO A TRIP TO THE HOSPITAL

Willie H. Smith¹; Erica Han¹; Laurence Balter²

¹Hospital Medicine, Emory Healthcare, Atlanta, GA; ²Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #3877197)

CASE: : A 23-year-old woman, recently immigrated from India for schooling, with no past medical history presented with 9 days of fever, nausea, vomiting, malaise & anorexia. On admission, her temperature was 39.5° C; remaining vitals & physical exam were normal. Pertinent labs included WBC 4.4 & negative malaria & HIV screens. Blood cultures grew gram-negative rods. She was initially placed on piperacillin-tazobactam, but remained febrile, prompting Infectious Disease consultation. Her antibiotic was narrowed to ceftriaxone once cultures showed S. enteritis by day 3. Continued fevers caused concern for occult abscess or endovascular infection. Abdominal & pelvic CT scans revealed splenic infarcts; transthoracic & transesophageal echocardiograms showed no vegetations; & whole body PET found no evidence of metastatic foci of infection.

By day 9, genomic sequencing facilitated serovar identification: S. enterica subspecies enterica serovar typhi.

She remained febrile for 12 days, then defervesced on ceftriaxone. Given the serovar diagnosis, absence of splenic embolic seeding on PET & CT, & no other concurrent etiologies, the patient received 2 weeks of ceftriaxone as outpatient.

IMPACT/DISCUSSION: Salmonellosis is on the differential for patients with recent travel from endemic areas. There were 2 diagnostic challenges in this case: delay in serovar determination & diagnostic imaging with sufficient accuracy to assess embolic phenomena.

Our patient had persistent fevers despite culture directed therapy (ceftriaxone) & diagnostic evaluation of confounding etiologies. Serovar molecular testing was needed to distinguish between S. typhi & S. enteriditis. Serovar testing is routinely sent to state department of health but can take 2 to 4 weeks, potentially impacting[BLB1] pre & posttest probability of diagnostic evaluation of septic embolic disease. Posttest probability of endovascular infection lowered when PET imaging ruled out splenic infarcts & other differential diagnoses & serovar was determined as typhi. Successful outcomes have been reported with several weeks of intravenous therapy for S. enteritis in setting of endovascular sequalae, versus 7–14 days of targeted antibiotic therapy for S. typhi.

CONCLUSION: Molecular serovar identification has clinical & epidemiological implications. Clinicians should note reclassification of enteritidis & typhi as S. enterica serovars. Obtaining travel history allows ruling out confounding fever etiologies; however, as differential diagnosis after travel should be broad, physicians should beware of anchoring bias. CT imaging alone has limited diagnostic yield in fever workup; literature on use of PET/CT as a diagnostic modality is evolving.

THE ULTIMATE BROKEN HEART: TAKOTSUBO CARDIOMYOPATHY WITH COMPLETE HEART BLOCK MIMICKING LEFT ANTERIOR DESCENDING INFARCTION

Brittany M. Denzer, Anna A. Samuel

Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #3876464)

CASE: A 92 year old independently living female with a history of hypertension presented with several hours of exertional, squeezing chest pain and dyspnea. Exam was significant for elevated jugular venous distension to 6 cm at 30 degrees, but otherwise unremarkable. Presenting studies notable for high sensitivity troponin increase from 500 to 2245 ng/L and BNP 584 pg/mL. EKG showed sinus bradycardia with rates in the 40s and 2:1 atrioventricular (AV) block, along with ST-segment depressions in diffuse leads. Transthoracic echocardiogram (TTE) on admission showed mid inferoseptal and basal to mid anteroseptal hypokinesis, concerning for left anterior descending (LAD) occlusion. She was given aspirin, nitroglycerin, and started on a heparin drip for presumed acute coronary syndrome. Several hours later, she developed medically refractory chest pain and complete heart block and was taken for emergent coronary angiography. Coronary angiogram showed no significant coronary artery disease however, left ventriculography showed ballooning of the left ventricular apex in a pattern consistent with (TCM). A temporary pacer was placed with improvement of hemodynamics. Persistence of high degree AV block prompted the placement of a leadless pacemaker on hospital day 2. Repeat TTE on hospital day 3 showed improved but persistent wall motion abnormalities and borderline reduced ejection fraction.

IMPACT/DISCUSSION: The pathogenesis of TCM is presumed to be due to catecholamine excess, classically in the context of emotional or physical stressors. Presenting symptoms typically include chest pain and dyspnea, often mimicking acute coronary syndrome. The diagnosis of TCM includes the following: transient left ventricular dysfunction, troponin elevation or EKG abnormalities, and the absence of obstructive coronary artery lesions or myocarditis. This case was notable for discordancy in the presenting TTE, which showed LAD region abnormalities, and the left ventriculogram, which showed classic TCM apical ballooning. This patient denied environmental stressors, however, we wonder if increased sympathetic activity in setting of high-grade AV block was the precipitant of her TCM. There is a known association between TCM and high-degree AV block, however, the causal relationship is not certain and has been reported rarely in a few case reports. Treatment for TCM is supportive care. In addition, if patients are found to have heart failure with reduced ejection fraction (HFrEF) they should be started on guideline-directed management therapy (GDMT). Following the placement of a leadless pacemaker implant, our patient started a beta blocker and low-dose ARB to initiate GDMT for heart failure.

CONCLUSION: 1. TCM is a transient cardiomyopathy that is most common in post-menopausal women.

2. Treatment includes supportive care and GDMT if patients develop HFrEF.

3. This case shows that there could be utility of left ventriculogram in the workup of chest pain in patients with negative coronary angiography.

THE UNEXPECTED CULPRIT: STATIN-ASSOCIATED AUTOIMMUNE MYOPATHY

Maya Sayarath^1,2

¹Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA; ²Internal Medicine, Harvard Vanguard Medical Associates, Cambridge, Cambridge, MA. (Control ID #3867530)

CASE: A 71-year-old woman presented to her outpatient primary care provider with three-months of bilateral lower extremity weakness and gait instability, resulting in multiple falls and acute alterations in her functionality. Given patient was on a high intensity atorvastatin 80 mg daily and physical exam findings significant for proximal bilateral upper and lower extremity weakness, labs were obtained including a creatinine kinase (CK) to evaluate for myopathy. Notably patient had been on this medication and dosage for six years in the setting of diagnosis of renal artery stenosis due to fibromuscular dysplasia. Labs resulted with CK elevation to 34,000 U/L with transaminitis with AST 689 U/L and ALT 669 U/L for which she was directed to present to the local emergency department for further evaluation and management. She was treated with aggressive intravenous hydration for a presumed diagnosis of rhabdomyolysis, however despite this intervention the CK did not improve nor return to baseline normal range. In turn, Rheumatology was consulted with increasing concern for statin-induced myositis, patient’s statin was discontinued on day 2 of hospitalization. Left vastus lateralis muscle biopsy was obtained for further evaluation, which demonstrated extensive muscle damage with necrotic fibers. Relevant labs were notable for the following, aldolase 125.2 U/L, antinuclear antibody titer negative, urine analysis with 6-10 red blood cells with 3+ blood. Additionally, serum HMG-CoA reductase antibody (Ab) was elevated at 176 (normal < 20) and myositis Ab panel was negative, both of which notably resulted status-post her discharge. She was treated empirically with prednisone 60 mg with improvement in her CK 20,582 U/L at time of discharge and 12,109 U/L at time of follow-up one week later.

IMPACT/DISCUSSION: Statin-associated autoimmune myopathy, resulting in progressive symmetric muscle weakness is an extremely rare side effect affecting two to three for every 1000,000 patients treated with this commonly prescribed HMG-CoA reductase medication. This infrequency results in difficulty recognizing diagnosis, delays in management, and definitive treatment. This case demonstrates the potential for severe adverse consequences of statin-associated autoimmune myopathy, namely muscle necrosis and devastating alterations in neuromuscular function. Further, the rarity of this complication, especially noting the unique, delayed presentation following chronic statin use, highlights the critical importance of provider recognition of this serious myopathy to allow for timely therapeutic intervention.

CONCLUSION: 1. Case demonstrates the severe adverse consequences of statin-associated autoimmune myopathy, namely muscle necrosis and devastating alteration in neuromuscular function

2. Case demonstrates a unique, delayed presentation of this rare myopathy and need for broad differentials in diagnosis

3. Critical importance of provider recognition of this serious myopathy to ensure timely therapeutic

intervention

THE UTILITY OF CARDIONEUROABLATION IN THE TREATMENT OF MALIGNANT CARDIOINHIBITORY SYNCOPE

Armen Zeitjian¹; Samuel S. Gordon²; Duc Do²

¹Internal Medicine, Harbor-UCLA Medical Center, Torrance, CA; ²Cardiovascular Medicine, Harbor-UCLA Medical Center, Torrance, CA. (Control ID #3871968)

CASE: A 32-year-old male with no significant past medical history was admitted for 3 episodes of syncope over 3 months. Prior to each episode, he became diaphoretic but denied chest pain, palpitations, or other associated symptoms. Telemetry revealed a 5.7 second sinus pause and a 9 second run of symptomatic sinus bradycardia to the 20s with diaphoresis and confusion. A transthoracic echocardiogram, cardiac magnetic resonance imaging, and comprehensive electrophysiology study were unrevealing. He was discharged with an implantable loop recorder. He presented 5 weeks later with multiple syncopal episodes corresponding to episodes of sinus asystole lasting up to 30 seconds on the loop recorder. Multiple episodes of prolonged sinus asystole with syncope were noted on telemetry monitoring. While vasovagal syncope may be associated with a vasodepressor response causing hypotension and/or a cardioinhibitory response causing sinus bradycardia, pauses and asystole, these findings on telemetry and the patient's loop recorder suggested a cardioinhibitory- predominant etiology for the patient’s vasovagal syncope. Furthermore, although pacemaker implantation is considered in patients with refractory vasovagal syncope (VVS) and prolonged pauses per current AHA guidelines, their use in patients below the age of 40 is questionable. Thus, cardioneuroablation (CNA) was utilized to ablate the right anterior and inferior vena cava/interatrial ganglionated plexi with no inducible bradycardia upon repeat high frequency stimulation of the vagus nerve (Figure 1). He was discharged home after 48 hours of monitoring. 3 months after CNA, our patient continues to do well without any symptoms or recurrent episodes of syncope.

IMPACT/DISCUSSION: This is a case of cardioinhibitory VVS in a young patient with debilitating symptoms at high risk for sudden cardiac death. Medical therapies have variable success in treating cardioinhibitory VVS, and pacemaker implantation subjects younger patients to significant long-term device- related complications. This case highlights the utility of CNA as an alternative and promising treatment of cardioinhibitory VVS in younger patients.

CONCLUSION: - To include cardioinhibitory syncope in the differential diagnosis of syncope in the proper historical context and suggestive electrocardiogram findings, such as symptomatic sinus bradycardia, prolonged sinus pauses, and asystole.

- To seek early consultation with an electrophysiologist if there is high suspicion for cardioinhibitory syncope to explore all available treatment options.

THREE ADMISSIONS WITHIN 72 HOURS: WHEN TO BE HYPERCRITICAL OF A HISTORY Corinne P. Camp³; Carston Dammann³; Sneha Shah^1,2

¹Internal Medicine, VA Eastern Colorado Health Care System, Aurora, CO; ²Internal Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ³Internal Medicine, University of Colorado, Denver, CO. (Control ID #3874620)

CASE: A 73-year-old male with hypertension and OSA who presented with cough and dyspnea was admitted for acute hypoxemic respiratory failure (AHRF). On initial presentation, he reported new water damage and ongoing home repairs due to suspected mold. HPI and findings of new ground-glass opacities (GGOs) and multiple nodules on high-resolution CT (HRCT) of the chest raised concern for hypersensitivity pneumonitis (HP). Transthoracic echocardiogram (TTE) demonstrated pulmonary hypertension. Pulmonology was consulted but bronchoalveolar lavage demonstrated neutrophilic predominance which is more commonly seen with bacterial pneumonia. Treatment for community-acquired pneumonia and diuresis improved patient's symptoms. He was discharged home on 1-2LPM O2 in stable condition. Less than 12 hours after discharge, he was readmitted with respiratory distress and acute hypoxemic hypercapnic respiratory failure (AHHRF). Chest CT was notable for bilateral GGOs, which again improved after aggressive diuresis. Repeat TTE demonstrated normal left ventricular systolic function. Once euvolemic, he was discharged on furosemide and encouraged consistent CPAP use. Less than 24 hours from a second discharge, he presented a third time and was readmitted to the ICU for AHHRF. Chest HRCT showed interval increase in GGOs. Given quickly relapsing respiratory distress upon returning home and rapid improvement while hospitalized, he was treated empirically with steroids for HP with significant improvement in his respiratory symptoms. Ultimately, he was discharged to a hotel with instructions to not return home until mold is eradicated. He has been recovering on a steroid taper without any further hospitalizations.

IMPACT/DISCUSSION: HP is a complex and often varied immune-mediated lung syndrome caused by exposure to inhaled organic antigens. Numerous antigens lead to HP (which can be acute, subacute, or chronic) including microorganisms, agricultural dusts, and bioaerosols. Because antigen exposure is key to developing HP, a detailed clinical history is imperative. Given the lack of international diagnostic guidelines, diagnosing HP is difficult. Nonetheless, chest HRCT findings of bilateral GGO or poorly defined centrilobular nodules and BAL with lymphocytosis (≥30% for non-smokers and ≥20% for active smokers) are suggestive of HP. Ultimately, in this case, it was the presence of a strongly suspicious clinical history for re-exposures to an antigen (mold) which led to the diagnosis of and empiric treatment for HP despite a BAL that was nondiagnostic for HP and GGOs seen on CTs were twice attributed to other etiologies.

CONCLUSION: Given the difficulty in diagnosing HP, a high index of suspicion is required especially in patients readmitted within a hyperacute timeframe. HP should be suspected when the clinical history is strongly compelling even if HRCT and/or BAL studies do not fully support it. Treatment should be initiated with steroids and, most importantly, with removal of the offending antigen.

THROMBECTOMY IN SUB-MASSIVE PULMONARY EMBOLISM

Kylie Anthony¹; Douglas Spaeth-Cook²; Dustin T. Smith³

¹Internal Medicine, Emory University School of Medicine, Atlanta, GA; ²Radiology, Emory University School of Medicine, Atlanta, GA; ³Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #3875282)

CASE: A 67-year-old male with a history of hyperlipidemia presented with 3 days of dyspnea on exertion associated with chest tightness and non-productive cough. He denied any leg swelling. He did not have a personal or family history of abnormal bleeding, clots, recent travel, and was up to date on cancer screening. He was hemodynamically stable with heart rate of 78 and respiratory rate of 16, but he was noted to be hypoxic to 89% on room air and was placed on 2 L/min oxygen by nasal cannula. Physical exam was unremarkable. Initial laboratory examination demonstrated a normal complete blood count and comprehensive metabolic panel, cardiac troponin of 0.25 ng/mL, BNP of 406 pg/mL, and D-dimer of 6874 ng/mL. ECG demonstrated sinus rhythm with normal axis, probable left atrial abnormality, and nonspecific T wave abnormalities most prominent in the inferior leads. Chest radiography was normal. CT angiography of the chest was pursued and demonstrated filling defects in the bilateral main pulmonary arteries and additional clots in the bilateral lower lobes without evidence of infarction. Echo demonstrated a mildly dilated right ventricle with mildly reduced right ventricular systolic function. Left ventricular systolic function was low- normal (EF 50-55%), and there were no regional wall motion abnormalities identified. The patient received an intravenous bolus of unfractionated heparin and was started on a continuous heparin drip. Interventional cardiology performed a thrombectomy the next day. He was discharged one day after thrombectomy on a direct-acting oral anticoagulant with planned initial therapy duration of 12 months.

IMPACT/DISCUSSION: This case represents an illustrative example of an uncomplicated patient with a sub-massive PE who may qualify for thrombectomy even when hemodynamically stable. PEs are a common diagnosis encountered in inpatient internal medicine, but management of intermediate-risk PE can pose challenges. In this case, the decision to pursue thrombectomy versus anticoagulation alone was determined primarily based on the Pulmonary Embolism Severity Index (PESI) score, an estimator of 30-day mortality in patients with PE. This patient’s hypoxia (other clinical criteria applicable to this patient included age and sex) placed him in the intermediate risk category (Class III, 3.2-7.1% 30-day mortality). It was determined that this patient could benefit from thrombectomy while inpatient. More advanced therapies like thrombolytics have traditionally been reserved for patients with hemodynamic instability because while improvement in perfusion occurs, there is also an elevated risk of major bleeding. Recent studies have shown that catheter- directed thrombectomy has an improvement with cardiac markers and less risk of bleeding.

CONCLUSION: Using the PESI score can help determine when to seek consultation for targeted interventions for PE in addition to standard medical therapy, particularly in patients who are hemodynamically stable.

THROMBOCYTOPENIA DUE TO COEXISTING THROMBOTIC THROMBOCYTOPENIC PURPURA (TTP) AND HEPARIN-INDUCED THROMBOCYTOPENIA (HIT) IN A PATIENT WHO RECENTLY UNDERWENT CORONARY ARTERY BYPASS GRAFT SURGERY

Vishnu Bharani^1,2; Christopher R. Grant^1,2; Tobin Mathew^1,2; Ann Jose⁴; Bharti Bharani³; Marygrace Zetkulic⁴

¹Internal Medicine, University of California Irvine, Irvine, CA; ²Internal Medicine, UC Irvine Douglas Hospital, Orange, CA; ³University of Washington School of Medicine, Seattle, WA; ⁴Internal Medicine, Hackensack Meridian Hackensack University Medical Center, Hackensack, NJ. (Control ID #3875677)

CASE: A 68-year-old male with a past medical history of hypertension, hyperlipidemia, type 2 diabetes, and heart failure with reduced ejection fraction presented to the emergency department with one day of acute bilateral foot pain. Ten days ago he had coronary artery bypass graft (CABG) surgery and received subcutaneous heparin for seven days for deep venous thrombosis (DVT) prophylaxis. He was discharged and asymptomatic until he presented with his current chief complaint. He had no fevers, confusion, nausea, vomiting, abdominal pain, diarrhea, constipation, or hematuria.

He was afebrile with tachycardia to 107 beats/minute. His bilateral plantar heels had painful purpura with no other skin findings of rashes, petechiae, or ecchymoses.

Lab work showed a hemoglobin of 8.7 g/dL, reticulocyte index of 3.40, and platelet count of 20,000/mm³ (baseline 275,000/mm³). A peripheral blood smear showed schistocytes. He had a creatinine of 2.0 mg/dL (baseline 1.4 mg/dL), GFR of 32 mL/min/1.73 m² (baseline >60 mL/min/1.73 m²), and lactate dehydrogenase of 738 U/L. Haptoglobin was normal. His prothrombin time was 19.5 seconds and fibrinogen was 60 mg/dL. Urinalysis showed blood and urine microscopy showed 5-10 RBCs. An enzyme immunoassay (EIA) was positive for heparin induced platelet antibodies. Duplex ultrasound of the lower extremities showed acute DVTs.

Urgent plasmapheresis was initiated as acute kidney injury, hemolytic anemia, thrombocytopenia, and DVTs were concerning for a thrombotic microangiopathy. Argatroban infusion was initiated due concern for heparin induced thrombocytopenia (HIT). After six days of plasmapheresis and ten days of argatroban infusion, his platelet count, hemoglobin, and renal function recovered to baseline.

A serotonin release assay and an ADAMTS13 inhibitor resulted six days after admission - both positive confirming a diagnosis of coexisting HIT and TTP. The patient was transitioned to Eliquis and discharged without complications.

IMPACT/DISCUSSION: In post-cardiac surgery patients, a syndrome resembling TTP has been described that responds to plasma exchange. Classic TTP results from decreased ADAMTS13 activity due to autoantibodies. However, postoperative TTP is hypothesized to occur due to inflammatory cytokines stimulating ultralarge von Willebrand factor multimers while simultaneously impairing ADAMTS13. Exposure to heparin further imparts risk of HIT. This patient's symptoms/labs support both HIT and TTP, suggesting coexistence and possible temporal relationship between the two.

CONCLUSION: This case highlights that multiple causes of thrombocytopenia may be at play in post- cardiac surgery patients. It is important to recognize that TTP occurs in this patient group more frequently and via a different mechanism than classic TTP. Prompt treatment via plasma exchange is highly effective. HIT, which is more common, can also occur postoperatively due to exposure to heparin products. It is possible that HIT and TTP are temporally related when occurring together.

THROMBOEMBOLIC EVENTS AND TRANSTHORACIC ECHOCARDIOGRAPHY IN COVID PATIENTS

Divya Bhanu Sree Madisetty, Gagandeep Singh Arora

Internal Medicine, University of California Riverside, Riverside, CA. (Control ID #3859905)

CASE: A 40-year-old female with significant medical history of polysubstance abuse presented to ER with shortness of breath x 1 week. It was associated with subjective fevers, blood-tinged coughs, and mild diffuse left-sided nonradiating pressure like chest pain. Denies aggravating & relieving factors. Vitas include temperature 100.4, sinus tachycardia HR 115, tachypneic, 98% saturation on room air, and normotensive. Labs included elevated WBC 13K, positive COVID PCR, elevated D-Dimer, BNP and troponin, and urine drug screen positive for meth. Imaging included chest X-ray which demonstrated mild bibasilar bronchovascular consolidation and cardiomegaly. EKG showed sinus tachycardia. CT chest with contrast demonstrated a large left lower lobe pulmonary artery embolism with mild bilateral pleural effusions. Transthoracic echocardiogram demonstrated mixed left ventricular heart failure with ejection fraction of 25% and a large mobile 36*22 mm right atrial thrombus extending from IVC, RVSP of 50 mm Hg with a mild decrease in right ventricular function.

Given submassive pulmonary embolism with evidence of right atrial/IVC thrombus and high risk in setting of systolic heart failure, the patient received Tissue plasminogen activator 50mg for 3 hours, and later heparin drip was initiated. The patient was started on antibiotics for possible community-acquired pneumonia along with dexamethasone & remdesivir for COVID. Given extensive meth use, there could be an acute exacerbation of chronically depressed ejection fraction in a setting of pulmonary embolism. A repeat echocardiogram did not show decrease in the size of the clot. The patient was transferred to a higher level of care for mechanical thrombectomy.

IMPACT/DISCUSSION: COVID-19 is primarily understood to be a respiratory infection, but it undoubtedly results in systemic illness that affects multiple systems. The high incidence of thromboembolic events is one distinctive clinical characteristic of COVID-19. In most cases, severe pulmonary parenchymal disease secondary to COVID-19 is associated with a higher incidence of thromboembolic complications, however, this was the opposite in the this case report.

CONCLUSION: It is crucial to keep in mind that COVID disrupts the equilibrium between pro-anti thrombotic pathways. For prompt diagnosis and treatment, primary care physicians must maintain suspicion of thromboembolic events in COVID patients regardless of the severity of the pulmonary parenchymal disease. Echocardiography plays a quick and widely available tool to help in the diagnosis and early treatment of thromboembolism in COVID patients. Further studies with clinical presentations including mild COVID patients, respiratory parameters, and inflammatory or thrombotic markers are required to determine the set of patients that might benefit from prophylactic and treatment doses of thrombolytics and anticoagulants. Better empirical therapies, protocols, and early intervention could considerably lower COVID-19 mortality and morbidity.

THYROID STORM IN THE CRITICAL CARE SETTING – A UNIQUE CASE OF THYROTOXICOSIS PRESENTING AS VENTRICULAR FIBRILLATION

Wesley A. Robertson¹; Victoria Ramirez¹; Ivy Zi Qian Liu²; Jennifer O'Hea¹

¹Internal Medicine, The University of Arizona College of Medicine Phoenix, Phoenix, AZ; ²Midwestern University Arizona College of Osteopathic Medicine, Glendale, AZ. (Control ID #3877088)

CASE: Patient is a 47-year-old previously healthy female who presented to ED after out-of-hospital cardiac arrest. She awoke overnight with agonal breathing and abruptly became apneic. She was found to be in ventricular fibrillation and defibrillation was performed, with total pulseless time >30 minutes. On presentation, she was comatose with fixed and dilated pupils, and in atrial fibrillation with rapid ventricular response. Noted goiter on examination.

Family observed exertional fatigue, unintentional weight loss, and tremulousness over several months. Patient has history of remote IV drug use and current tobacco use but is otherwise healthy. She does not take medications. She does not regularly follow with a physician and did not seek medical evaluation for recent symptoms. Family history is negative for early cardiac death, autoimmune or endocrine conditions.

Labs revealed TSH<0.01 with elevated T3 (571 ng/dL) and FT4 (4.32 ng/dL). She was acidemic and hyperkalemic. Urine drug screen was positive for THC. CT head showed diffuse cerebral edema concerning for anoxic brain injury. Upon arrival to ICU, she continued to be in atrial fibrillation resistant to synchronized cardioversion. Echocardiogram revealed EF of 59%. Glucocorticoids and targeted temperature management were initiated. Given patient was hemodynamically unstable on 4 pressors, beta blockers were withheld. Thionamides were considered, but due to continued deterioration in her neurologic and hemodynamic status, the family requested comfort care and the patient passed.

IMPACT/DISCUSSION: Thyrotoxicosis leading to cardiac arrest is exceedingly rare. Thyroid storm is the extreme presentation of thyrotoxicosis, manifesting as a severe life-threatening hypermetabolic state. The most common underlying mechanism is Graves’ disease, followed by toxic multinodular goiter. Common inciting events include infection, myocardial infarct, diabetic ketoacidosis, hypoglycemia, and stress. Diagnostic criteria include lab findings of suppressed TSH and elevated serum free T3 or T4, as well as clinical symptoms. These include CNS manifestations and non-CNS including fever, tachycardia, diarrhea, and evidence of heart failure. This patient meets criteria for high likelihood of thyroid storm. Treatment includes supportive cooling, inhibition of new hormone synthesis with thionamides, inhibition of hormone release, and beta-adrenergic blockade. Peripheral conversion of T4 to T3 is prevented with steroids.

This case illustrates a rare presentation of thyrotoxicosis presenting as cardiac arrest in a previously healthy female with limited risk factors. The purpose of this report is to increase provider awareness to signs of thyrotoxicosis to aid in early identification and management.

CONCLUSION: ● Suspect thyrotoxicosis in patients with abnormal thyroid studies and hypermetabolic signs, including Vfib cardiac arrest

● Treatment consists of supportive cooling, thionamides, beta blockade, and steroids

THYROTOXICOSIS FACTITIA: WHAT DOES THE HEART GOT TO DO WITH IT?

Tre'Cherie Crumbs⁴; Stephanie C. Miller²; Bianca Yoo³; Modele O. Ogunniyi¹; Anne Van Beuningen¹

¹Cardiology, Emory University, Atlanta, GA; ²Morehouse School of Medicine, Atlanta, GA; ³Duke University, Durham, NC; ⁴Emory University School of Medicine, Atlanta, GA. (Control ID #3873069)

CASE: A 27-year-old male presented to the ED with acute onset of chest pain, dyspnea, and hemoptysis. Notable vital signs included fever of 38.2°C, HR 132 bpm, and respiratory rate of 28 requiring CPAP for oxygenation. Cardiovascular exam was otherwise unremarkable. HS-Troponin was 12,000 and EKG showed inferolateral ST segment elevation and ST depressions in the reciprocal leads. Other notable labs included elevated ESR, CRP, and WBC. TSH was undetectable with elevated free T3 of 14, and normal free T4 levels. Viral panel was negative. There was no evidence of pulmonary embolism on the chest CT Angiogram but pulmonary edema was present. Transthoracic echocardiogram (TTE) showed severely reduced LV ejection fraction (LVEF) and inferolateral wall motion abnormalities. The patient went for a left and right heart catheterization which revealed clean coronary arteries and elevated left and right sided filling pressures with PCWP of 24 mmHg and normal cardiac output and index. Cardiac MRI displayed evidence of myocarditis. He received IV methylprednisone, intravenous diuretic, and was started on guideline directed medical therapy (GDMT) for heart failure. Endocrinology was consulted and further history revealed the use of Liothyronine 25 mcg TID 2 weeks prior to admission for weight loss. He was diagnosed with Thyrotoxicosis Factitia and a beta blocker therapy was initiated. He was counselled on cessation of exogenous T3 supplementation. Thyroid levels returned to normal by discharge. Repeat TTE showed LVEF of 45% and he was discharged on GDMT with Heart Failure clinic follow up.

IMPACT/DISCUSSION: Elevated thyroid hormone levels have direct effects on the heart and can lead to overall hemodynamic instability. Cardiovascular complications resulting from untreated acute thyrotoxicosis are associated with higher mortality rates. Thyrotoxicosis factitia is defined as a hyperthyroid state induced by accidental or intential ingestion of thyroxine. As such, a detailed medication history that includes supplements will facilitate prompt diagnosis and treatment of exogenous thyrotoxicosis. Thyroid disorders should be considered in the differential diagnosis of patients presenting with symptoms of new onset heart failure or myocarditis.

CONCLUSION: Elevated thyroid hormone levels can have devastating cardiovascular effects and result in hemodynamic instability. Untreated Thyrotoxicosis can lead to the development of both acute myocarditis and new onset left ventricular dysfunction.

TORSADES DE POINTES INDUCED CONVULSIVE SYNCOPE MIMICKING EPILEPTIC SEIZURES

Harika Bollineni¹; Arsalaan Choudhry²; Paul J. Wapner²; Jnana A. Challa³

¹School of Medicine, Wayne State University School of Medicine, Detroit, MI; ²Internal Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA; ³Ascension St. John, Detroit, MI. (Control ID #3875073)

CASE: A 48-year-old female with a past medical history of obesity and cholecystectomy presented to the ED after an episode of syncope in the morning. She reports after waking up, she lost consciousness for 10 minutes and the episode was witnessed by her husband. The patient’s husband reported he was unable to wake her up despite shaking her. He denied any urinary incontinence, tongue biting, or head trauma. Patient reports associated nausea and chest tightness. She denies any lethargy or focal neurological deficits after regaining consciousness.

On admission, cardiology was consulted due to her elevated troponin and was scheduled for cardiac catheterization(CC) the next day. While being transferred to the CC lab, she experienced another syncopal episode with associated myoclonic activity. She was immediately given 1g levetiracetam and 2mg Ativan per epilepsy protocol. At this time, neurology was consulted, and a neurogenic etiology was favored. Thus, her CC was placed on hold in pursuit of obtaining an emergent brain MRI and EEG. During the brain MRI, she experienced yet another syncopal episode with associated myoclonic activity. Rapid response noted the primary problem as polymorphic ventricular tachycardia, Torsades de Pointe given her QTc prolongation.

The EEG revealed no epileptiform activity during this episode. Consequently, levetiracetam was discontinued.

IMPACT/DISCUSSION: When working up causes of transient loss of consciousness with associated myoclonic activity, cardiogenic etiologies should be carefully evaluated. The delay of recognition of a cardiogenic etiology may delay appropriate treatment resulting in cardiac muscle damage and unnecessary complications. In addition, anticonvulsant medications have side effect profiles that could be avoided with a timely diagnosis. In our patient, the delay in identifying that the diagnosis as convulsive syncope secondary to Torsade de Pointes resulted in us administering levetiracetam, a QTc prolonging agent. While our patient already had a prolonged QTc at baseline, inappropriate administration of levetiracetam may have further prolonged her QTc thus inducing a ventricular tachycardia storm.

It is essential to rule out cardiogenic causes of convulsive syncope prior to administering antiepileptics. This can be done by a thorough inpatient workup with cardiac telemetry, evaluation of CK and lactic acid levels, EEG during episodes, and neurology and EP specialists on consult. If the convulsive syncope episodes are not reproducible during the admission, a Holter monitor should be considered with strict outpatient follow-up to assess for underlying cardiogenic etiology. Administering anticonvulsants without ruling out a cardiogenic cause may lead to irreparable damage and poor patient outcomes.

CONCLUSION: 1. It is vital include cardiac causes of loss of consciousness in differential diagnoses.

2. Distinguishing between convulsive syncope and epileptic seizures in a timely manner will lead to improved patient outcomes.

TRANSIENT ISCHEMIC ATTACK IN A PATIENT WITH LYMPHOCYTOSIS

Sohiel Deshpande¹; Sabah Iqbal¹; Karen Muindi¹; Krishna Desai¹; Niranjini Chandrashekaran¹; Akhil Jain²; Aisha Shaik¹; Rajesh Thirumaran³

¹Internal Medicine, Mercy Fitzgerald Hospital, Darby, PA; ²Medicine, Mercy Fitzgerald Hospital, Darby, PA; ³Hematology-Oncology, Mercy Fitzgerald Hospital, Darby, PA. (Control ID #3876590)

CASE: A 74-year-old male presented for evaluation of a 4-day history of intermittent leg weakness. His past medical history included coronary artery disease, hypertension, dyslipidemia and benign prostatic hyperplasia. His symptoms came on insidiously with left leg weakness, numbness, and tingling causing difficulties in ambulation. In the emergency room his vitals were heart rate 53, BP 164/83, respiratory rate 19 and SPO2 98% on room air. He was awake, alert and oriented to time, place, and person. His heart sounds were normal with no murmurs, rubs or gallops. There was no jugular venous distension. His abdomen exam was normal. Left lower extremity 1+ pitting edema was noted. Power was 5/5 in all 4 extremities. He had intact pinprick and temperature sensation in the upper and lower extremities symmetrically. Achilles deep tendon reflexes were absent bilaterally. No abnormalities in tone or coordination were appreciated on neurological examination. Romberg's test was negative. NIHSS was 0 but given the patient's presentation, he was admitted to the hospital for observation and for further work-up of possible cerebrovascular accident (CVA). Labs were significant for hemoglobin 14.8 g./dl, White Blood Cell Count of 8900 /ul, Differential Cell Count including Neutrophils 1800 /ul, Lymphocytes 6900 /ul, Eosinophils 200 /ul, Platelet Count 77000/ul, Total Protein 6.1 gm/dl, Albumin-globulin Ratio 2, INR 1, APTT 26 seconds, negative for Covid, Influenza A and B. CT and MRI of the brain did not reveal any acute stroke. As his symptoms were completely resolving within 24 hours without any deficit a diagnosis of TIA was made. In view of thrombocytopenia and lymphocytosis, Hematology-Oncology was consulted. Peripheral blood smear (PBS) revealed ‘soccer ball lymphocytes and smudge cells. Flow Cytometry revealed a monoclonal B- cell population with co-expression of CD5, CD23, and CD200, most consistent with chronic lymphocytic leukemia (CLL). However, CD20 and surface kappa light chain expression were not dimly expressed as is typical in CLL. IGVH mutation was found to be positive. He showed good response to steroids and Ibrutinib and did not have any recurrence of symptoms of TIA during his follow-up with Hematology till date (4 months).

IMPACT/DISCUSSION: Cancer-related CVA’s is a well-established phenomenon. This case is a unique presentation of CLL with isolated Lymphocytosis and thrombocytopenia without anemia. Hematological malignancies are known to cause hyper-viscous and hypercoagulable states. These are thought to be secondary to increased gamma globulins produced by the monoclonal proliferation of these B lymphocytes. Prognosis is usually good after initiating treatment.

CONCLUSION: CLL related lymphocytosis, in the absence of hyperleukocytosis, may be the cause of thrombotic episodes like TIA in our case.

TRANSIENT VISUAL HALLUCINATIONS IN A PATIENT WITH SUBACUTE RIGHT OCCIPITAL ISCHEMIC CVA

Raphael J. Crum¹; Matthew Fisch¹; Thanmayi Palegar⁴; Ngozi Osuji²; Rami Yanes²; Tyler Tate²; Jillian Kyle³

¹Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²Internal Medicine, UPMC, Pittsburgh, PA; ³Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ⁴UPMC, Pittsburgh, PA. (Control ID #3875965)

CASE: A 61-year-old female presented with a 2-week history of vertigo, vision changes, and vivid visual hallucinations with insight. During this time, she also endorsed the perception of light flashes and visual deficits in her peripheral vision. She reported no other neurological symptoms. Medical history was notable for mechanical mitral valve replacement secondary to bacterial endocarditis and atrial fibrillation. She was on rivaroxaban for anticoagulation due to dietary preferences and history of warfarin nonadherence despite adequate counseling. She had no history of underlying psychiatric illness, migraine headache, prior stroke, or transient ischemic attack. The remainder of her medical, surgical, and family history were non-contributory.

Vital signs were within normal limits. The neurological exam was notable for left pronator drift and left superior quadrantanopia with visual neglect consistent with an NIH stroke scale value of three. She endorsed vivid and benign visual hallucinations of insects, small fish, and a small “merry-go-round" in her room but retained insight into the unreal nature of her hallucinations. She did not report any non-visual hallucinations. The remaining neurologic and physical exams were grossly normal. Labs were within normal limits. CT head and MRI brain revealed subacute infarcts of the right occipital lobe, right insular cortex, and right basal ganglia. Her findings were thought to be consistent with cardioembolic stroke due to suboptimal anticoagulation in a patient with high clotting risk. Visual hallucinations with retained insight, visual field deficits, and occipital lobe infarct on imaging were consistent with acute-onset Charles Bonnet syndrome (CBS). Her hallucinations resolved prior to discharge.

IMPACT/DISCUSSION: CBS is a phenomenon characterized by visual hallucinations with insight in patients with intact cognition and without underlying psychiatric illness after evidence of vision impairment or loss. This is due to damage anywhere along the visual processing pathway which includes the eye, optic nerve, or brain. The specific underlying cause of this syndrome is unknown, but it is thought that these visual hallucinations are a product of absent afferent visual stimulation and disinhibition of the occipital cortex. While most documented cases occur in older individuals with structural damage to the afferent visual pathway (eye or optic nerve), here, we present a case of acute onset, transient Charles-Bonnet syndrome as an uncommon presentation of sub-acute occipital ischemic CVA.

CONCLUSION: Visual hallucinations with insight may represent an uncommon symptom of cerebral vascular disease. There are no evidence-based therapies for CBS and the mainstay of treatment includes reassuring patients that these are benign hallucinations, they are not indicative of underlying psychiatric disease, and many patients achieve resolution of these hallucinations.

TRANSVERSE MYELITIS MASQUERADING AS LIMB ISCHEMIA

Shangnon Fei

Internal Medicine, Washington University in St Louis, St Louis, MO. (Control ID #3853539)

CASE: A 60 year old male patient with a PMH of diabetes mellitus type 2, hypertension, hyperlipidemia, bilateral lower extremity peripheral vascular disease s/p multiple interventions, who presented to the hospital with worsening ambulation. When he was home, he was unable to move his right leg at all but was able to move the left leg, and moved himself around the house by hopping on his left leg with his walker. He was found on CTA to have complete occlusion of the R common femoral artery.

Upon initial exam, he had RLE cool from knee down with discoloration from the lower calf to the foot. LLE was warm with dopplerable signals down its length. However, he exhibited flaccid paresis of the bilateral lower extremities and was also incontinent of stool and urine. His exam was also significant for absent sensation to pain up to three inches above the belly button and absent lower extremity reflexes, prompting MRI of the total spine. The MRI found diffuse T2 hyperintense expansion of the lower cervical and upper thoracic cord extending from the C7 level through the T8 level concerning for intramedullary tumor or transverse myelitis. Brain MRI was negative for demyelinating lesions. PET-CT was negative for malignancy. Anti-MOG IgG autoantibodies were negative. LP showed a CSF white blood cell count 38/mm³ and protein level 75 mg/dL with present oligoclonal bands. Treatment with high dose glucocorticoids was initiated after R AKA.

IMPACT/DISCUSSION: Transverse myelitis is characterized by acute or subacute development of motor, sensory, and/or autonomic dysfunction. Autonomic symptoms include increased urinary urgency, bladder and bowel incontinence, difficulty with voiding or inability to void, bowel constipation, and sexual dysfunction.

Vascular pathology causing critical limb ischemia can easily mask concomitant neurologic pathology. This patient's initial disposition, clinical impression and care plan were impacted by providers anchoring on his known vascular pathology, and it was only through thorough neurologic examination that it was realized that he had neurologic deficits beyond the extent of his vascular occlusion. Objective lower extremity weakness or sensory deficits accompanied by bowel and bladder dysfunction should always trigger prompt investigation of spinal pathology.

CONCLUSION: Lower extremity weakness should always prompt a broad differential diagnosis, and "red flag" neurologic symptoms such as new bowel or bladder dysfunction deserve urgent spinal imaging.

TREPONEMA PALLIDUM INFECTION PRESENTING AS VISION LOSS

Tony Sun

Medicine, University of Rochester Medical Center, Rochester, NY. (Control ID #3867681)

CASE: A 50-year old man, with an unremarkable past medical history, has painless loss of vision. The symptoms began one month ago, acute in onset. There were no specific aggravating or relieving factors, but he did note associated changes in depth perception and occasional floaters and light flashes. His social history is notable for a new sexual partner two months ago. He has not noticed any rashes or skin lesions. After onset of visual symptoms, he called his primary care physician, who referred him to ophthalmology. The patient

was seen one month after onset of symptoms and was found to have a visual acuity of 20/100 in his right eye, 20/20 in his left eye. An RPR test was positive with a 1:256 serum dilution. The patient was then instructed by his ophthalmologist to go to a hospital for treatment. On admission, he reports no fevers or chills, no nausea or vomiting, no photophobia, and no neck stiffness. He describes a “dark cloud” in the center of his right visual field, largely unchanged from one month ago. Exam reveals a central visual field deficit and reduced visual acuity in his right eye. He has equal and reactive pupils, intact extraocular movements, and normal acuity and fields in his left eye. Romberg testing is negative. A head MRI reveals no hemorrhage or ischemia, and no contrast enhancement in the optic nerves. Labs are notable for a positive T. pallidum serum agglutination test, and a positive CSF fluorescent treponemal antibody (FTA) test, despite a negative CSF VDRL test. A diagnosis of neurosyphilis was made based on history, exam, and CSF lab results. The patient completed a 14-day course of IV penicillin. Remarkably, follow-up eye exams showed a visual acuity of 20/50 at treatment conclusion, and 20/30 at four weeks afterward.

IMPACT/DISCUSSION: Treponema pallidum is capable of infiltrating many organ systems, including the CNS. A 2015 study found the prevalence of CNS involvement to be 3.5% based on CSF testing. After primary infection, spirochetes cross endothelial cell junctions and enter the circulation. From the blood, these organisms can cross the blood-brain barrier through a mechanism involving proteases. These processes occur within days following primary infection. Acute neurologic symptoms can appear within months and include meningeal signs (headache, nausea, photophobia) and cranial nerve deficits. Our patient presented with a cranial nerve II deficit, resulting in poor visual acuity and visual field loss.

CONCLUSION: The case highlights the importance of combination VDRL and FTA testing in CSF if ocular syphilis is on the differential for vision loss. The case is also notable for recovery of visual acuity following antibiotic treatment.

TRIPLE THREAT: A CASE OF SEVERE CO-INFECTION OF BABESIA, LYME, AND SARS- COV-2

Eliot Rapoport²; Nora Feeney²; Lila Murphy²; Alan Ge²; Serena L. Roth¹

¹Department of General Internal Medicine, Montefiore Medical Center, Bronx, NY; ²Internal Medicine Residency Program, Montefiore Medical Center, Bronx, NY. (Control ID #3877124)

CASE: A healthy middle-aged man living in New York City had acute onset fever, cough, and myalgias, followed by a self-limited centrifugally spreading erythematous rash sparing palms and soles. A COVID-19 test was positive on day 7 of illness. On day 14 he developed left upper abdominal pain and presented to the ED. Upon admission he was febrile to 102.5, with labs notable for new hyponatremia, anemia, thrombocytopenia, hyperbilirubinemia, and transaminitis. Further history revealed that he frequently hunted outside of the city. Testing was sent for tick-borne illness and the patient was empirically started on doxycycline in addition to ceftriaxone and azithromycin due to interstitial infiltrates seen on chest x-ray. Blood smear showed hemolysis and 3% parasitemia with babesiosis microti; antibiotics were changed to atovaquone and intravenous azithromycin and doxycycline. The patient’s clinical status worsened with persistent fevers, progressive somnolence, and hypoxemic respiratory failure requiring intubation and exchange transfusion. On hospital day 8, Lyme panel returned consistent with active infection; ceftriaxone was restarted for presumed neuroborreliosis. He was ultimately extubated and discharged home on hospital day 24.

IMPACT/DISCUSSION: The incidence of tick-borne illnesses including Babesiosis and Lyme disease has risen in recent decades, fueled by climate change, land development, and deforestation. In endemic areas, about half of patients with Babesiosis may be co-infected with Lyme disease, highlighting the importance of testing patients with Babesiosis for other tick-borne illnesses. Evidence is mixed as to whether coinfection results in more severe clinical presentations, with one study showing co-infected patients had a longer duration of symptoms and another reporting shorter illness. To our knowledge, this is the first reported case of concurrent Babesiosis, Lyme, and COVID-19 infections, but given the ongoing COVID pandemic, this triple infection will likely be seen again. Our patient had no risk factors for severe disease such as immunocompromise, and it seems likely that his progression to critical illness was a result of his triple infection with Babesia, neuroborreliosis, and SARS-CoV-2. Given the rising incidence and expanding geography of tick-borne disease, our report highlights the importance of familiarity in diagnosing and treating these complex syndromes, and maintaining a high index of suspicion for potential coinfections, including in some urban environments.

CONCLUSION: In patients with persistent fevers, hemolysis, rashes or other non-specific symptoms, tick- borne disease should be strongly considered given their increasing incidence.

Concomitant Babesia and Lyme infections are not uncommon but do not always result in more severe disease.

Triple infection with Babesia, Lyme, and SARS-CoV-2 led to critical illness in an otherwise healthy patient, suggesting the possibility of more severe presentations in triple infected patients.

TRUST BUT VERIFY: TORSADES WITH A NORMAL QTC

Kirollos Roman¹; Alonso I. Heudebert²; Robert M. Centor²

¹Internal Medicine-Pediatrics, UAB Hospital, Birmingham, AL; ²Medicine, UAB Hospital, Birmingham, AL. (Control ID #3874602)

CASE: A 47 year old female with chronic lower back pain on methadone and anxiety presents to the emergency department with intermittent daily presyncope with a prodrome for 2 weeks, with episodes lasting 10-20 seconds with unidentifiable triggers. 2 days prior, she was hospitalized following a GTC seizure, with a reportedly normal CT head, ECG, and bloodwork. There is no family history of sudden cardiac death, arrhythmias, or seizures.

On presentation, her heart rate is 49bpm with otherwise unrevealing vital signs, physical exam, and initial bloodwork. ECG reveals sinus bradycardia without ST changes and is unchanged from prior ECGs. She then experiences a brief symptomatic episode aligning with a 10 second run of polymorphic ventricular tachycardia on telemetry. Cardiology is consulted and note that, despite a normal computer-generated QTc interval, manual calculation reveals a QTc of 560ms thus confirming LQTS complicated by TdP. The patient is admitted and receives a biventricular pacemaker with resolution of symptoms. Genetic testing ultimately reveals heterozygous CACNA1C-mutation associated with congenital LQTS.

IMPACT/DISCUSSION: The key to solving this case hinged on manual evaluation of the ECG to reveal the occult QTc prolongation. This demonstrates the importance of recognizing salient clinical features that either yield falsely normal QTc intervals and/or necessitate careful QTc calculation. Considering historical data demonstrating patients with LQTS being misdiagnosed as having primary seizure disorders, patients with first time seizures, syncope, or recurrent pre-syncope — even with a seeming prodrome — warrant deliberate, manual calculation of the QTc. Additionally, bradyarrhythmias not only independently increase risk for LQTS and TdP, they also consistently confound both the computer-generated QTc and the “half R-R interval” rule, thus yielding many falsely normal QTc intervals. Finally, our patient’s gain-of-function mutation in CACNA1C — a minor LQTS-susceptibility gene with variable penetrance — was likely subclinical prior to initiation of methadone, a notorious QT-prolonging drug. This explains the atypically late age of presentation and lacking family history, and even more strongly iterates the need for appropriate QTc monitoring when initiating or titrating known QT-prolonging drugs.

CONCLUSION: Patients that warrant a manually calculated QTc include those with: profound bradyarrhythmias; U-waves, as these not only confound computer-generated QT but also occur primarily in the setting of bradycardia and hypokalemia, both of which are independent risk factors for TdP; or any patient with first-time seizure, syncope, or recurrent presyncope. Additionally, although the absence of prodrome is indeed fairly specific for high-risk or cardiac syncope, it is not sensitive — hence, caution should be taken when intepreting the presence of syncopal prodrome in order to mitigate false reassurance against cardiac syncope.

TWO CASES OF CRYPTOCOCCAL PNEUMONIA IN IMMUNOCOMPETENT HOSTS AFTER MILD COVID-19 INFECTION

Jordan Cahn¹; Ayesha H. Sundaram¹; Linda Shipton²

¹Internal Medicine, Cambridge Health Alliance, Cambridge, MA; ²Infectious Diseases, Cambridge Health Alliance, Lincoln, MA. (Control ID #3872763)

CASE: In February 2022, two young healthy individuals presented to our hospital in New England and were found to have nodular lung infiltrates. Both patients had prior COVID-19 infection within the last 3 months with mild respiratory symptoms that completely resolved. Neither required hospitalization or treatment for COVID-19. Both were up-to-date on COVID-19 vaccinations prior to their infections.

Patient 1 presented with several days of fever, right sided back/shoulder pain, and a cough for one day. CT imaging showed multifocal nodular consolidations. There was initially concern for multifocal bacterial pneumonia, but her symptoms worsened despite treatment for community acquired pneumonia. After further workup, she had a positive serum cryptococcal antigen (1:1280) and lumbar puncture with negative CSF cryptococcal antigen. BAL was negative for AFBs, bacteria, and other fungi. Patient 2 presented with right- sided chest pain and CT imaging showed a right lung mass with multiple pulmonary nodules. Initially there was concern for malignancy and a subsequent PET scan had moderate FDG uptake. She then had a BAL and fungal cultures grew Cryptococcus neoformans. Both patients were diagnosed with cryptococcal pneumonia. Neither had traveled recently nor had known contact with birds or soil. Both patients began treatment with fluconazole and had symptomatic and radiologic improvement.

IMPACT/DISCUSSION: An increase in secondary invasive fungal infections (IFIs) was noted during the COVID-19 pandemic. Higher likelihood of infection was seen in patients on mechanical ventilation, with prolonged hospital stay, and undergoing treatment with immunomodulatory agents. Several studies have shown the prevalence of invasive candidiasis, aspergillosis, and mucormycosis among critically ill COVID-19 patients as well as rare cases of disseminated cryptococcal infection in the setting of similar risk factors. Our report highlights two cases of pulmonary cryptococcal infection in immunocompetent patients who did not have any risk factors prior to their COVID-19 infections. Per our literature review, these are the first reported cases of invasive cryptococcal infection following mild COVID-19 in immunocompetent hosts. While we cannot prove that COVID-19 pneumonia predisposed these patients to cryptococcal pneumonia, the association should not be dismissed and we urge clinicians to include it on their differential.

CONCLUSION: Cryptococcal pneumonia is an important IFI to consider in patients with persistent nodular pulmonary infiltrates following COVID-19 infection, regardless of immune status or COVID-19 severity.

TYPICALLY ATYPICAL: DIAGNOSTIC AND THERAPEUTIC MISSTEPS IN A CASE OF COMMUNITY ACQUIRED PNEUMONIA

Rachel S. Tenney, Scott Fabricant, Helene Strauss, Peggy B. Leung

Internal Medicine, New York Presbyterian/Weill Cornell, New York, NY. (Control ID #3876876)

CASE: An 84M w/ dementia was brought to the ED after a fall at his long-term care facility (LTCF). History was obtained by his daughter who noted increased confusion, which she attributed to pt’s recent cross- country move involving multiple flights and overnight hotel stays.

In the ED, vitals and CBC were normal. Imaging studies were obtained to evaluate for fractures after the fall. CT Chest showed bilateral pulmonary nodular opacities and mediastinal adenopathy, representing either an infectious or metastatic process. Without fever, hypotension or leukocytosis, a metastatic process was favored. The pt was discharged and told to undergo outpatient malignancy workup.

24h later, the pt returned to the ED with increased confusion. He was admitted and fevered to 40*C. Vancomycin and Zosyn were started.

Now febrile, infection was high on the differential. PNA was considered most likely due to the CT Chest findings. A PNA workup was sent and included: sputum culture, RVP, MRSA nares, procalcitonin, Fungitell and galactomannan.

The patient continued to worsen. 72h after presentation, a workup for atypical PNA was sent. Legionella urine antigen returned positive 2h later. All other antibiotics were discontinued and azithromycin was started. Despite starting appropriate treatment for Legionella PNA, the pt did not survive the infection.

IMPACT/DISCUSSION: This case highlights the importance of epidemiologic characteristics in creating diagnostic and therapeutic plans, and exemplifies how cognitive biases can delay accurate diagnosis and appropriate treatment.

Initially, the differential diagnosis (ddx) did not prioritize an infectious process. This may represent an anchoring bias: clinicians did not consider infection because the pt was afebrile, normotensive and without leukocytosis. However, in older adults, infection often presents without fever and leukocytosis. Increased confusion or fall may be sentinel signs of infection in older adults and should prompt an infectious workup.

Additionally, the PNA workup evaluated for viral, fungal, and typical bacterial pathogens. However, the pt lived in a LTCF and had a recent travel history. Per IDSA and CDC guidelines, these epidemiologic risk factors should have prompted Legionella testing earlier in the clinical course.

Finally, Vancomycin and Zosyn were started empirically. This may represent an availability bias, as Vancomycin and Zosyn are commonly selected as empiric antibiotics in severe illness. However, this pt had epidemiologic characteristics concerning for an atypical pathogen, like Legionella. Indeed, IDSA and institutional guidelines recommend a macrolide, such as azithromycin, in empiric coverage of CAP.

CONCLUSION: Epidemiologic data (age, travel history, and location of residence) provide invaluable information for planning workup and treatment. Cognitive biases can delay appropriate evaluation and therapy. Generating a broad ddx and referencing institutional and society guidelines can mitigate the impact of cognitive biases.

UNA”PEELING” CIRCUMSTANCES: A RARE CASE OF ACRODERMATITIS ENTEROPATHICA IN ADULTS

Aarthi Venkatramanan¹; Ritika Gadodia¹; Benjamin G. Goodwin¹; Deborah Topol¹; Freba Farhat²

¹Internal Medicine, MedStar Washington Hospital Center, Washington, DC; ²Dermatology, MedStar Washington Hospital Center, Washington, DC. (Control ID #3875089)

CASE: A 36-year-old female with a past medical history of depression, alcohol use disorder and morbid obesity, status post Roux-en-Y gastric bypass presented for a one week history of dizziness, and one month of progressive, symmetrical rashes over her breast, buttocks, thighs, popliteal and cubital fossae. The rash was hyperpigmented, blistering, painful and associated with superficial skin sloughing. Examination was also significant for glossitis. The differential diagnoses included SDRIFE (Symmetrical Drug-Related Intertriginous and Flexural Exanthema) since she had been recently started on buspirone and quetiapine, DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms), and nutritional deficiencies including vitamin B12 and Zinc. The suspected culprit drugs were discontinued, and she eventually underwent a shave biopsy of the breast lesions. Her lab work was revealing for a low zinc level of 27.2 mcg/dL (N:70-180 mcg/dL) and low copper levels of 40 mcg/dL (N: 63.7-140.12). The dermatopathological assessment revealed extensive parakeratosis, psoriasiform epidermal hyperplasia and mild focal spongiosis. The dermis featured a superficial perivascular lymphohistiocytic infiltrate. Although non-specific, the findings were deemed to be consistent with nutritional deficiency given the clinical context. The patient was started on 4mg IV Zinc chloride and 2mg IV Copper chloride supplementation and began to show an improvement of her symptoms. On discharge, the patient was transitioned to oral zinc and copper supplementation, in addition to thiamine and pyridoxine. The psychotropic medications were restarted and skin regrowth was noted at the time of discharge.

IMPACT/DISCUSSION: Acrodermatitis enteropathica references a group of disorders of zinc metabolism. The acquired form is increasingly rare in adults and has been documented in patients with conditions including chronic ethanol abuse, chronic pancreatitis, and patients who have undergone upper intestinal bypass procedures. It is also more common in regions such as southeast Asia and sub-Saharan Africa where gastro-intestinal malabsorption syndromes are more frequent. Because acrodermatitis enteropathica presents similarly to other common dermatological conditions, it can prove to be a diagnostic challenge.

It is important to ensure diagnosis of zinc deficiency, as it is associated with many complications such as diarrhea, lung and gastrointestinal infections and poor wound healing, which can potentially be fatal. It is also important to anticipate secondary copper deficiency, since zinc-induced formation of metallothionein on the intestinal epithelial cells can inhibit copper absorption.

CONCLUSION: This case illustrates the importance of considering vitamin and mineral deficiencies for progressive, symmetrical rashes. Patients who undergo bariatric surgery are at increased risk, and this case highlights the importance of adequate counselling regarding nutritional supplementation as well as close outpatient monitoring.

UNCOMMON PRESENTATION FOR LATE-LATENT SYPHILIS IN 28-YEAR-OLD MSM MALE WITHOUT RECENT SEXUAL CONTACT

Robert E. Foster¹; Dheepa R. Sekar²

¹Internal Medicine, Emory University School of Medicine, Atlanta, GA; ²General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #3876610)

CASE: The patient was a 28-year-old male who presented with a persistent headache for 5 days in the setting of several recent urgent care visits for abdominal pain that showed cholestatic liver injury. His headache was initially mild and progressed to severe pain rated 10/10. His headache was not improved with ibuprofen. The headache was bilateral, frontal, and associated with photophobia but without aura, lacrimation, or jaw claudication. He also had developed a new rash on his genitals. On exam he had several discrete localized lesions covering his scrotum and penis. The lesions were in varying stages of development and healing. Newer lesions were macular, non-erythematous with a dry scaling roof. Older lesions were clean, non- erythematous with a granular base. Sexual history was pertinent for MSM contact with most recent sexual contact being a year before his symptoms began.

Prior emergency department visits were notable for a chief complaint of left upper quadrant and epigastric abdominal pain associated with nausea and vomiting. Evaluation revealed a cholestatic liver injury pattern. Imaging studies including x-ray, a CT abdomen/pelvis and abdominal ultrasound revealed normal findings. Over his subsequent visits his liver enzyme studies demonstrated improvement in AST and ALT but an upward trend in ALP. HAV, HBV, HCV, and HIV studies performed on previous encounters for abdominal pain were negative. His abdominal pain, nausea and vomiting subsided before his headache began.

During our evaluation, we considered infectious etiologies including HIV and syphilis (given the latency of symptoms). We also considered autoimmune etiology including lupus, PBC, and PSC. The result of our work up revealed a positive RPR with a 1:64 titer and patient was diagnosed with secondary syphilis, consistent with delayed presentation from original exposure. CSF studies were negative for VDRL.

IMPACT/DISCUSSION: In 2020, there were 41,655 cases of primary and secondary syphilis with rates increasing year over year. Over 80% of new diagnosis are reported in men. The rise in rates is primarily attributable to men who have sex with men.

Secondary syphilis often presents with a rash that classically involves palms and soles. Localized lesions can also occur. While our patient’s genital rash was a clue to the sexually transmitted origin of his illness, it was the absence of recent sexual contact that increased our suspicion of syphilis. Other typical findings of secondary syphilis support this diagnosis, including onset of headache and hepatitis.

CONCLUSION: We reflexively order HIV when immune compromise or systemic viral illness is suspected. Yet, only with specific complaints, like encephalopathy, do we routinely rule out syphilis. Given the evidence presented in this case, we recommend assessing for the “great imitator” when a systemic illness is ongoing and sexually transmitted infection is suspected, especially when patients endorse a remote history of sexual contact.

UNCOVERING RAMSEY HUNT AND VZV ENCEPHALITIS

Sarah Grant, Jordan Nickols, Nathan Douthit

Internal Medicine Residency Program, East Alabama Medical Center, Opelika, AL. (Control ID #3871404)

CASE: An 80-year-old female with type 2 diabetes, hypertension, hyperlipidemia, asthma, and morbid obesity presented to the emergency department (ED) for altered mental status. Two days prior to admission she was seen in the ED for a perforated right ear drum, was treated and sent home with ENT follow-up.

On the day of admission, she had a fever of 102 F, vital signs were otherwise stable. On exam, she was able to follow commands but unable to vocalize. Kernig and Brudzinski signs were negative, and no focal neurological deficits were appreciated. Multiple ulcerations on her hard palate and posterior oropharynx were seen along with continued purulence of her right ear. Labs were notable for white count of 8.2x10³/mcl and CRP of 6.0 mg/dl. CT brain was negative for an acute process. Broad spectrum antibiotics and acyclovir were initiated.

On day two, she developed a right upper and lower facial droop with mild ptosis indicative of Bell’s Palsy attributed to infection or compression of cranial nerve VII. MRI showed no significant abnormality and MRV was non-diagnostic and could not rule out a cerebral venous sinus thrombosis. CSF from lumbar tap revealed 608 white blood cells (29% lymphocytes), 134 mg/dl of glucose, and 111 mg/dl of protein. CSF was then sent for a viral panel, AFB smear, HSV/CMV PCR, and mycoplasma tests. CSF viral panel result was positive for varicella encephalitis. Oral ulcerations, involvement of ear, and Bell’s palsy denoted Ramsay Hunt syndrome. Ceftriaxone and acyclovir were continued along with a seven-day course of prednisone and taping of her right eye.

IMPACT/DISCUSSION: Ramsey Hunt Syndrome is diagnosed clinically and has a classic triad of unilateral facial paralysis, otalgia, and vesicular rash which do not always present simultaneously. 80% of cases have a vesicular rash affecting the ear and or the mouth, making 20% of cases indistinguishable from Bell’s palsy. Fluid filled blisters can be sampled to confirm diagnosis if present. Bell’s Palsy and Ramsey Hunt are treated with a glucocorticoid along with eye taping and artificial eye lubricants. Acyclovir, however, is necessary for Ramsey Hunt treatment. Additional options are carbamazepine for neuralgic pain and antihistamines, anticholinergics, or valium for vertigo. Delayed or untreated Ramsey Hunt can lead to permanent hearing loss and facial paralysis.

VZV encephalitis is most prevalent in the elderly and children. Elderly patients with VZV encephalitis are at a higher risk of ischemic and hemorrhagic strokes, meningitis, and venous sinus thrombosis. Mortality if untreated ranges from 5-10% and 80% if they are immunocompromised. Survivors can be left with memory loss, emotional disturbance, and slowed cognition.

CONCLUSION: This case highlights the importance of early recognition of VZV encephalitis as well as tying together the triad of Ramsey Hunt to appropriately discern from Bell’s Palsy. Prompt treatment with acyclovir in both conditions can minimize serious and even life-threatening complications.

UNEXPECTED ORIGIN OF SPINAL LESION

Rhoshini Rajasekaran¹; varshitha kondapaneni²; jewell Halanych¹

¹Internal Medicine, The University of Alabama at Birmingham, Birmingham, AL; ²Internal Medicine, The University of Alabama at Birmingham Montgomery, Montgomery, AL. (Control ID #3872892)

CASE: 62-year-old man with a history of lung cancer treated with chemoradiation presented with back pain.

MRI spine showed a lytic lesion at the T2-T3 vertebra. Initially thought to be metastatic, the lesion was biopsied, and further evaluation pointed to infectious etiology. The patient denied fevers, chills, weight loss, dysphagia, radicular pain, or weakness. In the past, he underwent thoracic spine corpectomy and fusion from T5 to T10 with a metal implant. On exam, he was afebrile and other vitals were normal. He had no saddle anesthesia, leg weakness, or spinal tenderness. His initial labs were unremarkable except for elevated sedimentation rate and C-reactive protein. Though blood cultures were negative, bone biopsy and culture grew C. albicans, Lactobacillus, and S. mitis/oralis. A barium esophagram was negative for fistula but a CT chest showed a fistula extending from the posterior wall of the thoracic esophagus to the lytic lesion at the T2-T3 level. Antibiotic therapy with penicillin G and fluconazole was started. He underwent endoscopic stenting of the esophagus for palliation. His MRI showed inflammation possibly extending to the T5 level near his prosthesis. Since the eradication of infection is difficult in the presence of hardware, surgery was deferred, and he was medically managed.

IMPACT/DISCUSSION: Polymicrobial infections account for 9% of all vertebral osteomyelitis. In our case, the identified organisms were suggestive of the flora of the upper gastrointestinal tract flora. The common commensals of the upper GI tract include Streptococcus sp., Candida sp., Lactobacillus, H. pylori, and Prevotella. The more common mode of spread of spinal osteomyelitis is hematogenous, but contiguous spread can occur. Additionally, spinal hardware is an osteomyelitis risk factor, but S. aureus is the most common pathogen. Candida sp. as the predominantly isolated organism is seen in 1% of cases.

Radiotherapy for central lung tumors can cause trachea-esophageal fistulas in rare instances. Esophageal perforations, abscesses, and fistulas have been reported following stereotactic radiotherapy in patients with central non-small cell lung cancer. This case shows the importance of being aware of the long-term complications of radiation therapy in patients in remission.

CONCLUSION: The long-term complications of radiotherapy can present unusually and high suspicion is required to diagnose and treat these manifestations. Identifying the source of infection is crucial in the treatment of the underlying pathology. Polymicrobial spinal infection may be from the contiguous spread of infection.

UNMASKING THE GREAT IMITATOR - PERITONEAL TUBERCULOSIS MIMICKING SPONTANEOUS BACTERIAL PERITONITIS

Alejandro Nieto Dominguez, Enrique F. Martinez Trevino, Sarah E. Eichinger

Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, IL. (Control ID #3867698)

CASE: The patient was a 38-year-old man with a history of heavy alcohol and tobacco use, as well as cocaine use, who presented to the emergency department with diffuse abdominal pain, fever, chills, abdominal distention, and anorexia for four days. Laboratory studies showed an elevated serum ascites albumin gradient (SAAG) and a high white blood cell count with a predominance of neutrophils, monocytes, and lymphocytes. A CT scan revealed diffuse peritoneal enhancement and omental caking, and a liver duplex ultrasound showed cirrhotic morphology. The patient was started on ceftriaxone and albumin, and a biopsy was performed due to concerns for malignancy versus tuberculosis. The patient's fever persisted for several days despite antibiotic coverage. Subsequently, the patient was found to have an elevated ADA and omental biopsy results showed necrotizing granulomas. Acid-fast bacilli smears were negative at that time, but due to high clinical suspicion for peritoneal tuberculosis the patient was started on treatment with rifampin, isoniazid, ethambutol, and vitamin B6, then he was discharged home. A few days after discharge, acid-fast bacilli were found in the peritoneal fluid, further supporting the diagnosis of peritoneal tuberculosis. The patient is continuing treatment and has improved clinically, including resolution of his fever.

IMPACT/DISCUSSION: Peritoneal tuberculosis is one of the rarest presentations of tuberculosis, with an increasing incidence in the past years. Clinical presentation is variable, sometimes presenting as an acute illness, other times as chronic and intermittent. It is most common in patients less than 40 years of age. Risk factors include cirrhosis, diabetes mellitus and end stage renal disease on peritoneal dialysis. Signs and symptoms include ascites, abdominal pain, fever, diarrhea, constipation, diarrhea, weight loss, anorexia, and fatigue. Ascites is present in 90% of patients. SAAG is usually less than 1.1 g/dL. In our patient, SAAG was high, most likely due to his chronic liver disease and portal hypertension. Treatment regime includes isoniazid, rifampin, pyrazinamide, ethambutol, and streptomycin. Standard regime consists of 4 drugs for 2 months and then 2 drugs for 4 months or more. Nevertheless, if patient’s organism is sensitive to all drugs, treatment with 3 drugs is noninferior to a 4 drug regime. Given concerns for worsening our patient’s hepatic function, pyrazinamide wasn’t given and a 3-drug regime was opted with noted clinical improvement.

CONCLUSION: In patients with spontaneous bacterial peritonitis and persistent fever and worsening clinical condition despite appropriate antibiotic coverage, peritoneal tuberculosis should be considered as part of the differential diagnosis even if testing for acid-fast bacilli is negative.

UNMASKING TRIPLE POSITIVE ANTIPHOSPHOLIPID SYNDROME IN COVID-19 INFECTION: A CASE REPORT

Fareeha A. Khan

Hospital Medicine, Loyola University Health System, Maywood, IL. (Control ID #3857147)

CASE: 89 year old female with history of deep venous thrombosis treated with Coumadin and recent coronavirus-19 infection requiring hospital admission, presented with suprapubic pain radiating to the left lower extremity. Detailed review of systems did not reveal any localizing symptoms. Patient was hemodynamically stable and physical exam was notable for suprapubic tenderness, left lower extremity edema and tenderness. Laboratory workup was remarkable for chronic stable anemia, INR within therapeutic range and non-infectious urinalysis. CT abdomen/pelvis with contrast revealed marked enlargement and heterogeneous appearance of the inferior vena cava, bilateral common iliac, left renal and left gonadal veins suggestive of extensive deep venous thrombosis. A subsequent CT chest was negative for pulmonary embolism. Further testing, geared towards malignancy and hematological abnormalities was conducted. Cardiolipin IgM antibodies were noted to be highly elevated (119.7 MPL) as well as Lupus Anticoagulant ratio (1.64; reference range <1.21) and Beta 2 Glycoprotein IgM (>150 SMU; reference range <20SMU). This was confirmed over a span of 12 weeks.

Patient was diagnosed with Coumadin failure with triple positive antiphospholipid syndrome attributed to be uncovered by her recent COVID-19 infection. She was started on Apixaban and continued to improve with no further thrombotic events.

IMPACT/DISCUSSION: Vitamin K antagonists (VKA) are considered gold standard for secondary prophylaxis of high risk, triple positive antiphospholipid syndrome (APS) patients. However, the rate of recurrent thrombosis in such individuals ranges between 3-24%. While studies are ongoing to elucidate various contributory causes and optimal methods, the heterogeneity of antiphospholipid syndrome must be considered. Many studies have reported associations between antiphospholipid antibodies (aPLs) and infections, and as understood by the “two-hit” theory, this can then lead to eventual thrombosis. The correlation between COVID-19 infection and venous and arterial thromboembolism has been hard to ignore. However, data remains ambivalent with regards to causality versus the question of epiphenomenon.

CONCLUSION: Our case provides an interesting insight and stands unique due to previous diagnosis of well managed venous thromboembolism which resurfaced as VKA failure, weeks after having recovered from COVID-19 infection. Our patient’s triple positive status for aPLs, with the temporal association of COVID-19 infection may provide an answer to the much-debated causality question.

UNRAVELING A CASE OF EPIGASTRIC ABDOMINAL PAIN: A TALE OF TWO ARTERIES. Ishita Mehra¹; Abhinav Vyas¹; Harminder Vohra¹; Dania Kaur¹; Ahmed Gohar²

¹Internal Medicine, North Alabama Medical Center, Florence, AL; ²Critical Care, North Alabama Medical Center, Florence, AL (Control ID #3875551)

CASE: A 69-year-old female with no known medical history presented with 3 days of acute non-radiating, sharp epigastric abdominal pain, 10/10 in intensity, with nausea and non-bloody, non-bilious vomiting. Her initial vitals showed a pulse of 120 beats/min, BP 148/90 mmHg, respirations and saturation were normal. Diffuse abdominal tenderness was present. Labs reflected mild leukocytosis, normal lipase, and an elevated troponin I at 0.233. An EKG showed ST elevations in V3-V4 requiring urgent percutaneous intervention. A drug eluting stent was deployed in her proximal left anterior descending artery (LAD). Her clinical presentation was felt to be inconsistent with the nature of her coronary artery disease, therefore, a computed tomography (CT) of abdomen & pelvis with contrast was requested. This revealed a celiac artery in-situ thrombosis with splenic infarction. A lesion was also noted on her left seventh rib concerning for metastatic disease. Patient’s abdominal pain resolved without further intervention. Vascular surgery evaluated the patient and noted presence of good collateral circulation to her viscera precluding need for urgent surgery. General surgery recommended a conservative approach for the splenic infarction with appropriate vaccinations to be administered. She was discharged on full dose anticoagulation with follow up as an outpatient for a rib biopsy and repeat CTA abdomen/pelvis for surveillance of her celiac artery thrombus.

IMPACT/DISCUSSION: Cardiovascular disease (CVD) is a leading cause of mortality and morbidity in women; however, concomitant LAD disease, celiac artery thrombosis, and splenic infarction is rare and has not been frequently reported in literature. While patients can present with atypical symptoms for acute coronary syndrome, an anteroseptal infarct should not cause severe abdominal pain for multiple days. Splenic infarction independently is a very uncommon cause of abdominal pain and usually is a manifestation of underlying cardiovascular or hematological disease. A report stated only 10% of the patients with autopsy proven splenic infarcts were correctly diagnosed within their lifetime. Common causes of splenic infarcts include CVD and hematological malignancies, with some papers citing oral contraceptive use as a possible etiology. In the case we present above, both, an underlying prothrombotic state and high atherosclerotic burden appear to be contributing to the patient’s presentation. Literature suggests conservative management of celiac artery thrombosis and splenic infarction when there is presence of good collateral circulation and absence of splenic abscess or rupture. This patient had a combination of unusual co-existing vascular diseases making her clinical course unique.

CONCLUSION: Literature stresses on paying attention to atypical symptoms of acute coronary syndrome in women, however, acute abdominal pain has a vast differential diagnosis which should be adequately investigated based on the patient’s clinical presentation.

UNUSUAL PRESENTATION OF A COMMON DISEASE – COVID-19 WITH CHOLECYSTITIS Sarah Strausser¹; Mallory Peterson²; Rachel S. Casas³

¹College of Medicine, Penn State College of Medicine, Hershey, PA; ²Neurosurgery, Penn State College of Medicine, Hershey, PA; ³General Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA. (Control ID #3850065)

CASE: Ms. X is an 86-year-old female with hypertension who presented with 2 days of worsening RUQ pain, fever, nausea, vomiting, confusion, and skin yellowing. She recently traveled from India to the US. She had a BP of 135/110 with otherwise normal vitals. On exam, she had RUQ tenderness to palpation without rebound or guarding, scleral icterus, and mild confusion. Ultrasound showed biliary sludge with pericholecystic fluid without CBD dilation. Labs revealed transaminitis suggestive of biliary obstruction with ALT 156, T Bili 8.7, D Bili 7.0, AP 197, AST 100, and a mild leukocytosis 10.5. The patient was diagnosed with acute cholecystitis and ascending cholangitis and given piperacillin-tazobactam.

She underwent ERCP with one 3 mm stone, sludge, and pus swept from the duct after sphincterotomy. One biliary stent was placed with cholecystectomy planned for the following day. However, preoperative labs returned positive for COVID-19 despite being asymptomatic. The risks of untreated cholangitis compared to the risks of operating while COVID-19 positive were discussed, and the patient elected to undergo percutaneous biliary drain placement. She was transitioned to Amoxicillin/Clavulanate with improved abdominal pain and LFTs. She was discharged with plans to undergo cholecystectomy and stent removal in India.

IMPACT/DISCUSSION: While a causal relationship cannot be determined, it is possible that cholecystitis in this patient was related to the COVID-19 infection. These conditions were seen concurrently in other case reports, with SARS-CoV-2 detected in the gallbladder using qRT-PCR [1,2]. Unfortunately, sludge from the ERCP was not tested for SARS-COV-2 in this case.

COVID-19 can present with GI symptoms without other systemic or respiratory symptoms as SARS coronaviruses have tropism to the liver [2]. The virus enters cells by leveraging the angiotensin-converting enzyme 2 receptor (ACE2), which is present in the liver, bile ducts, and gallbladder epithelial cells. While the presence of ACE2 in the gallbladder and bile ducts explains how they are susceptible to SARS-CoV-2, it has not yet been elucidated why certain patients present with cholecystitis in the setting of COVID-19. Existing cases reported have all been in elderly patients, suggesting that older age predisposes to this condition.

Further research is needed to identify risk factors and molecular processes that facilitate cholecystitis due to SARS-CoV-2.

[1] Famularo G and Spada PL. COVID-19-related cholecystitis. Clin Res Hepatol Gastroenterol. 2021 Mar;45(2).

[2] Balaphas A et al. COVID-19 can mimic acute cholecystitis. J Hepatol. 2020 Dec;73(6).

CONCLUSION: COVID-19 can present with manifestations outside the lungs such as cholecystitis and ascending cholangitis.

COVID-19 may lead to cholecystitis through binding of SARS-CoV-2 to ACE2 receptors in the gallbladder. There are risks with performing and delaying cholecystectomy on COVID-19 positive patients in the setting of cholangitis.

USING CLINICAL AND RADIOLOGIC DIAGNOSTIC REASONING FOR SUCCESSFUL TREATMENT OF A CAVITARY PNEUMONIA

Hyun Bin Kim²; Douglas Spaeth-Cook³; Nirisha Commodore³; Francois G. Rollin¹

¹General Internal Medicine, Emory University School of Medicine, Atlanta, GA; ²Emory University School of Medicine, Atlanta, GA; ³Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #3874058)

CASE: A 35 year-old male patient with a history of seizure disorder presented to the ED after 6 days of left-sided chest pain and progressive dyspnea. Prior to symptom onset, he was in his usual state of health and working in construction. He had no history of smoking, alcohol or intravenous drug use, and no high risk sexual risk factors. He had stopped taking AEDs after his last seizure 5 months prior.

On examination he was tachycardic to 110 bpm with a respiratory rate of 22, and an oxygen saturation of 91% on room air. Diminished breath sounds were appreciated in the left lower lung field. Initial diagnostic workup revealed a white count of 10.9 K/mcL and bilateral patchy opacities on chest x-ray. A CT PE study showed no evidence of pulmonary embolism, but it revealed the presence of ground- glass and tree-in-bud opacities bilaterally, as well as a large 10.2 x 8.2 x 7.0 cm left lower lobe cavitary lesion with an air-fluid level. There was also an adjacent, partially-loculated pleural effusion consistent with empyema. A diagnostic thoracentesis was not indicated given the size and location of the effusion. Blood and sputum cultures were obtained and empiric broad-spectrum antibiotics were initiated with vancomycin and ampicillin-sulbactam (Unasyn). By day 4, the patient had made significant clinical improvement and extensive infectious workup was unrevealing. The patient was discharged home on an eight-week course of amoxicillin-clavulanate (Augmentin). At follow-up 7 weeks later, the patient was back to his functional baseline and a repeat non-contrast CT demonstrated interval resolution of the left lower lobe cavitation and empyema, with minimal residual consolidation suggestive of scarring.

IMPACT/DISCUSSION: Our first step in working up pulmonary cavitary disease is to confirm that imaging suggests true cavities versus mimics such as cysts, emphysema or infected bullae. Guidelines state that cavities must have walls >4mm thick, whereas cysts have thinner walls. Next, we determined the chronicity of the process using history of symptom duration, along with consideration of the patient's immune status and exposures. The imaging features, acute time course and history in an immunocompetent patient suggested a bacterial rather than a viral or fungal cause of our patient’s cavitary pneumonia.

CONCLUSION: -The differential diagnosis for cavitary lung lesions can be organized into infectious vs non-infectious (malignancy, autoimmune, pulmonary infarction, cryptogenic organizing pneumonia, etc) etiologies.

-Risk factors for cavitary pneumonia as a complication of community acquired pneumonia include diabetes, alcohol use disorder, and other conditions that cause immune suppression. However, as this case demonstrates cavitary pneumonia can still develop in immunocompetent individuals infected with virulent strains of common CAP-causing organisms.

VALPROIC ACID LEADING TO CARNITINE DEFICIENCY CAUSING HYPOGLYCEMIA Andrew Thomas¹; Deyanira Delgado²; Miqueas Gomez¹

¹Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; ²Internal Medicine, Nuvance Health, Lagrangeville, NY. (Control ID #3872842)

CASE: A 29-year-old male with PMH of fetal alcohol syndrome, seizure disorder, chronically malnourished with a BMI of 17.3 was initially admitted for partial small bowel obstruction and treated with bowel rest, IV hydration, and decompression via NG tube. Hospital course was complicated by multiple episodes of asymptomatic hypoglycemia with a blood glucose as low as 30 mg/dl. These episodes transiently resolved with dextrose; however, he experienced repeated hypoglycemic episodes despite tolerating a goal tube feeding rate. Insulin, proinsulin, C-peptide, and urinary ketones levels were all within normal limits. A whole-body CT did not reveal a mass such as an insulinoma. An adrenal insufficiency workup was normal. Lactic acid levels were normal, ruling out a disorder of gluconeogenesis. Upon medication review, it was noted that the patient was on Valproic acid (VPA) which can cause carnitine deficiency and lead to hypoketotic hypoglycemia. Thus, VPA was discontinued. Carnitine was supplemented in tube feeds with notable improvement in glucose levels.

IMPACT/DISCUSSION: Carnitine deficiency (CD) is often encountered in the pediatric population in congenital form. Rarely do we encounter the acquired form in adults due to severe malnutrition, malabsorptive states, medications, or increased renal excretion. Most cases of hypoglycemia are ketotic due to fasting but in patients with unexplained hypoketotic hypoglycemia, suspicion of a defect in fatty acid oxidation (FAO) is warranted. Carnitine is a cofactor required for the transfer of long-chain fatty acids across the inner mitochondrial membrane for beta-oxidation in tissues. In catabolic states, FAO and hepatic gluconeogenesis are the main sources of energy. A defect in FAO will impair gluconeogenesis and lead to nonketotic hypoglycemia. When FAO is impaired, glucose is readily consumed without replenishment by gluconeogenesis. Carnitine palmitoyltransferase is the rate-limiting step for FAO and requires carnitine as a cofactor. Dietary intake is the primary source of carnitine and accounts for almost 3/4th of the total body stores. Patients like ours, who have a history of poor dietary intake at baseline are at increased risk of CD when exposed to medications such as VPA. VPA is a fatty acid and a substrate for the FAO pathway and can deplete carnitine stores by binding to carnitine causing increased urinary excretion, decreased renal tubular reabsorption, and decreased endogenous production.

CONCLUSION: CD with resulting hypoglycemia is not a common phenomenon. Anorexic patients have a higher predisposition to CD due to poor nutritional intake and low carnitine stores at baseline. This in conjunction with VPA use can lead to a state of hypoketotic hypoglycemia. When hypoglycemia cannot be explained, the possibility of CD must be explored, and attention must be given to the medications that the patient is receiving as valproic acid can increase the risk.

VANISHING CLUES: DIAGNOSTIC UNCERTAINTY IN IDENTIFYING CARDIOEMBOLIC SOURCE AFTER THROMBOLYTICS

Kaitlyn McLeod¹; Prerna Gupta²; Lavanya Kondapalli²; Aken A. Desai²

¹Internal Medicine, University of Colorado, Denver, CO; ²Cardiology, University of Colorado, Denver, CO. (Control ID #3877227)

CASE: A 64-year-old presented with acute onset left facial droop and was found to have right middle cerebral artery emboli. She was successfully treated alteplase. Hospital course was notable for an NSTEMI which was treated medically given concern for hemorrhagic conversion after recent stroke. Subsequent coronary angiogram showed multi-vessel disease and a subacute right coronary artery occlusion. Transthoracic echocardiography revealed biventricular dysfunction with basal to mid inferior and inferolateral wall akinesis, severe tricuspid regurgitation, pulmonary hypertension and no left ventricular thrombus. Atrial fibrillation was not seen on telemetry monitoring. Transesophageal echocardiogram revealed an aneurysmal interatrial septum and patent foramen ovale (PFO) with bidirectional flow. Lower extremity ultrasounds were negative for venous thromboembolism (VTE). Computed tomography (CT) angiography of the chest demonstrated ulcerated aortic plaque. Ultimately, cardiac CT revealed thrombus along the basal right ventricular (RV) free wall. PFO closure not pursued, and the patient was discharged on clopidogrel and apixaban.

IMPACT/DISCUSSION: Multiple sources for cardioembolic stroke were considered in this case: common sources like left ventricular or left atrial appendage thrombus and carotid atherosclerosis and more rare causes like aortic atherosclerosis and paradoxical embolism of RV thrombus or VTE. Thrombolytic administration, while essential to the treatment of stroke, hindered efforts to identify a cardioembolic source. It introduced the possibility that the source had been treated with altepase and made it unclear when to end the search. For instance, paradoxical embolism can result from VTE traversing a PFO; however, VTE may have dissolved after alteplase. PFO closure was not done given the risk for worsening RV function with closure. Ultimately, the only identified source was a small RV thrombus on cardiac CT. In cases with high suspicion for cardioembolic source, cardiac magnetic resonance imaging (MRI) or CT can be considered. This case also highlights nuances in managing antiplatelet and anticoagulants in a patient with high risk for hemorrhagic conversion of stroke, acute coronary syndrome, and an isolated RV thrombus. We leaned on evidence from anticoagulation after stroke in the setting of LV thrombus, RV thrombus with concomitant pulmonary embolism, the CURE trial (Effects of Clopidigrel in Addition to Aspirin in Patients with Acute Coronary Syndromes without ST-Segment Elevation) and social factors to develop the final approach of clopidogrel and apixaban.

CONCLUSION: Identifying source of cardioembolic stroke after lytics is challenging. If high suspicion for intracardiac thrombus exists, advanced cardiac imaging should be considered. There is limited data to guide anticoagulation in isolated RV thrombus. Patient factors and evidence from related clinical scenarios can aid decision-making.

VAPING INDUCED ATYPICAL PNEUMONIA

Abdul Mukhtadir Kalaiger

Internal Medicine, Montefiore Health System, Bronx, NY. (Control ID #3877041)

CASE: A 21-year-old male with no significant past medical history presented to the emergency department with complaints of dyspnea, cough with yellow sputum, fever, and generalized weakness for three days. On examination, the pulse rate was 110 beats/minute, blood pressure was 160/90 mmHg, respiratory rate 26 breaths/minute, and temperature was 102F. The arterial oxygen saturation on pulse oximetry was 92% on room air. The patient revealed that he had been vaping for the preceding seven months and heavily over the last two months (more than 400 puffs/day). The patient denied a history of travel or sick contacts. The physical examination was significant for bilateral lung wheezing with coarse inspiratory crepitations over the right lower lung.

The patient was admitted and given nebulization with ipratropium (250 mcg), Albuterol (5 mg) four times a day, and Paracetamol 500 mg Intravenously. His chest X-ray showed Bilateral diffuse patchy inflammation. The initial laboratory investigation revealed elevated total leukocyte count (22000/mm 3) with neutrophilia (90%) and raised CRP (120 mg/dL). The patient was started on ceftriaxone 2g IV once a day, Azithromycin 300 mg once daily, and nebulization’s were continued. All blood, sputum, and urine cultures, acid-fast bacillus (AFB) and respiratory panel including COVID-19 were negative. The Pulmonologist’s opinion was sought because of lack of clinical improvement even after 48 hours of treatment. Vaping-induced pneumonia was suspected, and started on steroids. High-Resolution Computed Tomography (HRCT) chest revealed bilateral interstitial changes of both lungs. The patient responded to the new treatment regimen and clinical improvement was observed after the fifth day. The patient was subsequently discharged and advised to stop vaping.

IMPACT/DISCUSSION: The vaping devices are marketed as safer compared to traditional cigarettes, which aids in smoking cessation, although they are not approved. Hazardous chemical substances like ketene gas which has carcinogenic potential were identified in vaping devices. The Centers for Disease Control (CDC) named the epidemic as e-cigarettes and vaping induced lung injury (EVALI), that has been causing lethal respiratory illness, particularly in teenagers.

A case series study of 98 patients on EVALI demonstrated the disease severity with 95% hospitalization and some requiring mechanical ventilation. Many studies have shown a correlation between vaping with lung injury and lipoid pneumonia, but none have shown an association with atypical pneumonia. In our case, a young adult who had a history of heavy vaping presented with atypical pneumonia symptoms and did not respond to the empirical antibiotics. Prompt Pulmonology consult, HRCT, and starting steroids helped in his revival. His extensive vaping could have predisposed him to atypical pneumonia.

CONCLUSION: Vaping could probably put the teenagers at risk of respiratory illnesses like atypical pneumonia. More research is warranted in this field.

VIRAL OVERLOAD: HSV-2 MENINGITIS IN A PATIENT WITH HIV AND DISSEMINATED MONKEYPOX

Neel Kale, Helen Pope

Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #3875054)

CASE: A 28-year-old man with HIV-1 and moderate adherence to anti-retrovirals presented with severe throat pain and a painful rash. Physical examination showed a diffuse pustular rash with well-circumscribed, umbilicated lesions in different stages of healing in addition to lesions in the oropharynx. Rash was preceded by several days of fever and malaise. A head computed tomography demonstrated epiglottitis and the patient was intubated and stepped up to the ICU due to concern for airway compromise. PCR of skin lesion swabs tested positive for monkeypox virus. The patient was started on IV tecovirimat and quickly extubated. Over the next three days, his throat pain continued to improve and he was switched to oral tecovirimat. The patient complained of a headache after taking tecovirimat which is a common side effect. He was clinically stable and tolerating treatment, therefore he was discharged to finish treatment and isolate at home. A few days later the patient returned to the hospital for persistent headache, throat pain and new onset fever and nuchal

rigidity. A lumbar puncture demonstrated mildly elevated protein, mildly elevated white blood count with lymphocytic predominance, and positive herpes simplex 2 (HSV) testing. The patient was started on IV acyclovir in addition to finishing his course of tecovirimat. His symptoms improved and he was discharged after completing his course of antivirals for monkeypox and HSV-2.

IMPACT/DISCUSSION: While co-infection with monkeypox virus in endemic regions is primarily a result of VZV, co-infection with other viruses should be considered especially in immunocompromised patients. Review of the literature reveals two documented cases of co-infection of monkeypox and HSV-2. The typical presentation of HSV-2 meningitis is fever, photophobia, headache, and nuchal rigidity. HSV-2 is a less common cause of viral meningitis and often presents without a history of genital herpes, recurrent meningitis, or genital symptoms. This diagnosis can be missed in the setting of disseminated monkeypox, as both the diffuse lesions and adverse effects of tecovirimat can mimic the symptoms of meningitis. It is important that any unresolved headache in a patient with disseminated monkeypox is treated with a high degree of clinical suspicion for a potential meningitis and/or encephalitis. Treatment of monkeypox, HSV-2 and HIV with appropriate antivirals is necessary to prevent further morbidity and mortality.

CONCLUSION: Patients with disseminated monkeypox can have concurrent infections with other pathogens. The risk of co-infection is especially prevalent in immunocompromised patients. Hospitalist physicians should be aware that adverse effects of treatments for monkeypox or diffuse spread of monkeypox rash can obscure signs and symptoms of another serious co-infection.

VITAMIN K SUPPLEMENTATION MORE THAN JUST LEAFY GREENS

Brian R. Hughes¹; Reem M. Hanna²

¹Internal Medicine, University of Colorado - Anschutz Medical Campus, Aurora, CO; ²Department of Medicine, University of Colorado, Denver, CO. (Control ID #3860612)

CASE: A 76 year old year old female with history of mesenteric ischemia 15 years ago s/p resection (4-5ft of bowel) c/b short bowel syndrome (SBS) and chronic diarrhea, admitted after a syncopal episode 2/2 orthostasis from worsening of chronic diarrhea. On admission, vital signs positive for orthostasis. Labs showing Hgb 7.7 (MCV 111), Plt 23, lactic acid 4.1, INR 2.4, PT 25.6, PTT 43.5, Copper (Low), Zinc (Low), Folate 3.2 (Low) Homocysteine 23.9 (High), MMA w/in normal limits.

Patient resuscitated with isotonic fluids and lactate cleared. Hematology consulted for macrocytic anemia, thrombocytopenia, and abnormal coagulation studies. Macrocytic anemia and thrombocytopenia deemed to be multifactorial; but most likely secondary to nutritional deficiencies. Given prolonged PT and PTT concern was for a common pathway deficiency or vitamin K deficiency. Factor levels ordered: Factor V 53%(Low), Factor: VII 20%(Low), Factor VIII 266%(High), Factor IX 38% (Low). In absence of known liver disease, patient was diagnosed with vitamin K deficiency. With concern for inability to absorb PO, patient instead treated with IV vitamin K 10 mg x3 days. INR down trended to 1.4, PT 16.8, and PTT 35.2 on discharge.

IMPACT/DISCUSSION: In USA and Europe, majority of vitamin K comes from diet (leafy green vegetables). Vitamin K is a fat-soluble vitamin and requires bile salts to be absorbed through the GI lumen. Disorders that either physically disrupt the GI lumen or recycling of bile salts (ie IBD and SBS) lead to an inability to absorb vitamin K. The current recommendation for vitamin K repletion is PO, based on prior studies comparing PO vs. IV repletion which found no significant difference in normalizing INR, but had increased rates of anaphylaxis and thrombosis with IV. However, in patients with known history of malabsorptive disorders, IV formulation may be required for effective supplementation.

Although rates of vitamin K deficiency are well-documented in IBD, much less data is available regarding vitamin K deficiency in SBS patients. Via literature search, only one paper including 33 patients with SBS (Age 0 to 16 yrs), found 9% to be vitamin K deficient. However, this study is limited by both its small sample size and narrow age range. Our case presents a SBS patient in her eighth decade found to have vitamin K deficiency. Vitamin K deficiency may be underreported in the SBS population and additional research is required to determine a more accurate representation of prevalence among these individuals. Additionally, factors such as length of bowel removed or removal involving the terminal ileum can be further examined for their effects on risk of developing vitamin K deficiency.

CONCLUSION:

● Fat soluble vitamin deficiencies are common in intestinal malabsorption disorders

● IV, instead of PO vitamin K, may be required to replete deficiency in those with malabsorptive disorders (specifically Crohn’s and SBS)

● More research is needed to evaluate prevalence of vitamin K deficiency in SBS

WAS THIS HEART MEANT TB?: TUBERCULOUS PERICARDITIS PRESENTING AS EARLY CARDIAC TAMPONADE

Bhanvi P. Ramchandani¹; Thomas Erwes²; Ashwin Mahesh¹

¹Internal Medicine, UConn Health, Farmington, CT; ²Infectious Diseases, UConn Health, Farmington, CT. (Control ID #3876910)

CASE: A 61-year-old otherwise healthy Yemeni American female presented to the emergency department with a two-week history of retrosternal pressure-like chest pain, radiating to her back and shoulder blades. This was aggravated by deep inspiration and bore no association with exertion or positional changes. Two months prior to presentation, she was in Yemen and endorsed transient nasal congestion upon return. Cardiac examination revealed sinus tachycardia without a rub. No pulsus paradoxus, jugular venous distention, or peripheral edema was appreciated. Lung auscultation revealed clear sounds. Labs revealed an elevated ESR (54 mm). Her complete blood count and basic metabolic panel were within normal limits. Serum anti-nuclear antibodies and Rheumatoid Factor were undetectable. Electrocardiogram (EKG) revealed sinus tachycardia with no alternans or ST-T wave changes. A Chest X-ray showed an enlarged cardiac silhouette with

normal lungs. Echocardiography revealed a circumferential pericardial effusion with diastolic right atrial and ventricular diastolic collapse and a plethoric inferior vena cava suggestive of an early tamponade. She was started on non-steroidal anti-inflammatory agents (NSAIDs) and colchicine. QuantiFERON GOLD TB testing returned positive. HIV and COVID-19 testing were negative. Pericardiocentesis yielded 410 ml of serosanguineous fluid that did not stain Acid Fast Bacilli but grew Mycobacterium Tuberculosis Complex, establishing a diagnosis of tuberculous pericarditis. Following an Infectious Diseases consultation, she was appropriately initiated on rifabutin, isoniazid, pyrazinamide, ethambutol, and pyridoxine with a goal of completing 6 months of therapy.

IMPACT/DISCUSSION: Extrapulmonary manifestations of Mycobacterial tuberculosis (TB) are often seen among the immunocompromised and typically involve the pleura, lymph nodes, and bone. Pericardial involvement is rare, with non-specific presentations making the diagnosis challenging. In developed countries, TB-related pericardial disease is uncommon and accounts for less than 1-2% of cases of extrapulmonary TB, with 7% of these cases presenting with cardiac tamponade.

CONCLUSION: This case highlights the importance of considering tuberculosis as an etiology of pericardial effusions in select patient populations, even in the absence of any pulmonary disease. Prompt diagnosis and anti-tuberculous therapy can dramatically reduce long-term complications of pericardial tuberculosis, including life-threatening cardiac tamponade and constrictive pericarditis.

WEAK IN THE KNEES: ELEVATED TROPONIN AND MYOSITIS IN THE HOSPITALIST PATIENT

Leah Cotter^1,3; Benish Baqai²

¹General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI; ²Medical College of Wisconsin, Milwaukee, WI; ³Pediatrics, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3867464)

CASE: An 84-year-old male with a history of hypertension, type 2 diabetes mellitus and multiple skin cancers presented with progressive shortness of breath, fatigue and weight loss. The patient was seen by his primary care physician on the day of admission for his symptoms. He was hypoxic to 87% and sent to the Emergency Department for further evaluation. He reported shortness of breath after walking twenty steps. He recalled weakness and multiple falls in the last month without head trauma. He denied orthopnea, paroxysmal nocturnal dyspnea, abdominal pain, edema or chest pain. His work up was remarkable for an elevated

troponin of 2,260 ng/L (reference range <16), normal basic metabolic panel, mild anemia with hemoglobin of 13.5 g/dL, and an elevated B-natriuretic peptide of 1,155 pg/mL (reference range <450). His EKG had nonspecific T wave abnormalities. Due to concerns for acute coronary syndrome, the patient was started on aspirin, plavix, metoprolol, atorvastatin and a continuous heparin infusion, and admitted to the Cardiology team. However, the patient’s echocardiogram demonstrated no wall motion abnormalities making acute coronary syndrome unlikely. Further work up revealed elevated levels of CK to 6167 U/L, AST 297 U/L, ALT 260 U/L, a sedimentation rate of 46 mm/hr and a C-Reactive Protein of 1.28 mg/dL. A lower extremity MRI demonstrated diffuse bilateral muscle inflammation consistent with myositis. Muscle biopsy of the biceps brachialis was remarkable for active necrotizing myopathy. HMG-CoA reductase inhibitor antibody was positive at 127 units (reference range <19). Given the above findings, the patient was diagnosed with HMG-CoA reductase inhibitor associated necrotizing myositis and started on immunosuppression. IMPACT/DISCUSSION: HMG-CoA reductase inhibitor myositis is a statin-associated autoimmune myopathy. Autoantibodies recognize HMG-CoA reductase causing direct muscle injury. Symptoms typically present as proximal, symmetric muscle weakness or pain with a significantly elevated CK. Further workup typically includes MRI and muscle biopsy which demonstrate muscle edema and muscle necrosis without inflammation, respectively. Despite the significant muscle involvement, other non-muscular tissues are often involved. Up to fifty percent of patients in one series presented with dyspnea related to either restrictive lung disease or intrinsic pulmonary dysfunction. Cardiac tissue may also be involved in inflammatory myositis. Associated findings may include abnormal electrocardiogram, echocardiogram, elevated troponin, and arrhythmia. With the combination of pulmonary and cardiac symptoms, HMG-CoA reductase can mimic conditions like acute coronary syndrome and heart failure, making the diagnosis difficult.

CONCLUSION: Inflammatory myopathies, like HMG-CoA reductase inhibitor myositis, are difficult to diagnose as they can mimic acute coronary syndrome. In patients with atypical cardiac complaints and significant weakness, hospitalists should be mindful of myositis.

WELLS’ SYNDROME IN AN ADULT PATIENT MASQUEARDING AS RECURRENT CELLULITIS

Sadia A. Tanami, Saria Tasnim, Md Rockyb Hasan, Falah I. Abu Hassan, Abhijit Gutal

Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX. (Control ID #3872338)

CASE: A 46-year-old male with no past medical history presented to the emergency department with complaints of erythema, swelling, and pruritis of bilateral lower extremities for the last few days. On review of his history, the patient received systemic antibiotics a couple of times in the last six months due to recurrent episodes of similar clinical manifestations. On initial evaluation, the patient was afebrile and hemodynamically stable. Examination of the lower extremity showed erythema, swelling, tenderness, and weeping of malodorous fluid from both legs, more on the right side. Laboratory results found high eosinophilia of 10% in peripheral blood smear, CRP 38.80, ESR >130, elevated total IgE of 523 IU/ml, and negative autoimmune panel. Histologic examination of a lesional skin biopsy found mild diffuse perivascular chronic dermatitis mixed with many eosinophils and negative fungal stains. Blood culture was negative, but wound culture was positive for Staphylococcus aureus and Pseudomonas aeruginosa. Based on clinical presentation and the characteristics of histologic pattern, Wells syndrome (WS) with secondary cutaneous bacterial infection was made. The patient was treated with systemic antibiotics, a tapering dose of prednisone, and an antihistamine. The patient’s symptoms as well as the appearance of skin lesions improved significantly upon discharge on day 7.

IMPACT/DISCUSSION: WS, also known as eosinophilic cellulitis, is a rare skin disorder of unknown etiology. George Wells first described it as recurrent granulomatous dermatitis with eosinophilia in 1971. The pathogenesis of WS is unclear, but various factors like infections (bacterial, viral, fungal, parasitic), vaccines, drugs, insect bites or stings, and malignancy can act as triggering factors. It is hypothesized that a type 4 hypersensitivity reaction in response to various, often unidentified antigenic stimuli can lead to WS. A clinical and histopathological correlation is required to make a diagnosis. The treatment of WS is not well- ordered. A topical corticosteroid can relieve mild symptoms. But patients with a generalized disease or localized disease not controlled on topical corticosteroids require a short course of systemic corticosteroid. Antihistamines can be administered to treat pruritus but have no effect on the skin lesions. The overall prognosis of WS is good but recurrence is common. All patients with WS need follow-up in clinic to assess the response to treatment and disease recurrence.

CONCLUSION: The diagnosis of WS is often delayed, as most patients are initially misdiagnosed with bacterial cellulitis and treated with antibiotics therapy. The clinical suspicion should be high in patients with a history of recurrent, pruritic, cellulitis plaques that are not responding to antibiotic treatment. Systemic corticosteroids are effective therapy, but immunosuppressants and phototherapy are considered in recurrent or refractory cases.

WEST NILE VIRUS OUT WEST

Chelsea E. Carver¹; Adam Beitscher²

¹Internal Medicine, University of Colorado, Denver, CO; ²Denver Health, Denver, CO. (Control ID #3871921)

CASE: A 59-year-old woman presented to the hospital in late autumn with fevers [102.5], generalized weakness, profound fatigue, diplopia, nausea, decreased urine output, and myalgias for one week. She had gone to an urgent care after 3 days of symptoms and was prescribed doxycycline; however her symptoms continued to worsen despite treatment. She was a very avid hiker and camper, spending the summer outside in New England and several weeks in autumn in the Rocky Mountains. She had never traveled outside of the United States. Her only medical problem was hypothyroidism on levothyroxine. On physical exam, she had normal extraocular movements and no other neurologic deficits. CT and MRI of the brain were both performed without mass-occupying lesion, showing some enhancement of abducens and facial nerves. She was started on vancomycin, ceftriaxone, and acyclovir. LP was performed with 116 nucleated cells, 87% lymphocytes, glucose 84, protein 50. CSF PCR performed testing for 14 causes of meningitis, all negative. On hospital day 4, leptomeningeal carcinomatosis was considered and CT of the chest, abdomen, and pelvis was performed without evidence of a new malignancy. The patient’s symptoms continued to improve with supportive care and she was discharged on hospital day 7. The day after discharge, serum West Nile Virus IgM antibody resulted at 5.11 (<0.89 normal) and CSF West Nile Virus IgM antibody was 6.32 (<0.89 normal). Lyme serologies and CSF cytology also returned negative.

IMPACT/DISCUSSION: Aseptic meningitis is the acute onset of meningitis with negative gram stain and culture of the CSF and has an excellent prognosis. However, there are over a hundred causes, which leads to diagnostic uncertainty, leading to longer hospitalizations and unnecessary testing and antimicrobials. There are many infectious culprits, such as viruses, fungi, mycobacterium, and spirochetes. Malignancies, vasculitidies, and neurosarcoidosis may also have similar presentations. West Nile Virus (WNV) is a cause of aseptic meningitis, transmitted from the bite of an infected mosquito, typically between July and September. Cases have been found in all 50 states. 70-80% of infections are asymptomatic. If symptomatic, the most common presentation is flu-like symptoms referred to as “West Nile fever (WNF).” In 1% of cases, WNV invades the CSF causing meningitis, encephalitis, and a flaccid paralysis syndrome, termed West Nile Neuroinvasive Disease (WNND). 40% of these patients will have persistent symptoms of fatigue, memory impairment, weakness, and gait instability with variable ranges for recovery. The gold standard for diagnosis is IgM in serum (WNF) and IgM in CSF (WNND).

CONCLUSION: Aseptic meningitis has a broad differential which leads to diagnostic uncertainty, especially as these tests may take days to result. WNV infection can cause a flu-like illness, and in rare cases can become neuroinvasive, leading to aseptic meningitis, encephalitis, flaccid paralysis, and death.

WHAT’S ALL THE TYPHUS ABOUT?

Nathan DeRon¹; Leigh K. Hunter²

¹Internal Medicine, Methodist Dallas Medical Center, Dallas, TX; ²Infectious Diseases, Methodist Dallas Medical Center, Dallas, TX. (Control ID #3877154)

CASE: The patient is a 50-year-old male with no significant past medical history who presented to the emergency department with fever and melena. He reported associated symptoms of generalized weakness and fatigue such that he was not able to accomplish his typical daily activities. He reported a fever of 103F at home along with chills and myalgias. He also reported black, sticky, malodorous stools as well as three episodes of frank bloody emesis. In the emergency department, the patient was found to by hypotensive and tachycardic with an elevated procalcitonin, leukocytosis, and moderate thrombocytopenia. The patient’s liver enzymes were also elevated along with lactate. The gastroenterology service was consulted, and the patient underwent esophagogastroduodenoscopy without evidence of a bleeding source. The infectious disease service was also consulted, and the patient underwent extensive infectious work-up. Rickettsia Typhi antibody titer resulted as elevated at 1:1024 indicating positivity. The patient was initiated on doxycycline for 14 days with full resolution of symptoms.

IMPACT/DISCUSSION: Typhus infection is commonly overlooked due to the rarity in the general population. However, it is a disease which requires high suspicion by internal medicine physicians as the primary burden of diagnosis typically lies with hospital physicians. Early diagnosis is extremely important as this disease is easily treatable if it is identified quickly. Serology is the gold standard for diagnosis of this disease, and elevated IgG titers confirms active disease. Treatment is simply doxycycline for approximately 14 days. Symptoms typically resolve quickly after initiation of appropriate antibiotic therapy.

CONCLUSION: In summary, recognition of Rickettsia typhi disease, appropriate laboratory assessment, and early institution of therapy is important for internal medicine physicians to decrease morbidity and mortality in liver transplant recipients.

WHEN A NOSEBLEED IS NOTHING TO SNEEZE AT – A RARE CASE OF AN ACQUIRED FACTOR INHIBITOR CAUSING COAGULOPATHY IN A PATIENT WITH GASTRIC ADENOCARCINOMA

Christopher R. Grant¹; Priyanka Kumar²; Danielle Brazel¹; Garo Hagopian²

¹Internal Medicine, UC Irvine Douglas Hospital, Orange, CA; ²Internal Medicine, University of California Irvine, Irvine, CA. (Control ID #3867962)

CASE: A 48-year-old man with gastric adenocarcinoma presented with epistaxis. He denied trauma, other bleeding, fevers, or joint swelling. He denied personal history or family history of bleeding disorders and denied recent NSAID or anticoagulation use. He was tachycardic and had mild bruising on his thigh and back. Labs revealed low hemoglobin (5.8 g/L) and platelets (44,000 mL), but elevated PT (22.2), PTT (41.7), and D-dimer (>20,000 ng/mL). Fibrinogen was normal and hemolysis labs were largely unremarkable. Ultrasound revealed no hepatobiliary disease, no hepatosplenomegaly and patent portal and hepatic venous

systems. He was transfused and admitted for further work up. The next day, his anemia worsened. Coagulopathy work-up showed schistocytes, vitamin K 2.72 nmol/L, and factor assays with decreased levels of factors 5, 7, and 10. PTT mixing study demonstrated an inhibitor. He was treated with 5-fluorouracil and subsequently had his PT and PTT minorly improve.

IMPACT/DISCUSSION: Coagulopathy from acquired factor inhibitors is rare but can be associated with malignancy. Inhibitors to factor VIII are most often reported, but other inhibitors have also been reported. Timely recognition of factor inhibitors as a cause of coagulopathy in cancer patients, especially once disseminated intravascular coagulation (DIC) is ruled out, can be lifesaving.

This case highlights the importance of a thorough coagulopathy work up. Analyzing whether PT and/or PTT are elevated is the first step in determining the etiology of a coagulopathy. Our patient had elevated PT and PTT, concerning for liver disease, DIC, vitamin K deficiency, or factor inhibitors. Once DIC is ruled out, a mixing study may be helpful since lack of correction with normal plasma suggests an inhibitor. Our patient’s coagulopathy was from factor inhibitors associated with his cancer. In cancer patients with coagulopathy, keeping a broad differential for coagulopathy and considering a mixing study may consolidate the diagnosis. The treatment for inhibitors is to provide high dose steroids and subsequently treat the underlying cause of the creation of inhibitors, which in our case would be the gastric adenocarcinoma. Given the high tumor burden of the carcinoma and affect on our patient's quality of life, the patient transitioned to comfort care as it aligned with him and his family's goals

CONCLUSION: - Acquired factor inhibitors are characterized by no/partial correction of a mixing study with normal plasma and can be caused by drugs such as heparin, autoimmune diseases, malignancy, or nonspecific inhibitors such as lupus anticoagulant

- Recurrent epistaxis without trauma should raise suspicion of a coagulopathy

- Treatment of acquired factor inhibitors is to treat the underlying cause as well as provide immunosuppressants

WHEN HYDRALAZINE LEADS TO RENAL DESTRUCTION: HYDRALAZINE-INDUCED ANCA VASCULITIS

Hussein Abu-Hashish¹; Georgina Ang¹; Jose Canabal¹; Barbara Berger¹; Jeena Varghese²

¹Medicine, Forest Hills Hospital, Forest Hills, NY; ²Endocrinology, The University of Texas MD Anderson Cancer Center, Houston, TX. (Control ID #3869754)

CASE: A 71-year-old woman presented to the ED complaining of cough with brown sputum, fatigue and abdominal pain. Medical history included hypertension, hyperlipidemia, and chronic kidney disease. Medication included losartan, hydralazine, and metoprolol succinate. She denied dyspnea, urinary symptoms, or musculoskeletal pain. She was febrile, COVID positive, saturating 96% on room air with an unremarkable chest X-ray and clear breath sounds. There were no pertinent physical examination findings. Lab studies were remarkable for an elevated creatinine of 1.82mg/dL, normocytic anemia, iron studies consistent with anemia of chronic disease. Renal imaging demonstrated no hydronephrosis with punctate left renal calculus and a left lower pole renal cyst. Her urinalysis had microscopic hematuria, large blood, and proteinuria of 100. Upon further inquiry, she recalled longstanding microscopic hematuria. These findings prompted a vasculitis work- up, resulting in a positive ANA 1:640 with a centromere pattern, p-ANCA >1:1280, positive myeloperoxidase, and low C3 complement. Proteinase 3 antibody, c-ANCA and glomerular basement membrane antibody were negative. She was diagnosed with ANCA-associated vasculitis and given pulse steroids for 3 days. Left kidney biopsy showed crescentic glomerulonephritis with mild immune complex mesangial deposition with predominantly healed lesions and global segmental sclerosis in 80% of glomeruli, indicating a chronic process. Her renal function was deemed unsalvageable, thus expected to require hemodialysis in the near future. Since her biopsy findings aligned with drug-induced ANCA vasculitis, hydralazine was discontinued and losartan was started for hypertension and renal-protection.

IMPACT/DISCUSSION: Drug-induced ANCA vasculitis is an autoimmune process involving pauci- immune glomerulonephritis, low complement levels, interstitial lung disease with elevated ANA, ANCA, and MPO antibodies. Hydralazine use in hypertension dates back to 1950s with JNC guidelines using it as a second line medication, and later falling out as new medications such as calcium channel blockers, angiotensin convertase enzyme inhibitor (ACEI), angiotensin receptor blockers (ARB), and beta-blockers became more favored in the 1980-1990s. Hydralazine remains an effective medication and its use is extended to heart failure patients who are unable to tolerate ACEI/ARB in the past two decades.

CONCLUSION: Given the irreversible nature of hydralazine-induced ANCA-vasculitis, a high index of suspicion in patients on hydralazine is important when presenting with hematuria, proteinuria, elevated serum creatinine, and vague symptoms as the mainstay therapy is discontinuation and preservation of current kidney function, to delay initiation of hemodialysis.

WHEN IBD TRAVELS

Marley J. Foertsch¹; Linda Baier Manwell²; David A. Feldstein³

¹Internal Medicine, University of Wisconsin-Madison, Madison, WI; ²Department of Medicine, Division of General Internal Medicine, University of Wisconsin-Madison, Madison, WI; ³Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI. (Control ID #3875530)

CASE: A 25-year-old previously healthy woman presented to ID clinic one month after developing bloody diarrhea while on a trip to Ecuador. She had received treatment for traveler's diarrhea with Flagyl and ciprofloxacin without improvement. She also underwent sigmoidoscopy at an outside facility that showed nonspecific rectal mucosal inflammation with microabscesses. On exam, her BP was 101/71 and she was orthostatic. Abdominal exam was normal; rectal exam revealed a small internal hemorrhoid. Remainder of her exam was normal. She was admitted to the hospital for further workup. Additional stool studies and serology for E. histolytica, Strongyloides, Brucella, and Q fever were negative. Given her negative infectious workup and persistent symptoms, new onset IBD was suspected. She underwent colonoscopy which showed diffuse chronic colitis with crypt abscesses and basal plasmacytosis of the lamina propria, consistent with ulcerative colitis.

IMPACT/DISCUSSION: Traveler's diarrhea is common, occurring in 30-70% of travelers. It is typically bacterial or viral, and symptoms vary from loose stools with mild cramping to severe abdominal pain, fever, vomiting, and hematochezia. Symptoms begin with 6-72 hours of exposure and should self-resolve in 2-7 days. A diagnosis can be made clinically within these timeframes, but stool studies should be sent for severe cases including if dysentery is present. Mild diarrhea that does not limit daily activities requires no treatment. Antibiotics can be considered for moderate disease, and should always be used for severe/debilitating diarrhea (including hematochezia). If symptoms persist beyond 14 days or despite antibiotics, you must investigate for ongoing infection (including C diff), a previously undiagnosed GI condition (possibly triggered by enteric infection), and postinfectious complications such as IBS or lactose intolerance. At that point stool testing for ova and parasites, Giardia antigen testing, C diff toxin assay, and a D-xylose absorption test are warranted. Celiac disease and IBD also need to be considered. Biopsy results characteristic of UC include basal plasmacytosis and architectural changes, however these may not be present in very early disease. This case did not follow the expect course of traveler's diarrhea given her prolonged symptoms despite antibiotics and negative infectious workup. Infection is a common IBD trigger; thus, it's important to re-biopsy. This patient's second biopsy showed classic UC findings. This case taught me what to expect when a recent traveler presents with diarrhea, and how to recognize when there may be more to the story.

CONCLUSION: Traveler's diarrhea typically causes mild symptoms and resolves within 1 week. When symptoms persist beyond 14 days or despite appropriate treatment, further testing for ongoing infection and underlying GI disorders is warranted.

WHEN METASTASES DISAPPEAR: A CASE OF PHEOCHROMOCYTOMA-INDUCED CARDIOMYOPATHY

Patricia N. Tyson, Rosalie Siciliano, Janel Hanmer

Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #3876896)

CASE: A 36 year old man with a history of hypertension and prediabetes who was treated for pneumonia two weeks prior presented to the ED with orthopnea, cough, shortness of breath, and hemoptysis. Over the last 6 months he reported 50lb weight loss, subjective weakness, worsening dyspnea on exertion, rare episodes of feeling clammy with “kaleidoscope” vision without headaches, and occasional lightheadedness with palpitations. Vitals notable for BP 192/115 with HR to 150s and requiring 3L of O2. CT imaging showed numerous lung nodules and a large adrenal mass concerning for metastatic pheochromocytoma vs adrenocortical carcinoma (ACC). Labs showed markedly elevated catecholamines, metanephrines, and chromogranin A, with normal DHEA-S and cortisol, consistent with pheochromocytoma. Cardiac imaging showed dilated cardiomyopathy with EF 25% and diastolic dysfunction with no ischemic changes. Repeat CT imaging 4 days later showed resolution of the pulmonary lesions, suggesting they were from flash pulmonary edema. This allowed him to receive potentially curative surgical excision rather than chemotherapy and/or radiation for metastatic disease.

IMPACT/DISCUSSION: Although the majority of pheochromocytoma tumors are benign, about 10% can be metastatic with a variable prognosis depending on the surgical resectability. Given we initially thought the patient had diffuse bilateral metastatic disease, the prognosis would likely have been poor. Correctly identifying diffuse pulmonary densities as pulmonary edema rather than metastases or pneumonia can avoid unnecessary interventions such as lung biopsies and antibiotics.

While pheochromocytoma originating from the adrenal medulla is the most renowned tumor of the adrenal gland, ACC is a malignancy of the cortex that often has a worse prognosis. Unlike pheochromocytomas that secrete epinephrine and norepinephrine, ACC secrete cortisol and DHEA-S. Therefore, studies analyzing these hormonal levels are needed to direct treatment and prognosis.

The symptomatic triad of sweating, tachycardia, and headache is often used in screening for pheochromocytomas; however, only a minority of patients report all three. Additionally, evaluation for pheochromocytoma is often included in the workup of secondary hypertension, however blood pressure elevation is often absent or paroxysmal. Acute decompensated heart failure due to cardiomyopathy from longstanding catecholamine excess can be the presenting symptom of pheochromocytoma.

CONCLUSION: The symptomatic triad (headache, tachycardia and sweating) are not present in the majority of patients with pheochromocytomas.

It is important to differentiate between pheochromocytoma and ACC through analysis of metanephrines and DHEAS products as ACC tends to carry a poorer prognosis

While the majority of pheochromocytoma are local tumors with good prognosis, approximately 10% are malignant with poor prognosis.

WHEN MONKEYPOX GOES WILD

Matan Malka¹; Athina Vassilakis²

¹Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY; ²Medicine, Columbia University, New York, NY. (Control ID #3874475)

CASE: 29-year-old man with HIV/AIDS, off medications, presented with painful skin lesions. 4 months prior, a blistering lesion developed on his face followed by diffuse lesions. He was prescribed 14 days of tecovirimat (TPOXX) for positive monkeypox (MPX) PCR. The lesions became pruritic, increased in size/number, and caused difficulty ambulating. He denied systemic symptoms as well as nausea, vomiting, diarrhea, dysuria, abdominal pain, cough or dyspnea. He had prior recurrent HSV-2 infection and no prior known contact with MPX.

On exam, T 37C BP 140/90 HR 140 O2 sat 98% on room air. OP had white exudate. There were numerous 3-5 cm well-delineated ulcerated vegetative friable tender ulcers and plaques with hypertrophic, rolled borders and central necrosis on the arms, legs, perineum, feet, upper back, bilateral face including right mucosal lip, and bilateral ear canals. Some lesions had surrounding erythema, some serosanguineous discharge. A large purulent plaque was around the penile base, extending onto the scrotum. The rest of the exam was normal except for tachycardia. Labs: CD4 22 WBC 5.96 Hgb 9.5 MCV 85 and ESR 107 CRP 149. IV TPOXX, vancomycin, piperacillin/tazobactam, valacyclovir, and fluconazole were started on admission. The CDC approved administration of Vaccinia IG (VIG) on hospital day 3. ART was reinitiated after negative cryptococcal Ag test. Lesions visibly improved during the hospital stay. He is still hospitalized at the time of abstract submission.

Perineal/lip wounds: +MRSA. Penile lesion: +HSV-2. Other skin lesions: -HSV/VZV/HHV8. Right foot biopsy: +MPX. Fungal cultures neg.

IMPACT/DISCUSSION: Our immunosuppressed patient had severe but indeterminate lesions of multiple possible etiologies including MPX, HSV, VZV, superimposed cellulitis, oral thrush, or even Kaposi sarcoma. Broad-spectrum antimicrobial treatment was important to avoid increased morbidity and mortality.

MPX usually presents with firm or rubbery, well-circumscribed, deep-seated, and often umbilicated lesions.

Our patient had atypical ulcerating lesions previously seen in immunocompromised patients. Given the

known higher mortality and complication rates of monkeypox infections in this setting, it is important to keep this illness on the differential even without direct known exposure.

There are currently no approved MPX treatments. TPOXX, cidofovir, and VIG are approved for smallpox treatment and complications of vaccinia vaccination. They are available to treat MPX with CDC approval and patient consent for moderate to severe disease. No efficacy data is available to date in MPX. It is unclear whether this treatment or ART re-initiation led to our patient’s improvement.

CONCLUSION: Immunosuppressed patient skin lesions have a wide differential including MPX even without known exposures and should be aggressively treated to avoid morbidity and mortality.

Treatments for smallpox can be used in moderate to severe MPX with CDC and patient approval even though effectiveness has not been demonstrated yet.

WHEN PLATINUM IS NOT PRECIOUS: A RARE CASE OF CARBOPLATIN-INDUCED PNEUMONITIS

Xiancheng Wu¹; Catherine Chang¹; Khvaramze Shaverdashvili²; Heejae Kang¹; Shelly Xie¹; Risa L. Wong²; Diwakar Davar²

¹Medicine, UPMC, Pittsburgh, PA; ²Hematology/Oncology, UPMC, Pittsburgh, PA. (Control ID #3873932)

CASE: A 68-year-old man with newly diagnosed extensive stage small cell lung cancer presented to the hospital for treatment initiation given impending visceral crisis from liver metastases. He received intravenous (IV) carboplatin on day 1 and IV etoposide on days 1-3 of hospitalization. On day 5, he developed acute hypoxemic respiratory failure (HRF) and was found to have extensive bilateral ground glass opacities (GGOs) on CT. He was diuresed without improvement and was treated with empiric antibiotics and stress dose steroids. A repeat CT showed a reduction in GGOs after 12 days of steroids, and he was discharged on a steroid taper for presumed etoposide-induced pneumonitis. He presented again to the hospital 9 days later for abdominal pain due to disease progression. He was trialed on another round of chemotherapy with carboplatin and paclitaxel. Approximately 12 hours later, he developed worsening hypoxemia requiring non-invasive ventilation. Repeat CT showed a significant increase in GGOs, and steroids were restarted. Unfortunately, his symptoms continued to worsen, and he passed away from HRF.

IMPACT/DISCUSSION: The pathogenesis for chemotherapy-induced pneumonitis is unclear. Proposed mechanisms include direct injury to pneumocytes and alveolar capillary endothelium with the release of cytokines and inflammatory cell recruitment, the systemic release of cytokines, cell-mediated injury from lymphocyte and macrophage activation, and oxidative injury from free radicals. Corticosteroids are a mainstay of therapy due to their anti-inflammatory effect. Chemotherapy-induced pneumonitis is a diagnosis of exclusion, and no specific test exists to determine the offending drug. Given that platinum chemotherapeutic agents are often coadministered with other drugs in the treatment of advanced cancers, their role in lung toxicity may be underrecognized; for example, many case reports implicate paclitaxel and etoposide as the prime culprits of pneumonitis and lung fibrosis, even in the setting of concurrent platinum agent use. However, a phase 3 trial showed that the combination of carboplatin plus gemcitabine led to an increased risk of grade 3/4 lung toxicity compared to gemcitabine alone in patients with non-small cell lung cancer (Sederholm et al., J Clin Oncol 2005). Due to the lack of prior reports of platinum-induced lung injury, in our case, etoposide was initially thought to be the culprit of our patient’s pneumonitis rather than the accompanying carboplatin. However, a chemotherapy rechallenge containing carboplatin without etoposide led to irreparable damage, suggesting carboplatin as the cause. Our case report highlights the importance of considering carboplatin, and other platinum chemotherapeutic agents, as possible offenders of pulmonary toxicity.

CONCLUSION: Platinum chemotherapeutic agents may be underrecognized offenders of drug-induced pneumonitis and should be considered as possible culprits when pneumonitis occurs after administration of a platinum doublet regimen.

WHEN SLEEP HURTS THE BRAIN: IMPORTANCE OF EARLY DETECTION AND INTERVENTION OF HYPERCARBIA FOR INPATIENT PROVIDERS

Michael K. Jones¹; Nicholas Bianchina¹; Kathryn F. Huber¹; Arun Kannappan^1,2

¹Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ²Pulmonary & Critical Care, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #3847819)

CASE: A 53-year-old man with a history of class III obesity (BMI 48.6), undiagnosed sleep apnea and obesity hypoventilation syndrome, was admitted for newly diagnosed right heart failure and acute on chronic hypoxic respiratory failure. While admitted he developed severe altered mental status following an afternoon nap. He was initially unresponsive and unable to follow commands, requiring urgent stroke evaluation with CT imaging of his head. There was no evidence of hemorrhagic stroke, but it did reveal diffuse cerebral edema including sulcal effacement, thought to be subsequent to profound hypercarbia. Venous blood gas at time of alteration was notable for PCO₂ >100 mmHg, pH 7.20, and bicarbonate 42 mmol/L. He was started on non-invasive positive pressure ventilation (NIPPV), with rapid improvement in mentation. However, he had no recollection of evaluation by the rapid response team or of the CT scan. Neurology did not recommend additional stroke evaluation with MRI following the patient’s improvement. For the duration of his admission, he remained on NIPPV during naps and while sleeping overnight, without any additional

concerns for altered mental status. He was discharged home with nocturnal NIPPV and Pulmonary follow up.

IMPACT/DISCUSSION: This case highlights the clinical and radiologic complications that can be seen with severe hypercarbia. It is particularly salient in the context of rising obesity rates, as inpatient providers can often be the first to diagnose and treat sleep apnea and obesity hypoventilation syndrome in previously undiagnosed patients. The severity of altered mental status in this patient allowed for rapid evaluation with venous blood gas, CT brain, and basic metabolic panel, identifying hypercarbia and allowing for quick treatment with NIPPV. Cerebral edema secondary to hypercarbia has been identified in previous case reports, primarily in severe asthma exacerbations. In those cases, hypercarbia-related cerebral edema has progressed to the point of acute deficits, such as oculomotor nerve palsies. This is a unique case of hypercarbia related cerebral edema from obstructive sleep apnea, which resolved with appropriate treatment before focal neurologic deficits appeared.

CONCLUSION: Hypercarbia secondary to obstructive sleep apnea can be cause of altered mental status in inpatients with obesity.

Obstructive sleep apnea can lead to diffuse cerebral edema from hypercarbia. This may lead to focal neurologic deficits, which can resolve rapidly with appropriate ventilatory support.

WHEN SODIUM IS THE WEAKNESS LINK

Madeline Treasure

Internal Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #3876792)

CASE: A 50-year-old man without significant medical history presented to the hospital endorsing bilateral lower extremity heaviness over one week. He denied other symptoms or triggers and had never experienced the sensation prior. His initial workup was notable for a mildly low sodium and potassium with his symptoms attributed to his metabolic derangements. He was discharged home with a plan for outpatient follow up. He promptly returned with progressive numbness and tingling in his lower extremities to the level of his mid- abdomen. He was once again hyponatremic without improvement in his sodium following administration of fluids. On physical exam he had diminished sensation and hyporeflexia in his lower extremities. He ultimately developed significant weakness requiring assistance with ambulation. No abnormalities were found on MRI imaging of the brain and spine. While a comprehensive workup was underway, his urine and serum studies were consistent with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). This diagnosis was further supported by improvement in the patient’s serum sodium with fluid restriction and salt tab administration. With persistent neurologic symptoms, a lumbar puncture (LP) was performed which demonstrated high protein content with a mildly elevated white count and infectious studies unrevealing. Given the severity of his weakness, hyporeflexia, and lumbar puncture analysis, the patient was initiated on intravenous immunoglobulin (IVIG) for treatment of presumed Guillain–Barré Syndrome (GBS) with gradual improvement in symptoms. As the remainder of his broad workup (including infectious studies) was unrevealing and his symptoms continued to improve with IVIG administration, the team grew confident in the GBS diagnosis despite lacking a clearly identified preceding infectious trigger.

IMPACT/DISCUSSION: There is a known but easily overlooked association between SIADH and GBS with several proposed mechanisms including dysautonomia and hypothalamic involvement. This case highlights a noteworthy point that the neurologic symptoms of GBS typically precede the onset of hyponatremia; however, the sodium derangement may occur first. Population-based data reflects that a large proportion of patients with GBS have SIADH at some point during their illness with SIADH serving as a poor prognostic factor for these patients.

CONCLUSION: While a cause of SIADH is not always evident, recognizing the link between SIADH and GBS may prompt earlier diagnosis and appropriate management of GBS. The case also highlighted the difficulty in treating the two conditions synergistically as the fluid restriction with SIADH was believed to exacerbate the dysautonomia associated with GBS. Similarly, the administration of IVIG can manifest a pseudohyponatremia which influences the monitoring of serum sodium for correction. Ultimately, with the help of an interdisciplinary team, the patient’s sodium corrected with improvement in his neurologic function.

WHEN THE LIVER KEEPS SCORE: AN UNUSUAL PRESENTATION OF SYPHILIS IN A PATIENT WITH HIV

Blythe A. Butler¹; Kenneth Hubbell¹; Mia F. Williams³; Irina (Era) Kryzhanovskaya²

¹Internal Medicine, University of California San Francisco, San Francisco, CA; ²Medicine, University of California San Francisco, San Francisco, CA; ³Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #3877010)

CASE: 57M with history of HIV on ARVs (CD4 342, VL undetectable) presented to clinic with six weeks of nausea, low appetite, 15 pound weight loss, and abdominal pain. Two weeks prior, he developed a rash and red eyes. He denied fever, chills, night sweats. He recently retired and lives with his husband. He traveled to Mexico 12 weeks prior, where he had unprotected receptive anal sex with one new partner. On exam, he was afebrile with normal vital signs. He had bilateral conjunctival erythema, mildly tender right upper quadrant, and a blanching erythematous macular rash over his trunk. He was sent to the emergency department.

Initial labs showed elevated LFTs (ALT 120, AST 80, ALP 768 U/L), Cr 2.5 mg/dL (baseline 1.1mg/dL). Urinalysis showed 4+ protein, no WBCs. A 24-hour urine collection demonstrated nephrotic range proteinuria. CT abdomen-pelvis with contrast showed rectal wall thickening and adjacent fat stranding, consistent with proctitis. MRCP was without acute findings.

Further testing revealed negative ANA and hepatitis serologies. He had a strongly positive antimitochondrial and weakly positive anti-smooth muscle antibodies. A liver biopsy showed portal lymphoblastic inflammation with bile duct injury. On hospital day 3, RPR titer returned 1:128 with a positive treponemal antibody. Overall findings were consistent with syphilitic hepatitis. Lumbar puncture was performed, notable for WBC 64 and non-reactive VDRL, diagnostic of neurosyphilis. He was treated with IV penicillin G benzathine 3 million units on hospital day 4.

IMPACT/DISCUSSION: The rates of syphilis infections in the US have been rising since 1993. Males living with HIV are disproportionaly affected. Hepatic treponemal involvement is rare and often non-specific. However, there are increasing case reports of syphilitic hepatitis, predominantly in people living with HIV. It has been described in the literature as a mimicker of PBC and often occurs with a concomitant macular rash, as for this patient. Syphilitic hepatitis should be considered in the presence of cholestatic liver injury in the absence of alternative causes of hepatic dysfunction, especially in the presence of serologic treponemal evidence. Additionally neurosyphilis can occur any time after infection, and early neurologic involvement may also be seen more frequently in patients with HIV. Patients with HIV who are not on ARVs, who have any neurologic or ocular symptoms or an RPR >1:32, CD4 <350, HIV RNA >50 copies/mL, should undergo an LP to evaluate for neurosyphilis. CSF WBC >20 or positive CSF VDRL is diagnostic for neurosyphilis. Patients should undergo repeat LP 3-6 months after treatment. Patients living with HIV are more likely to have slower resolution of CSF abnormalities.

CONCLUSION: Syphilitic hepatitis should be included in the differential diagnosis for patients living with HIV presenting with cholestatic liver injury. Patients with HIV are more likely to present with early neurosyphilis and have a slow resolution of CSF abnormalities.

WHEN THERAPEUTIC PLASMA EXCHANGE IS NOT ENOUGH

Phoebe Garcia^1,2; Kellie Spector²; Phyllis Kim²

¹Internal Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Internal Medicine, UCLA Medical Center Olive View, Sylmar, CA. (Control ID #3875481)

CASE: A 66 year old male with no past medical history was brought to the emergency room by his roommate for one day of abdominal pain. History was obtained from his roommate and was notable for one day of abdominal pain without any nausea, vomiting, or diarrhea. The patient had not mentioned any consumption of new foods, recent travel, any new medications or any illicit drug use. His mental status prior to presenting was normal, but he became encephalopathic within a few hours, to the extent where he could no longer speak or follow commands. On physical exam, the patient was awake, alert but agitated, nonverbal, moving his limbs, unable to follow commands with Glasgow Coma Scale of 12. He had ecchymosis over the right flank.

His labs on admission were notable for hemoglobin of 7.2 g/dl, platelets 7 K/cumm, reticulocyte percent of 9.7%, haptoglobin <15 mg/dL, folate 16.2 ng/ml, LDH 1,129 U/L, total bilirubin 2.7 mg/dl, and direct bilirubin of 0.4 mg/dL. His PT/INR were 14.3 sec/1.13 and peripheral smear of the patient’s blood demonstrated metamyelocytes, schistocytes, polychromasia and RBC fragments.

His creatnine was 1.41 mg/dL, with urinalysis demonstrating moderate amounts of blood. His troponin was elevated to 1.110 ng/ml without any EKG abnormalities. MRI brain was notable for left subcortical and rightcortical parietal infarction secondary to microangiopathic hemolytic anemia (MAHA). His presentation was consistent with thrombotic thrombocytopenic purpura (TTP) which can present as a severe hematologic emergency causing neurologic dysfunction, MAHA, thrombocytopenia, acute kidney injury, and cardiac dysfunction.

IMPACT/DISCUSSION: Since the full pentad of TTP: MAHA, thrombocytopenia, fever, acute kidney injury, and severe neurologic findings is present in less than 10% of cases, early diagnosis requires a high index of suspicion which is why the PLASMIC score is clinically useful. An emergent peripheral smear should be performed in any patient who presents with new or unexplained thrombocytopenia and hemolytic anemia to examine for schistocytes. The decision to initiate TPE can be challenging because it is a clinical decision and results of ADAMTS13 activity are often not immediately available, however TPE should not be delayed given it can be lifesaving. Recurrence of TTP is common and aggressive alternative treatments such as caplacizumab for patients who present with high-risk features including severe neurologic dysfunction is warranted to avoid morbidity and mortality.

CONCLUSION: The recognition of severe TTP and addition of caplacizumab was critical for this patient's recovery as he had no response to the standard regimen of TPE, steroids and rituximab. With the addition of caplacizumab, he was able to make a full neurological recovery from his stroke and is back to his baseline functional status.This case highlights the importance of the early recognition of TTP and utilization of caplacizumab in severe cases because of its potential for inducing a remarkable recovery.

WHEN TO WORRY ABOUT PANICKING PATIENTS

Weston J. Ernst¹; Christopher Smith²

¹College of Medicine, University of Nebraska Medical Center, Omaha, NE; ²Internal Medicine, University of Nebraska Medical Center, Omaha, NE. (Control ID #3876509)

CASE: A 23-year-old previously healthy man presented with 5 months of progressive anxiety-induced “panic attacks.” The panic attacks occurred daily, with each episode lasting 20 minutes to 4 hours. He described rapidly decreased fields of vision, palpitations, tremulousness, diaphoresis, and loss of consciousness followed by urinary incontinence. There was often a sense of foreboding and guilt. He noted a recent increase in psychosocial stressors.

Upon encountering the patient, he appeared worried but was not in acute distress. His heart had regular rate and rhythm, his lungs were clear to auscultation bilaterally, and he was alert and oriented. His troponin was 0.26. Electrocardiogram showed normal sinus rhythm with 87 beats per minute for both atrial and ventricular rates. Echocardiogram showed an LVEF of 55-60% with a mildly dilated right ventricle and normal systolic and diastolic function. A CT chest showed no signs of PE or aortic dissection. Psychiatric evaluation revealed a four-year history of audiovisual hallucinations and obsessive-compulsive behaviors with social anxiety since childhood.

Later in the day, the patient went into supraventricular tachycardia which required increasing doses of adenosine and cardioversion interspersed with apneic episodes and loss of consciousness requiring painful stimuli to arouse. While in supraventricular tachycardia, the patient was diaphoretic, tachypneic, panicked, and anxious. Following cardioversion, no subsequent cardiac events or panic attacks occurred while the patient was inpatient. A potential pre-excitation syndrome was thought to be the root cause of this patient’s supraventricular tachycardia. However, no additional testing has been possible as the patient was lost to follow-up.

IMPACT/DISCUSSION: Panic attacks and tachyarrhythmias can present similarly with elements of sympathetic arousal such as palpitations, diaphoresis, and altered perceptions. It can be difficult to discern the distinction, particularly in someone who has had long-standing psychiatric comorbidities with intermittent cardiac symptoms. Often these two disorders can exist concomitantly, or one can exacerbate the other. Thus, it is necessary to evaluate anyone who presents with panic disorder for associated cardiac etiologies via electrophysiology studies and electrocardiograms after the inciting events have concluded, especially if angina or arrhythmias are present.

Patients with underlying angina, ischemic events, or arrhythmias must have proper workup to prevent sudden cardiac death. The brief nature of panic attacks and some supraventricular tachycardias can make pinpointing a root cause difficult, but the mortality risks these patients face require further evaluation. This patient likely has elements of both cardiac and psychiatric diagnoses that increase his risk of harmful cardiac events later in life if left unevaluated.

CONCLUSION: Panic disorder and tachyarrhythmias exist cyclically and concomitantly. Precise diagnosis can prevent later cardiac injury.

WHEN TUBERCULOSIS PRESENTS VIA TELEMEDICINE

Elena Butler¹; Anna U. Morgan²; Alesha Levenson³

¹Medical School, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ²Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ³Medicine, Pennsylvania Hospital, Philadelphia, PA. (Control ID #3878452)

CASE: Mr. R is a 31-year-old male who presented to virtual primary care with 4 months of weight loss, neck swelling, cough, and fatigue. Initial workup revealed negative HIV testing, positive IGRA, and CXR with R anterior mediastinal mass and ground glass opacities. 1 week later, CT neck/chest showed cervical and supraclavicular lymphadenopathy with central caseation and extensive miliary nodularity in the chest, concerning for miliary tuberculosis (TB).

1 week after CT, Mr. R was seen virtually by Pulmonology and started on rifampin, isoniazid, and ethambutol. 6 days later, he presented to the Emergency Department (ED) for worsening clinical status. He was afebrile with HR 130, BP 84/71, RR 22, 98% saturation on room air. Weight was 97 lbs (baseline 177 lbs). Exam demonstrated cachexia, temporal wasting, and course breath sounds. Labs were notable for Tbili 3.7 mg/dL and ALT/AST of 397/599 IU/L.

Mr. R was admitted to the ICU. Anti-TB medications were held due to hepatotoxicity and he was started on N-acetylcysteine (NAC) for liver protection. After 1 week Tbili improved to 1.8 and ALT/AST were 109/62. The patient was started on rifampin, ethambutol, and levofloxacin. Pyrazinamide was added after LFTs remained stable.

Mr. R moved to the U.S. from India 5 years prior to presentation. At that time, he had a positive tuberculin skin test (TST) and normal CXR. Positive TST was attributed to his BCG vaccine and he was not treated for TB given his lack of additional risk factors. During admission, sputum/blood AFB smears were negative however a sputum NAAT was positive for M. tuberculosis. After a 3-month inpatient course Mr. R was discharged on TB therapy to complete a 6-month course.

IMPACT/DISCUSSION: Telemedicine provides access and convenience for patients, however its constraints include limited physical exam and provider reliance on the patient’s description of symptoms.

These challenges may explain why it took 2 weeks to initiate TB treatment despite history of living in an endemic area, positive IGRA, and active TB symptoms. Higher suspicion for TB coupled with immediate referral to the ED may have resulted in earlier treatment that could have benefited the patient.

Rifampin, isoniazid, and pyrazinamide can all cause anti-TB drug-induced liver injury (AT-DILI), defined as Tbili ≥3 mg/dL or ALT/AST >5X upper limit of normal (ULN). Globally, AT-DILI occurs in 2-28% of patients. Isoniazid is the most common culprit. Guidelines recommend stopping anti-TB medications until Tbili is <2 mg/dL and ALT/AST are <2X ULN. RCT suggests that N-acetylcysteine (NAC) may shorten hospital stays for AT-DILI patients.

CONCLUSION: Telemedicine may not be suitable for critically ill patients. Consider TB in patients from endemic areas with concerning symptoms such as cough, lymphadenopathy, and weight loss. For patients with BCG vaccine, positive IGRA is more definitive for TB infection than TST. AT-DILI necessitates stopping TB treatment until improvement of LFTs. NAC may improve clinical outcomes.

WHY DID ACUTE BULBAR PALSY DEVELOP IN A 48-YEAR-OLD WITH PRECEDING COMMON COLD SYMPTOMS?

Moeka Toyama¹; Takahiro Shimizu²; Yasuhiro Ito²; Kazuo Komamura³; Mitsunori Iwase⁴

¹Internal Medicine, Toyota Kinen Byoin, Toyota, Aichi, Japan; ²Neurology, Toyota Kinen Byoin, Toyota, Aichi, Japan; ³Rehabilitation, Toyota Kinen Byoin, Toyota, Aichi, Japan; ⁴Cardiology, Toyota Kinen Byoin, Toyota, Aichi, Japan. (Control ID #3875488)

CASE: A 48-year-old man with no past history was admitted to our hospital for difficulty of swallowing and speaking. He started to feel numbness in both hands 2 days prior. An additional interview revealed he had coughs and fever 10 days before admission. On the first examination, his voice was muffled and drooling was evident. Neurological exam revealed decreased deep tendon reflexes, but no reduced motor strength, including limbs and the neck. Flexible laryngoscope showed no sign of acute epiglottitis. Laboratory data were notable for elevated levels of WBC(17900/μL), CK(486U/L), and CRP(1.45mg/dL). Brain and spine MRI, nerve conduction studies (NCS), and cerebrospinal fluid (CSF) examination were unremarkable. For the presumed diagnosis of Guillain-Barre syndrome (GBS), the patient received a five-day course of intravenous immunoglobulin (IVIG). Subsequently, anti-GT1a and anti-GT1b antibodies were found to be positive. Symptoms gradually declined, and showing full recovery, the patient was discharged home on the day 21 of hospitalization.

IMPACT/DISCUSSION: GBS is considered post-infectious, immune-mediated neuropathies which commonly cause acute, flaccid, neuromuscular paralysis. The diagnosis is based on clinical history and physical examination, supported by ancillary investigations such as CSF examination and NCS. Rare variants of GBS include pharyngeal-cervical-brachial (PCB) types and acute bulbar palsy plus (ABPp) syndrome, which both present with bulbar palsy without limb weakness. PCB is characterized by weakness of neck and upper limb muscles, whereas ABPp is likely to present external ophthalmoplegia. However, in this patient, the only presentation was bulbar palsy and paresthesia in hands and feet, and this was thought to be a rare subtype of the two variants above. Several antiganglioside antibodies are known to be associated with certain clinical phenotypes, as anti-GT1a IgG antibodies have often been detected in GBS with bulbar palsy. Although we found no abnormalities in CSF and NCS, which made the initial diagnosis difficult, anti-GT1a antibodies turned out to be positive and established the diagnosis.

CONCLUSION: Taking detailed patient history and physical examination can be the only key to diagnosis in atypical cases of GBS. Acute bulbar palsy may cause serious complications such as upper airway obstruction, hence requires the appropriate beginning of initial treatment.

WOUND HEALING AND FOOD STINK WITHOUT ZINC. IF YOU CAN’T TASTE IT, LET’S TEST IT.

Iaong Vang¹; Ajaya Sharma¹; Hari Paudel²

¹Medical School, Medical College of Wisconsin, Milwaukee, WI; ²Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3875436)

CASE: A 66-year-old male with a past medical history of significant alcohol use (1L vodka per week), peripheral neuropathy, hyperlipidemia and hypertension presented with wounds on his right toes and chronic bilateral hand and lower extremity numbness that worsened over the past 4 weeks. He also endorsed a history of recent decrease in appetite and inability to taste food. He denied any recent upper respiratory infections.

He was non-vegan and denied any history of malabsorption or bariatric surgery in the past. On physical exam, he appeared malnourished with a BMI of 19 and was found to have a right anterior shin wound with wet gangrene of his right toes 1-5. He was diagnosed with critical right lower ischemia with gangrene, infected wound of anterior right lower extremity, and hypogeusia secondary to zinc deficiency with a zinc value of 54.8 (normal level: 80 to 120 mcg/dL, levels below 70 mcg/dL in women and 74 mcg/dL indicate deficiency per National Institute of Health). The wounds were likely driven by peripheral neuropathy, poor wound healing in the setting of malnutrition and underlying peripheral artery disease. He underwent a right SFA-anterior tibial artery bypass with right non-reversed greater saphenous vein, guillotine trans metatarsal amputation of the right toes 1-5, and excisional debridement of his right anterior shin wound. He was started on zinc supplementation for his hypogeusia and mirtazapine for his decreased appetite and flat affect/mood. He clinically improved as he reported an improvement in appetite and taste as early as 5 days into treatment and was discharged in stable condition to a rehabilitation facility for post-operative recovery.

IMPACT/DISCUSSION: Zinc has significant physiological roles and deficiency has many manifestations. Assessing zinc levels in individuals at risk, especially elderly population, and those with chronic illnesses with complaints of decreased taste can lead to early diagnosis. While zinc deficiency can result in dysgeusia which can result in malnutrition, people with malnutrition are already at risk of zinc deficiency, thereby, starting a never-ending spiral. Zinc deficiency in the settings of wounds can delay wound healing.

CONCLUSION: Zinc supplementation can improve nutrition and healing of active wounds. Further studies are needed to determine the appropriate dose of supplementation in zinc deficiency.

XANTHOMA DISSEMINATUM WITH EROSIVE DISEASE IN AN ADULT PATIENT Sundeep Bekal¹; Haifaa Abdulhaq²

¹Internal Medicine, University of California San Francisco, San Francisco, CA; ²Hematology Oncology, University of California San Francisco Fresno, Fresno, CA. (Control ID #3874119)

CASE: A 24 year old male with no prior history first presented to primary care clinic with complaints of a rash. The patient reported that the initial lesion started in his armpit several weeks ago. The lesions progressively spread, affecting his inner thighs bilaterally, around his mouth and upper eyelids. The diagnosis was first believed to be acne vulgaris however he reported no relief with medication after a few weeks. Approximately 3 months later he then developed bilateral knee and hip pain. He later had a punch biopsy obtained from his L shoulder lesion which commented on “dermal proliferation of histiocytes with scattered Touton Giant Cells compatible with xanthogranuloma”. However due to the persistent symptoms of joint pain the patient then had a PET CT scan which commented on “Hypermetabolism involving multiple joints with associated erosive changes and areas of synovial thickening and joint effusions, consistent with joint space involvement”. Patient was later referred a rheumatologist and had an ultrasound of bilateral knees ordered, commenting on “Large distention of the suprapatellar, medial, and lateral joint spaces with homogenous hypoechoic material consistent with the xanthogranulomatous disease. There is no associated synovitis or hyperemia within this tissue”. Given his imaging findings it was believed less likely his symptoms were a result of inflammatory arthritis and more consistent with infiltration of xanthogranulomatous tissue into the joint. The patient was then referred to oncology clinic where the decision was made to start him on chemotherapy based off prior case reports.

IMPACT/DISCUSSION: Xanthoma disseminatum (XD) is a type of non-Langerhans cells histiocytosis with skin involvement of primarily the orifical region and flexor surfaces of the body. Our case remains unique due to the rare presence polyarticular joint involvement. Though there have been case studies mentioning XD involvement of deeper tissue structures, these have been more commonly associated with pediatric patients. Due to the complex course that XD can manifest as, it is important to approach treatment through a multidisciplinary course. Treatment remains difficult, with local therapies such as liquid nitrogen cryotherapy, radium patches, Xray irradiation, surgical excision and systemic therapy with oral clofibrate have been attempted with only mixed effects.

CONCLUSION: Though associated with a benign course, XD’s rare presentation along with even rarer potential to invade articular and joint involvement can pose a diagnostic and treatment challenge for many clinicians. The purpose of this report is to familiarize clinicians with an unusual variant of this entity in order to facilitate an early diagnosis and raise familiarity for possible complications. With more documented cases in the future, we remain optimistic on an eventual established treatment guideline for adult patients with XD involvement of the joints.

YOU MAKE ME WEAK: A SEVERE CASE OF STATIN-INDUCED MYOPATHY

Emily T. Young, Nisha Punatar

Internal Medicine, University of California Davis Department of Internal Medicine, Sacramento, CA. (Control ID #3874807)

CASE: Our patient is a 61-year-old man with hypertension, hyperlipidemia, and type II diabetes who presented with worsening proximal muscle weakness and dysphagia for two months. He was hospitalized for similar muscle weakness one month ago and was found to have rhabdomyolysis secondary to atorvastatin which was stopped. He was discharged on prednisone. On this admission, vital signs were normal and strength was decreased in all four extremities. Lab work was notable for AST 496, ALT 507, and CK 10,399. The patient was started on IV fluids and admitted for urgent workup of his myopathy.

Rheumatology was consulted on hospital day (HD) #1 and workup for inflammatory myositis was initiated, including sending Anti-HMG-CoA reductase (HMGCR) Antibody. Our patient was started on oral prednisone and the weakness in his lower extremities improved. On HD#5, a muscle biopsy was obtained. Due to persistent upper extremity weakness and worsening dysphagia, he was transitioned to IV solumedrol and mycophenolate on HD#6. Though his weakness stabilized, CK rose again to 10,980. He subsequently received intravenous immunoglobulin (IVIG) after which his CK slowly improved to 4,382. He was then put back on oral prednisone.

On HD#13, Anti-HMGCR antibody resulted positive suggesting a statin-related HMGCR induced myositis. On HD#20, preliminary muscle biopsy confirmed toxic necrotizing myopathy.

Ultimately, the patient was transferred to an inpatient rehabilitation center on an oral prednisone taper, mycophenolate, and IVIG outpatient as needed.

IMPACT/DISCUSSION: This case highlights the rare statin-induced necrotizing autoimmune myopathy (SINAM) that occurs in 1 of 100,000 people. Statins can trigger overexpression of HMG Co-A reductase leading to autoantibodies which damage muscle. Our patient’s clinical presentation – severe proximal muscle weakness despite discontinuation of statins – is typical. Bulbar symptoms such as dysphagia can occur along with rash, joint pain, and respiratory distress. Onset of statin-associated myopathy is usually expected within weeks to months of statin initiation. Interestingly, this patient had been on a statin for several years. It is therefore important to consider statin myopathy even years after initiation. High clinical suspicion and a thorough history is critical for early identification and treatment since diagnostic tests (muscle biopsy and

anti-HMG Co-A reductase antibody) can take days to result. As demonstrated by our patient’s initial lack of improvement with steroid monotherapy, combination therapy with immunosuppressants such as methotrexate, mycophenolate, or rituximab is often needed. More cases are essential to better clarifying the clinical course of SINAM and its response to various therapies.

CONCLUSION: Statins may cause severe myopathy years after initiation

SINAM is diagnosed via presence of anti-HMG Co-A reductase antibodies

SINAM can require months long treatment with steroids, immunosuppressants, and physical therapy

“IT’S STILL NOT COVID”: A CASE OF ADULT-ONSET STILL’S DISEASE

Anna C. Jameson¹; Pranav Shah^1,2

¹Internal Medicine, Medical University of South Carolina, Charleston, SC; ²Internal Medicine, VA Medical Center Ralph H Johnson, Charleston, SC. (Control ID #3876208)

CASE: A 19-year old female with no significant past medical history presented with a 7-week history of intermittent fevers, lymphadenopathy (LAD), arthralgias, rash, and hair loss. Over this time course she had presented to multiple clinics and emergency departments and was misdiagnosed with both SARSCoV-2 and Mononucleosis or prescribed antibiotics. At each of these presentations, she was tachycardic to the 110-120s and febrile with a non-pruritic rash that was intermittent only during these febrile episodes. She also noted severe alopecia and arthralgias. Multiple times these were attributed to a viral illnesses. On presentation, she was afebrile with T 37.9°C and tachycardic to 132 beats/min. Her exam was notable for bilateral cervical LAD and a maculopapular rash on the dorsum of bilateral hands and ankles. Her travel history was pertinent for a recent trip to Appalachia. Her labs were notable for a WBC of 11.77 K/cumm, Hb of 10.0 gm/dL, and Ferritin of 7300.6 ng/mL. Her AST and ALT were normal on admission. Her CRP was 29.2 mg/dL and ESR was >100 mm/hr. IL 2 receptor was 4379.5 pg/mL. SSA antibody was >8.0 AI and Anti-DNA was 11.0 IU/mL. Viral studies including EBV, HIV, and SARSCoV-2 as well as bacterial studies were negative. Parasitic and tick-borne studies were negative. RF was negative. Chest x-ray and abdominal ultrasound were unremarkable. A punch biopsy of her rash was obtained and favored Still’s disease. The patient’s presentation and labs were consistent with adult-onset Still’s disease (AOSD), meeting the Yamaguchi criteria for diagnosis. Her AST, ALT, and Ferritin worsened, concerning for Macrophage Activation Syndrome (MAS), though she did not require Anakinra. Steroids were initiated and tapered with improvement of symptoms and labs. She was discharged on Methotrexate and made a full recovery.

IMPACT/DISCUSSION: AOSD is incredibly rare, making it challenging to diagnose. This patient’s presenting symptoms feature key manifestations and characteristics of the disorder. Although similar to SARSCoV-2 and EBV with daily fevers and lymphadenopathy; key distinguishing features include polyarthralgia, rash, and hair loss, all of which are associated with AOSD. This case was also notable in that this patient developed Macrophage Activation Syndrome (MAS), a form of hemophagocytic lymphohistiocytosis that occurs in only a minority of patients (12-19%) and is often thought to be underdiagnosed. MAS is marked by worsening liver function and hyperferritinemia. It is critical to determine whether MAS is present on presentation of AOSD as this can guide therapy.

CONCLUSION: This case illustrates a disease with significant overlap in symptoms seen in a wide variety of illnesses. As AOSD is rare, it is commonly misdiagnosed. Fevers, arthralgias, rash, alopecia and sore throat should prompt further investigation in to AOSD. Attention should also be noted to MAS, a potentially deadly complication of AOSD.

“SEARCH UN-SATISFYING”: A CASE OF SPINAL EPIDURAL ABSCESS AND COGNITIVE BIASES

Connor Stephenson¹; Emily Robertson¹; Alexander Sougiannis¹; Margaret Kimzey¹; Brenna Sanders¹; Monica Klaybor¹; Pranav Shah^1,2

¹Medicine, Medical University of South Carolina, Charleston, SC; ²Internal Medicine, Ralph H. Johnson VA Medical Center, Charleston, SC. (Control ID #3876831)

CASE: 71-year-old male with past medical history of Crohn’s disease, short gut syndrome, and malnutrition requiring total parenteral nutrition (TPN) via peripherally inserted central catheter (PICC) line for 7 years, presented with acute onset lower extremity weakness and urinary retention. Shortly after admission, he developed acute encephalopathy with physical exam notable for cognitive disorientation, myoclonic jerks, and a positive Babinski reflex bilaterally. CT head imaging was unremarkable. MRI was discussed, but unobtainable due to his agitation and encephalopathy. Subsequent infectious workup demonstrated Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia and Pseudomonas aeruginosa urinary tract infection (UTI). His PICC line was removed, and he was started on Vancomycin and Cefepime. His encephalopathy improved along with his lower extremity weakness. His symptoms were initially all attributed to sepsis from an infected PICC line and urinary tract infection. Transthoracic ultrasound was negative for vegetations. After 4 days, his mentation improved enough for MRI imaging to be obtained. A spinal MRI series demonstrated epidural abscesses from C7-T10, displacing the spinal cord dorsally, as well as a second epidural abscess extending from T9-T12, contributing to severe spinal stenosis. Emergent surgical irrigation and debridement was conducted. Abscess cultures grew MSSA. Upon completion of his UTI coverage, he was switched to IV nafcillin for 6 weeks with subsequent symptoms resolution and discharge.

IMPACT/DISCUSSION: This case highlights a near-miss diagnosis due to cognitive biases, such as search satisfying, confirmation, and anchoring. Initially, Patient’s presentation was attributed to UTI, infected PICC line, and sepsis due to MSSA bacteremia. However, his physical exam findings along with persistent back pain and lower extremity weakness did not fit this picture. Given vast initial improvement in symptoms, it was easy to fall into multiple biases and not pursue further imaging. Disruption of the pyramidal tracts can cause positive Babinski sign, in addition to weakness of extremities, hyperreflexia, and spasticity. The most common presenting symptoms of spinal epidural abscesses (SEA) are vague: fever, back pain, and neurologic deficit. This variety of clinical features contributes to the high rate of misdiagnosis of SEAs with up to 75% of cases being misdiagnosed. Through clinical reasoning tools such as “can’t miss diagnoses” and asking “what doesn’t fit” we were able to overcome our biases in identifying SEA.

CONCLUSION: Clinical reasoning is an essential component in the diagnosis of SEA, in the absence of imaging. Through detailed physical exam and clinical reasoning tools, we can overcome different biases in identifying highly missed diagnoses, such as SEA.

“THE BLUE MAN- WHEN TREATING ED LEADS TO A TRIP TO THE ED”

Yedla Parekha²; Sindhu Lakkur²; ryan a. zaniewski¹

¹School of Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL; ²Internal Medicine, UAB, Huntsville, AL. (Control ID #3874715)

CASE: A 66 yo man presented with acute onset altered mental status, hypoxemia, and hypotension after drinking an entire bottle of “liquid Viagra” which he had purchased at a gas station along with his home prescription of sildenafil 100mg prior to entering a strip club. He denied alcohol use, illicit drug use and any significant family history. His medications include amlodipine, oxybutynin, tamsulosin, paroxetine, levothyroxine. In the ED, he was hypotensive to 80/38 with oxygen saturations at 83% on nonrebreather. He subsequently required phenylephrine and high flow nasal cannula oxygen. Physical exam was notable for confusion with waxing and waning consciousness, tachypnea, and pronounced cyanosis to his distal extremities. Initial blood gas was chocolate-colored in appearance and demonstrated slight acidemia with normal PO2 but decreased SP02. His CBC, CMP, TSH urine drug screen, blood alcohol, salicylates, acetaminophen levels, chest x-ray, EKG were unremarkable. The patient was treated with 2 mg/kg IV methylene blue. Methemoglobin levels were persistently elevated at 56%, requiring another dose. The patient was intubated for worsening altered mental status and admitted to the ICU where he was intubated for one day and was discharged home three days later following an uncomplicated hospital course.

IMPACT/DISCUSSION: Methemoglobinemia is a potentially life-threatening condition which is rare and under-recognized. Clinical presentation can range from confusion and dyspnea to severe respiratory depression and coma. Methemoglobinemia should be suspected in a patient with 1) high PaO2 and low SpO2, 2) cyanosis with SpO2 80-90%, and 3) dark blood. Definitive diagnosis is determined by measuring methemoglobin level. Treatment with methylene blue should be promptly initiated, unless G6PD deficiency is present. The agent which induced methemoglobin should be identified and discontinued. Methemoglobin is produced when heme-ferrous iron is oxidized to ferric iron, which does not bind O2. There are several well- known agents which can cause methemoglobinemia such as dapsone, topical anesthetics (benzocaine, lidocaine), and nitrites. Our patient did not take any of these medications, only “liquid Viagra” which was purchased at a gas station. Sildenafil inhibits phosphodiesterase 5, which prevents the degradation of cGMP, and causes smooth muscle relaxation. Only one case report has attributed the cause of methemoglobinemia to “under the counter Viagra” and no studies have attributed this to prescription Sildenafil. This indicates that Sildenafil is not the cause of methemoglobinemia, but additives to the preparation of “liquid Viagra”

CONCLUSION: Methemoglobinemia is a rare side effect of under the counter Viagra but should be suspected in persistently hypoxic patients with cyanotic extremities and chocolate appearing blood on lab draws.

Additives capable of inducing methemoglobinemia are easily accessible to the public and can be purchased online and locally.

Clinical Vignette - Chronic Disease Management

A "COAL" FINDING: A CASE OF PULMONARY ANTHRACOFIBROSIS

Oghenetejiri Gbegbaje¹; Chelsey Bertrand-Hemmings²; Angila Bag¹; Veronica R. Jacome Lopez²; Tanganyika Barnes¹

¹Internal medicine, Englewood Hospital and Medical Center, Englewood, NJ; ²Internal Medicine, Englewood Health, Englewood, NJ. (Control ID #3875522)

CASE: A 73-year-old woman from Colombia presented with 3 weeks of worsening non-productive cough, shortness of breath, and hoarseness with 4 days of fever. On presentation, she was febrile and hypoxic to 88%. Examination revealed diffuse wheezing, rales, and bibasilar crackles. She had leukocytosis, anemia, and hyponatremia. Blood cultures, streptococcal, and legionella antigens were all negative. Sputum culture was also negative for acid-fast bacilli. Chest x-ray showed right middle lobe consolidation, and chest CT showed right middle lobe collapse. Initially, she was treated for acute exacerbation of asthma secondary to bacterial pneumonia with ceftriaxone, azithromycin, methylprednisolone, and bronchodilators, but symptoms persisted.

Bronchoscopy revealed bilateral multisegmental mucosal black pigments. Bronchoalveolar lavage and bronchial washing were negative for malignancy. Biopsy confirmed fibrosis and anthracosis of the right middle lobe without acute inflammation or malignancy. The patient was then diagnosed with diffuse pulmonary anthracofibrosis with middle lobe syndrome (MLS). Further history revealed that she had been exposed to a charcoal-burning stove for 16 years while in Colombia.

IMPACT/DISCUSSION: Pulmonary anthracofibrosis (PAF) is characterized by hyperpigmented deposits on the tracheobronchial tree and lung parenchyma with associated narrowing and stenosis. The etiology is unknown; TB was thought to be causative, with 27-60% of patients with PAF having TB. It has also been associated with biomass fuel exposure. Kim et al. proposed that chronic smoke inhalation from incomplete combustion of biomass fuel leads to carbon particles being engulfed by macrophages, which remain in the respiratory submucosa and lead to chronic inflammation and fibrosis. Nearly half the world uses biomass fuel for heating and cooking. As such, PAF is more common in women of developing countries who prepare meals in poorly ventilated spaces, with the median age of diagnosis being 67.9 years.

Patients often present with chronic cough and dyspnea, are frequently diagnosed with COPD and asthma, and have a poor response to therapy. According to Kim et al., bronchial narrowing is most common in the right middle lobe (68%), leading to middle lobe collapse due to airway obliteration, as in our patient. The predilection for the right middle lobe may be due to a lack of collateral ventilation, sharp bronchial angle, and extrinsic compression by enlarged lymph nodes. Although no conventional treatment has been reported, bronchodilators, corticosteroids, and antibiotics have been used.

CONCLUSION: Patients with PAF have nonspecific symptoms with undetected risk factors, leading to delayed diagnosis. Physicians must be able to conduct an extensive exposure history to help with diagnosis. PAF should be considered a differential diagnosis in female patients with chronic respiratory symptoms and radiologic evidence of MLS.

A CASE FOR PCSK9 INHIBITORS IN A PATIENT WITH FAMILIAL HYPERCHOLESTEROLEMIA

Claire Arnold¹; Christopher Stephenson²

¹Internal Medicine, Mayo Clinic Department of Internal Medicine, Rochester, MN; ²Medicine, Mayo Clinic, Rochester, MN. (Control ID #3848768)

CASE: A 34-year-old male presented to an outpatient clinic for lipid management. He had a history of CAD with a prior NSTEMI requiring stenting, former tobacco use and obesity. Family history was notable for hypercholesterolemia in his brother and father, but no premature history of ASCVD. His physical exam revealed arcus senilis and tendon xanthomata. Before his NSTEMI two years prior, his medical history was notable for hypercholesterolemia with an LDL of 397. After his NSTEMI and atorvastatin initiation, his LDL decreased to only 207. Given his extremely elevated LDL, early history of CAD, family history, and physical exam findings, he elected to undergo genetic testing of FH. A heterozygous pathogenic variant was identified in the LDLR gene consistent with FH. He was started on triple therapy with evolocumab, ezetimibe and atorvastatin. After starting triple therapy, his lipids improved with an LDL of 39. However, due to cost concerns, the patient discontinued evolocumab and his LDL subsequently increased to 147 on dual therapy ezetimibe and atorvastatin.

IMPACT/DISCUSSION: Familial hypercholesterolemia (FH) is the most prevalent monogenic, autosomal dominant genetic disease in humans. Previous studies have suggested that 1:217 people in the general population have mutations that cause FH. The most common genes involved include low-density lipoprotein receptor (LDLR) gene, proprotein convertase subtilisin kexin 9 (PCSK9) gene and apolipoprotein B gene, all which are crucial for low-density lipoprotein cholesterol (LDL-C) catabolism and result in higher LDL-C in the blood if mutated. The diagnosis of FH is established through genetic testing or clinical picture, which typically includes high LDL-C. Patients with an elevated LDL-C have the propensity to develop early ASCVD and intense LDL-C lowering in patients with FH leads to marked improvement in prognosis. Treatment typically begins with maximally tolerated statin therapy followed by ezetimibe and a PCSK9 inhibitor if LDL-C is not at goal. PCSK9 is a protease that prevents recycling of LDLR to the cell surface resulting in higher LDL-C in the blood, thus, inhibiting it leads to lower LDL-C. There is no consensus on LDL-C target in FH heterozygotes. However, a more aggressive target of an LDL-C <70, is typical in very high-risk FH individuals, especially those with prior ACS. Studies such as the FOURIER trial are thought to support the use of PCSK9 inhibitors in people with FH since they have a higher risk of cardiovascular disease events. However, there is a financial barrier with these medications. PCSK9 inhibitors might not be covered by insurance companies even in areas where they have received approval for use, or they might have high monthly copayments.

CONCLUSION: This case highlights the challenges of pharmaceutical costs in the management of FH as well as how social determinants of health can impact an individual’s care.

A CASE OF JAK2-POSITIVE ESSENTIAL THROMBOCYTOSIS WITH VASOMOTOR SYMPTOMS

Melissa Chiang, Divya Shah

Internal Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #3876009)

CASE: The patient is a 47-year-old woman and active smoker who presented to establish care with a primary care physician at an academically affiliated federally qualified health center in the Mid-Atlantic region. She presented with chronic holocranial headaches, intermittent blurred vision, transient vision loss, lightheadedness, and easy bruising. She had recently presented to an emergency department and received a negative Head CT. On history taking, the patient noted a history of JAK2-positive essential thrombocytosis. She had been lost to follow up with a hematologist in Florida due to insurance issues, last seen two years

prior to presentation. She had undergone two bone marrow biopsies, notable for increased megakaryocytes and without evidence of other conditions. On laboratory testing, the patient was found to have platelets of 1435x10³/mcL. She was quickly seen by hematology and started on hydroxyurea with platelet reduction to 897x10³/mcL, then 413 x10³/mcL over the course of one month. In addition, with assistance from her primary care physician, she successfully quit smoking in order to decrease her risk of thrombotic complications.

IMPACT/DISCUSSION: Risk stratification of patients with essential thrombocytosis considers the presence of a JAK2 mutation, history of thrombosis, and age. Any patient with a history of thrombosis or age over 60 with JAK2 mutation is considered high risk. Those without thrombotic history or those over 60 without JAK2 mutation are considered intermediate risk. Low risk patients do not have thrombotic history, are under 60, and may be JAK2 positive or negative. Cytoreductive therapy, typically with hydroxyurea, is recommended for high and intermediate risk patients, with a target platelet count of 100 to 400x10³/mcL. Other options for cytoreductive therapy include anagrelide and peglyated interferon (safe in pregnancy). Cytoreductive therapy is used in conjunction with daily low dose aspirin therapy, though systemic anticoagulation is preferred in cases of venous thrombosis. Aspirin therapy can be considered in low risk patients if they have vasomotor symptoms, are JAK2 positive, or have cardiovascular risk factors, but observation is appropriate in patients without these risk factors. However, patients with extreme thrombocytosis (platelet count >1500x10³/mcL) are at increased risk of bleeding due to acquired von Willebrand factor deficiency and cytoreductive strategies are often used in this scenario.

CONCLUSION: Essential thrombocytosis is a chronic myeloproliferative neoplasm in which excessive clonal platelet production leads to thrombosis and hemorrhage. Clinical presentation varies widely, as approximately 50% of patients may be asymptomatic. Symptomatic patients commonly experience nonspecific vasomotor symptoms such as headache, dizziness, and lightheadedness. Primary care physicians should readily be able to recognize this disease, triage its severity, and monitor patients for complications.

A CASE OF NEPHROTIC SYNDROME: TO BIOPSY OR NOT TO BIOPSY?

Preetha Hebbar, Shayna Schor, Amed Logroño

Internal Medicine, Yale School of Medicine, New Haven, CT. (Control ID #3875140)

CASE: An 85-year-old jazz musician was sent to the ED from PCP office due to 2 weeks of elevated blood pressures despite alterations in his medications. His review of symptoms was negative except for 1+ lower extremity edema, which was attributed to amlodipine. Past medical history was significant for long standing hypertension, prostate cancer in remission, and a previous nephrectomy secondary to organ donation to family member.

In the ED, initial blood pressure reading was 232/109 and physical exam was unremarkable except for trace lower extremity edema. Initial lab data compared to one year prior was the following: Cr 1.9 (bl 1.10), eGFR 34 (61), Hgb 12.3, UA with 4 RBC and 3+ protein, AST 111, ALT 170, ALP 144, Alb 2.4. Renal ultrasound was performed and demonstrated an unremarkable single kidney without hydronephrosis.

Further work up demonstrated intrinsic renal injury with nephrotic range proteinuria with urine albumin/creatinine ratio (uACR) of 2,822.6 mg/g, urine protein/creatinine ratio (uPCR) of 418 mg/mmol). Nephrology guided the serologic work up for the nephrotic syndrome, which was as follows: Hgb A1c 7.4%, ANA/ANCA, C3/C4, HIV/hepatitis panel/syphilis, SPEP/UPEP unremarkable. Phospholipase A2 receptor Antibody (PLA2R) positive 1:2560. Patient was diagnosed with primary membranous nephropathy.

Following hospitalization, patient continued to have worsening nephropathy and underwent a CT abdomen/pelvis for worsening liver function tests. Patient was found to have an enhancing 2.3 cm left upper pole renal neoplasm with multifocal pancreatic masses. Pancreatic biopsy was performed, which was consistent with metastases from renal primary. Renal biopsy now planned due to unclear etiology of nephrotic range proteinuria.

IMPACT/DISCUSSION: Nephrotic range proteinuria is defined by a uPCR of greater than 3-3.5 g/24-hour period or spot uPCR of greater than 300-350 mg/mmol. This patient had risk factors for focal segmental glomerulosclerosis with HTN and DM2. However, work up revealed primary membranous nephropathy (MN) as well as cause for secondary MN with renal malignancy.

The gold standard for diagnosing etiology of proteinuria is a kidney biopsy. Given that the PLA2R antibody has been found in 70-80% of people with primary membranous nephropathy, biopsy can be deferred for trial of medical management if no other risk factors present. In this unique case, the patient had both primary and secondary causes for nephrotic range proteinuria, further complicated by single kidney. Biopsy was initially deferred due to patient’s age and risk of procedure but was ultimately scheduled.

CONCLUSION: - PLA2R is considered a major antigen for primary MN and should be checked as part of initial nephrotic syndrome work up

- Renal biopsy can be deferred for trial of medical management in primary MN if no other risk factors present

A CASE OF TREATMENT RESISTANT HYPERTENSION

Shing Chao¹; Nyla N. Leonardi²; Mohamad Beidoun¹; Austin J. Parsons¹; Megan Dekker¹

¹Internal Medicine, Henry Ford Hospital, Detroit, MI; ²Medical Education, Wayne State University School of Medicine, Detroit, MI. (Control ID #3874909)

CASE: A 58-year-old man with a past medical history significant for long-standing hypertension, coronary artery disease, cerebrovascular accident, and a 43 pack-year smoking history, who presented to the clinic for evaluation of resistant hypertension. The patient's blood pressure was persistently elevated with systolic above 160 mmHg and diastolic above 100 mmHg despite adherence to 10 mg amlodipine, 40 mg benazepril, and 25 mg chlorthalidone as well as compliance to a low-salt diet. He had no family history of resistant hypertension and denied any illicit drug use.

The patient was asymptomatic on presentation. Basic metabolic panel showed normal electrolytes and kidney function, while renal ultrasound showed no sonographic evidence suggesting renal artery stenosis. Metanephrine and normetanephrine levels, random cortisol levels, and thyroid stimulating hormone were within normal limits. Aldosterone level was elevated at 23.7 ng/dL and direct renin level was low at <2.1 pg/mL. The aldosterone to direct renin ratio was 11.3. Given suspicion for primary hyperaldosteronism, the patient underwent saline infusion test and aldosterone was non-suppressed (12.4 ng/dL - measured after saline infusion). Computed tomography of adrenal glands showed a lobulated left adrenal gland with negative Hounsfield units – likely indicating a lipid-rich adenoma. The patient was started on spironolactone and had improvement in blood pressure. However, repeat aldosterone to direct renin ratio remained elevated at 12.8. The patient was referred for adrenal vein sampling for evaluation of a functional left adrenal adenoma.

IMPACT/DISCUSSION: The prevalence of hypertension secondary to primary hyperaldosteronism was thought to account for less than 1% of hypertension etiology. However, some studies have suggested a much higher detection rate with the use of screening tests such as plasma aldosterone/renin activity ratio. (1) Currently, it is recommended that patients with severe hypertension or resistant hypertension undergo testing for endocrine etiologies. However, it is important to promptly test these patients as they frequently present with end-organ damage and cardiovascular events. (2) Although the classic triad of hyperaldosteronism includes hypertension, hypokalemia, and metabolic alkalosis, most patients are actually normokalemic. This case presents a patient who was normokalemic with resistant hypertension. Therefore, it is important to have high clinical suspicion and test these patients early to avoid development of complications.

CONCLUSION: 1. Patients with resistant hypertension should be promptly screened for endocrine hypertension to avoid the development of complications.

2. A normal potassium does not preclude patients from having underlying hyperaldosteronism.

3. Mineralocorticoid receptor antagonists are an effective initial therapeutic option in patients with hyperaldosteronism for both resistant hypertension and hypokalemia if present.

A COMPLICATED PRESENTATION OF ULCERATIVE COLITIS IN AN ELDERLY PATIENT

Juhi Gor, Brenda Queen

Internal Medicine, Virginia Commonwealth University, Richmond, VA. (Control ID #3859956)

CASE: A 75-year-old female with a past medical history of hypertension, hyperlipidemia, vitiligo, and generalized anxiety disorder presented to the hospital with bloody diarrhea and abdominal pain that began about a week prior to presentation. She was recently placed on Trimethoprim-Sulfamethoxazole for treatment of lower extremity cellulitis. Labs on presentation showed magnesium of 1.5 mg/dL, bicarbonate of 20 mmol/L, hemoglobin of 7.7 g/dL, and platelets of 539 10e9/L. C-reactive protein (CRP) elevated to 6.0 mg/dL and erythrocyte sedimentation rate (ESR) elevated to 44 mm/hr. Stool studies showed positive stool leukocytes and elevated fecal calprotectin. Infectious labs showed positive Cryptosporidium. CT abdomen showed concerns for pancolitis. Flexible sigmoidoscopy with biopsy showed active chronic crypt destructive colitis with ulceration and reactive epithelial cell changes without dysplasia or malignancy. The gastroenterology (GI) team was consulted, and the patient was started on 5-ASA 2.4 gm orally and 5-ASA 1 gm twice a day rectally. This regimen was continued until outpatient follow up with GI. For treatment of Cryptosporidium, the patient was started on Nitazoxanide, initially for three days, but extended to a total of seven days due to continued diarrhea. We later learned that the patient had a remote history of Cryptosporidium infection in 2019 where symptoms seemed to self-resolve.

IMPACT/DISCUSSION: We report a case of new diagnosis of ulcerative colitis with overlying Cryptosporidium infection in an elderly patient. Inflammatory bowel disease (IBD) is an inflammatory gastrointestinal condition that is separated into two major categories, Crohn’s disease and ulcerative colitis. A study performed by Kappelman in 2007 estimated the prevalence of ulcerative colitis in adults to be 238 per 100,000. The age distribution is thought to be bimodal with the initial peak occurring in the second and third decade of life, but about 15% of patients have been found to be diagnosed after the age of 65 years old.

Caring for elderly patients with ulcerative colitis comes with its own challenges due to increased comorbidities, increased risk for overlapping infections, and adverse drug-drug interactions with medications. The patient initially presented to an outside hospital where overlying infections were not widely considered, and the diagnosis of Cryptosporidium was missed. Cryptosporidium is an opportunistic infection that commonly self resolves and recurrence is rare. This highlights the importance of considering IBD in patients over the age of 65 years old, as these patients may only present during severe acute flares, leading to increased risk of complications.

CONCLUSION: It is crucial to keep in mind the bimodal distribution of IBD when patients present with severe gastrointestinal symptoms. Elderly patients have challenging presentations due to comorbidities, increased infection risk, and an unpredictable trajectory of immunocompromised state.

ACQUIRED ICHTHYOSIS VULGARIS (“FISH SCALE SKIN”) SHOULD PROMPT CLINICIANS TO LOOK BENEATH THE SURFACE

Mark A. Moses¹; Monica Mehta²; Elizabeth Plakseychuk¹; Gaetan Sgro³

¹School of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²Internal Medicine, UPMC, Pittsburgh, PA; ³Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #3873976)

CASE: A 73 year old man presented due to progressive weakness and fatigue and a 30 lb weight loss over the past several months. He was having on average 7 watery bowel movements per day, experiencing unrelenting chills, and had developed skin changes on his lower and upper extremities. The patient was a current ½ pack per day smoker, with an approximate 40 pack-year history and was undergoing surveillance for an 8x7 mm juxtapleural nodule seen on LDCT lung cancer screening 2 months prior. Physical exam was notable for right mandibular lymphadenopathy and scaly, hyperpigmented, dry skin most pronounced on the lower extremities, identified as ichthyosis vulgaris. His clinical picture and initial CT scan suggested malignancy, with lucent lesions in T9/T11 vertebral bodies. Workup of chronic diarrhea included negative stool cx/C. diff, calprotectin, O&P, sudan stain, EGD showing abnormal gastric mucosa (pale with hyperemic appearance) and colonoscopy showing normal colonic mucosa aside form a 4mm superficial ulceration. PET scan revealed hypermetabolic nodules in the right parotid gland, liver, pancreas, and axial/appendicular skeleton. FNA of his parotid mass detected anaplastic large cell lymphoma. He was not a candidate for systemic palliative chemotherapy due to his low performance status. While planning for hospice care, he died of peritonitis secondary to a perforated bowel, suggesting possible intestinal involvement of the lymphoma.

IMPACT/DISCUSSION: Anaplastic large cell lymphoma most often occurs in lymph nodes, with known, yet less common involvement of non-nodal structures including the skin, bone, lung, and gastrointestinal organs. Systemic involvement of the malignancy can make for a complex clinical picture that can delay the diagnosis of ALCL if the varying presentations are unfamiliar to the clinical team. It is therefore important to recognize the variety of presentations that accompany this lymphoma.

Acquired ichthyosis (AI) is associated with a range of infectious, metabolic, medication-related, endocrine, and neoplastic processes. Although uncommonly associated with CD30+ lymphoproliferative disorders including ALCL, the emergence of AI in patients with coincident findings such as B symptoms or lymphadenopathy should prompt workup for malignancy and infectious processes.

Further, patients who present with profuse diarrhea in addition to AI and image findings suggestive of malignancy should undergo workup for malignancy with EGD and colonoscopy in order to assess for extra- nodal GI involvement of lymphomas. Gastrointestinal lymphomas account for 20% of lymphomas with features of GI involvement of ALCL being more common in males over the age of 50 with the primary neoplasm located in the stomach.

CONCLUSION: ALCL has varying clinical presentations. AI and GI involvement are associated with ALCL.

A JOURNEY OF WEAKNESS THROUGH SPACE AND TIME

Jeffrey Jang, Emmalee Barrett, John L. Gracely

The George Washington University, Washington, DC. (Control ID #3876658)

CASE: 70 year-old man with lumbar stenosis presented with bilateral lower extremity weakness for the past three years. He also noted recent difficulty with ambulation and dizziness.

Exam was notable for 4/5 motor strength in lower extremities.

MRI showed multilevel degenerative changes with stenosis and multifocal T2 hyperintense lesions. Lesions were within the supratentorial compartment, medulla, as well as scattered throughout the cervical and thoracic spinal cord.

CSF studies were significant for oligoclonal bands and increased IgG index. B12 was borderline normal and the patient was positive for C-ANCA. Further diagnostic testing was largely negative for rheumatological disorders.

With a leading diagnosis of multiple sclerosis (MS), a five-day course of methylprednisolone 1gm daily was initiated. Patient’s weakness improved with steroids and physical therapy.

IMPACT/DISCUSSION: Diagnosis of late onset MS (LOMS), defined as those diagnosed with MS after the age of 50, can be a challenge for the internist. Clinical signs are often misdiagnosed with some studies suggesting a delay of three years before establishing the correct diagnosis. Misdiagnosis may occur due to differences in LOMS clinical presentation, imaging, and overall female predominance in receiving this diagnosis.

It is important to understand how clinical presentation may differ in those with LOMS. Studies have shown that 90% of patients with LOMS present initially with motor symptoms in comparison to 67% of those diagnosed before age 50.

MRI is the gold standard for diagnostic study. Common findings include white matter lesions in the periventricular, juxtacortical, and infratentorial region of the brain and the spinal cord. The incidence of white matter lesions of the brain not due to MS increases with age. This poses a challenge for diagnosis as hyperintensities can be a result of other pathologies including vasculitis or small vessel disease. Furthermore, white matter lesions in the brain can be found at a higher rate in healthy asymptomatic elderly adults. Spinal cord hyperintensities are less associated with normal aging and can be useful when brain MRI is equivocal.

Clinical signs of LOMS should prompt high suspicion for MS even with unclear MRI results. It is important to recognize the predominance of motor symptoms and higher proportion of spinal cord lesions as more prevalent in LOMS. Motor deficits represent a broad differential including demyelinating diseases, spinal cord compression, rheumatological diseases, and peripheral neuropathy. CSF analysis positive for oligoclonal bands, while not explicitly required according to the 2017 McDonald criteria, can assist in the diagnosis of MS given the opacity of MRI findings in elderly populations.

CONCLUSION: Late onset Multiple Sclerosis consists of only 5% of all MS cases and is frequently missed. There is an increasing trend in aging males to be diagnosed with MS.

Motor dysfunction is often the first disease presentation with late onset MS.

AMYOTROPHIC LATERAL SCLEROSIS MASQUERADING AS POLYMYOSITIS

Areeka Memon²; Melanie Graber¹; Henry Uradu²; William Traverse²

¹New York University, New York, NY; ²University of Connecticut, Farmington, CT. (Control ID #3875313)

CASE: A 76-year-old male with prior diagnosis of polymyositis arrived at the emergency department with complaints of acutely worsening generalized chronic weakness. Six years prior, he experienced generalized weakness and fatigue with tremors of his bilateral hands, and later, lower extremities. He was found to have elevated creatinine kinase and a muscle biopsy revealed nonspecific T-lymphocytic infiltrates; thus, the patient was given a provisional diagnosis of polymyositis. He was treated with mycophenolate mofetil and hydroxychloroquine, however, symptoms continued to progress. Over the last year his weakness continued to worsen, resulting in the patient being wheelchair bound for the past few months.

On physical exam, he was found to have decreased breath sounds at bases with bibasilar rales and a grade 2/6 systolic murmur. He had decreased motor function diffusely, ranging from 2-4/5. Prominent muscle atrophy was present in upper extremities, especially hands and deltoids and frequent fasciculations in bilateral upper extremities and thighs. Reflexes were decreased in the upper extremities and ankles.

He underwent an MRI which revealed abnormal signal changes within the musculature and an EMG revealed diffuse, chronic reinnervations in all muscles with fasciculations and denervation in many muscles. It was suggestive of chronic and diffuse disorder of motor neurons with a superimposed axonal large fiber neuropathy.

The patient's final diagnosis was a motor neuron disease most consistent with ALS. His previous diagnosis of polymyositis, based on weakness and a muscle biopsy with inconclusive results, served as a cofounder for his final diagnosis. The patient had a worsening clinical course that was not consistent with polymyositis which prompted further investigation. The patient was transferred to a long-term care hospital and advised to have close neurology follow-up.

IMPACT/DISCUSSION: PM is an autoimmune condition which presents with symmetric, proximal muscle weakness without sensory loss or ocular muscle involvement. Progressive cases have weakness of distal muscles, pharyngeal muscles, neck flexors, and respiratory muscles. It is uncommon for patients to have myalgias or fasciculations. Some present with decreased deep tendon reflexes.

ALS is the most common motor neuron disease in adults. It presents with a combination of upper and lower motor neuron deficits and usually lacks sensory and extraocular involvement, like PM. Electrodiagnostic testing, abwork, and biopsy, can support one diagnosis over another. Previous cases have been reported in which patients were first diagnosed with ALS, but later found to have an autoimmune condition, delaying their treatment, but few cases have been discussed in which patients’ diagnosis of polymyositis masked ALS.

CONCLUSION: Early diagnosis and detection can usually decrease morbidity and mortality. When diagnosing polymyositis, it is important to consider additional, similar diagnoses such as ALS, to prevent delay in treatment.

AN ATYPICAL PRESENTATION OF HIV-ASSOCIATED DISTAL SYMMETRICAL POLYNEUROPATHY: A CASE REPORT

Krystal Austin, Jacob Walker

School of Medicine, University of Colorado Denver School of Medicine, Aurora, CO. (Control ID #3871926)

CASE: A 54-year-old man presented to clinic with the chief concern of pain and numbness in his feet and hands that has steadily become more debilitating over the past 8-10 years. The pain, at times sharp but mostly tingling, extends from his toes to mid-calf bilaterally, and from fingertip to metacarpophalangeal joints bilaterally. His pain is aggravated by the pressure of blankets while in bed, sitting for prolonged periods, and wearing shoes. He is notably uncomfortable and continually adjusts his position throughout the visit.

The patient has been living with HIV since 1993. He did not seek treatment until 2010 when he presented with multiple opportunistic infections. His CD4 count reached a nadir of 34. Since then, he has consistently been taking antiretroviral therapy (ART) and his current long-term regimen is emtricitabine, rilpivirine, and tenofovir alafenamide. His past medical history is also significant for an episode of treated neurosyphilis, mild HIV-associated neurocognitive disorder, and stage II CKD.

His exam is notable for decreased sensation to pinprick and light touch, diminished vibratory sensation below the ankles, and decreased proprioception at the great toes. He was diffusely hyperreflexic, with positive Hoffman sign and reflex testing eliciting brisk responses in both contralateral and distant ipsilateral limbs.

The patient’s most recent HIV labs show a CD4 count of 648 cells/uL (27%) and HIV viral load of 0 copies/mL. Cervical and lumbar MRIs show degenerative change but no cord or nerve compromise. Electromyography revealed a symmetric sensory neuronal large fiber polyneuropathy, along with a mild-to- moderate, chronic, right L5 and C8-T1 radiculopathy, without evidence of active denervation. Based on these findings, a diagnosis of HIV-associated distal symmetric polyneuropathy (HIV-DSP) was made.

IMPACT/DISCUSSION: Apart from the patient’s hyperreflexia, his clinical picture conforms to the classic presentation of HIV-DSP with painful paresthesias, hypersensitivity, decreased sensation in a stocking and glove distribution, and decreased proprioception.

With the advent of ART, incidence of HIV-DSP has decreased, but it remains the most common presentation of neurologic disease in patients with HIV. The use of ART has been shown to significantly slow disease progression. Such extensive progression of symptoms despite continuous ART and excellent viral control is unexpected. The presence of hyperreflexia was also unusual as HIV-DSP typically presents with hypo- or areflexia.

CONCLUSION: Progression of HIV-DSP, the most prevalent neurologic complication in patients living with HIV, can be slowed with consistent use of ART. With this clinical vignette, we present an atypical case of progressive HIV-associated distal symmetrical polyneuropathy with diffuse hyperreflexia in a patient on longstanding ART as a reminder to clinicians that HIV-associated neuropathy should remain on their differential for patients with remotely diagnosed and well-controlled HIV.

AN INCIDENTAL FINDING OF NONBACTERIAL THROMBOTIC ENDOCARDITIS DUE TO ANTIPHOSPHOLIPID SYNDROME

Lillian Sangha¹; Benjamin Ravichander¹; Adalberto Guzman¹; Maria Ibarra²; Harleen Kaur³; Rashmeet Brar⁴; Irina Mishagina¹

¹Internal Medicine, UPMC Central PA, Harrisburg, PA; ²Pediatrics, Woodhull Medical Center, Brooklyn, NY; ³Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India; ⁴Adesh Institute of Medical Sciences and Research Bathinda, Bathinda, Punjab, India. (Control ID #3875461)

CASE: A 62-year-old female with a history of heart failure with reduced ejection fraction presented to the hospital with shortness of breath. She was found to be hypotensive and tachycardic with a rhythm of atrial fibrillation with rapid ventricular response. Amiodarone was initiated for rate control in the setting of hypotension. There was a lack of clinical response to the amiodarone, and after discussion with cardiology, the decision was made to cardiovert the patient. A transesophageal echocardiogram (TEE) was obtained prior to cardioversion, and the patient was noted to have a vegetation on her aortic valve. She did not tolerate the remainder of the procedure due to worsening hypotension, so the TEE was aborted, and the patient was moved to the intensive care unit and started on norepinephrine infusion to maintain adequate perfusion. Workup for her valvular vegetation was initiated, and the common causative agents, including Staphylococcus aureus, Streptococcus viridans, Streptococcus bovis, Streptococcus sanguis, Enterococcus faecalis, Chlamydia psittaci, Bartonella, Brucella, or HACEK organisms were not discovered. Further evaluation involved autoimmune workup, which was remarkable for positive titers of cardiolipin, B2- glycoprotein, and phosphatidylserine antibodies. Due to negative infectious workup, it was deemed that the vegetation's origin was due to her new diagnosis of antiphospholipid syndrome (APS). The patient was diagnosed with Nonbacterial thrombotic endocarditis (NBTE) and started on heparin infusion with a cross- bridge to warfarin for anticoagulation.

IMPACT/DISCUSSION: NBTE is characterized by the deposition of sterile platelet thrombi on undamaged heart valves. These vegetations consist of thrombi woven with fibrin, immune complexes, and mononuclear cells. Compared to vegetations secondary to infective endocarditis, NBTE vegetations are more easily dislodged due to an inflammatory reaction at the site of the attachment. As such, patients with this condition are at higher risk for embolization and infarction. NBTE is commonly associated with advanced malignancy and systemic lupus erythematosus. It is also seen, but more rarely in antiphospholipid syndrome, rheumatoid arthritis, and traumatic burns. Patients with NBTE are typically asymptomatic, however large vegetations can sometimes induce arrythmias, or cause valvular symptoms that can exacerbate heart failure as seen in this case. When suspected, patients should have at least three sets of negative blood cultures in conjunction with a positive autoimmune workup. The mainstay of therapy of NBTE is anticoagulation.

CONCLUSION: NBTE is likely going to an incidental finding. Patients with this finding should be evaluated for infectious causes of endocarditis. If workup is noncontributory, an autoimmune source should be considered. Patients should be promptly started on anticoagulation if there are no contraindications.

AN ISOLATED SADDLE NOSE DEFORMITY IN PATIENT WITH GRANULOMATOSIS WITH POLYANGIITIS(GPA)

Joud Enabi¹; Samhitha Gonuguntla¹; Muhammad Waqar Sharif¹; Kejal Shah¹; Bosky Modi²

¹Internal Medicine, Texas Tech University Health Sciences Center, Permian Basin, Odessa, TX; ²Internal Medicine, Texas Texas University Health Sciences Center- Permian Basin, Odessa, TX. (Control ID #3873316)

CASE: A morbidly obese 68-year-old female with a significant medical history of chronic sinusitis, hypertension, and hyperlipidemia noticed a new onset deformity of her nose while getting a CPAP mask fitter for a sleep study test. She visited Otorhinolaryngology, where she was diagnosed with acquired saddle nose deformity and was referred to Rheumatology for that. She had no symptoms of cough, wheezing, shortness of breath, joint pain, or blood in the urine. Antineutrophil cytoplasmic antibodies (ANCA) (1:80), myeloperoxidase, and Antinuclear antibodies (ANA) with speckled pattern were positive in her laboratory results. Anti-MPO, however, was negative. CT scan on sinuses was normal. Nasal septal cartilage biopsy showed 'necrobiotic chronic inflammation, focal vasculitis, and fibrotic scar,' consistent with granulomatosis with polyangiitis. Methotrexate and folic acid treatment were started.

IMPACT/DISCUSSION: Granulomatosis with polyangiitis (GPA) is a rare autoimmune vasculitis mediated that mainly affects small blood vessels and has systemic clinical manifestations. 80%-95% of patients with GPA have the risk of developing head and neck manifestations during their life, mainly presenting with otorhinolaryngological signs and symptoms[1,2]. Granulomatosis with polyangiitis can be either limited or diffused. Limited GPA affects only the head and neck region. On the other hand, generalized GPA is characterized by systemic involvement, including fever, weakness, renal and pulmonary systems involvment. Limited GPA subtype commonly affects young females with poor medical treatment compliance[3]. In addition, limited GPA patients commonly present with nasal involvement that starts in the nasal septum area and then spreads paranasal sinuses[4]. In our case, the patient has symptoms limited to the sinonasal region, including recurrent chronic sinusitis involving the nasal cartilage leading to a saddle nose deformity[5,6]. A recently published systematic review of the literature explains that around 80% of the autoimmune-mediated perforation of the nasal septum is related mainly to GPA and chronic polychondritis[7]. Early diagnosis of GPA may be challenging, but it is essential to start the treatment early on and prevent irreversible damage[8]. Serological testing and histological features are essential to confirm GPA diagnosis.

CONCLUSION: Granulomatosis with polyangiitis (GPA) is a rare autoimmune vasculitis mediated that mainly affects small blood vessels and has systemic clinical manifestations. GPA is characterized by an inflammatory pattern of vasculitis, granulomatous inflammation, and necrosis, mainly affecting the kidneys and the upper and lower respiratory tracts. The pathophysiology of GPA remains largely unknown, but it is believed to be an autoimmune process triggered by environmental factors in patients with genetic susceptibility. Diagnosis of GPA is reached through proper clinical assessment and specific serological tests.

AN UNDERRECOGNIZED CAUSE OF CARDIAC COMORBIDITY

Ceshae Harding

Internal Medicine, Duke University Health System, Durham, NC. (Control ID #3875623)

CASE: A 56-year-old man with diastolic heart failure was evaluated in cardiology clinic for dyspnea and worsening lower extremity edema. Workup revealed atrial fibrillation with rapid ventricular response, prompting admission. A year prior to presentation, EKG with lateral T-wave changes prompted treadmill stress testing, which was positive. Cardiac catheterization followed with placement of four stents. He developed atrial fibrillation a week after the procedure, which recurred despite multiple ablations. In addition to dyspnea and lower extremity swelling, he described a constellation of symptoms upon admission including fatigue, weight loss, decreased appetite, loose stools, and easy bruising. His additional comorbidities included hypertension and osteoporosis complicated by vertebral compression fractures. No first-degree relatives had premature cardiovascular disease. Furthermore, he lacked major lifestyle risk factors for coronary artery disease (CAD) such as tobacco use, illicit drug use, excess alcohol intake, or inactivity. On medication review, he endorsed strict adherence to all medications including goal directed medical therapy for CAD, amiodarone, rivaroxaban, and teriparatide. After initial stabilization, exam revealed a tired appearing male with a soft systolic murmur, faint bibasilar crackles, and a distended, soft, and non-tender abdomen. He was well perfused with 2+ pitting edema of the lower extremities and bruising on the upper extremities. Basic labs revealed only hypoalbuminemia without proteinuria and iron deficiency anemia. Thyroid labs were within normal limits, stool studies unremarkable, and amyloid testing negative. Extensive cardiac workup including echocardiogram, cardiac MRI, and right heart catheterization provided no new etiologic insights. No malignancy was identified on whole-body CT, endoscopy, or colonoscopy. Additional workup was pursued with 24-hour urine free cortisol, which was markedly elevated, as was overnight dexamethasone suppression testing. Together, these established his diagnosis of Cushing’s syndrome. Follow up measurement of adrenocorticotropic hormone (ACTH) was elevated, pointing to an ACTH-dependent source of Cushing’s syndrome. Since pituitary MRI showed no evidence of pituitary adenoma, inferior petrosal sinus sampling was completed and confirmed the diagnosis of Cushing’s disease. He underwent successful transsphenoidal resection of a pituitary microadenoma and was discharged to rehab eight days later.

IMPACT/DISCUSSION: This case highlights Cushing’s syndrome as an etiology for cardiovascular comorbidity even in the absence of multiple cardiovascular (CV) risk factors. Cushing’s markedly increases risk for atherosclerotic and thromboembolic CV events, cardiac arrythmias, and heart failure

CONCLUSION: Cushing’s syndrome can cause cardiac comorbidities in patients without cardiovascular

risk factors.

Screening for hypercortisolism should be completed in patients with CV comorbidities and decreased bone density.

AN UNUSUAL CAUSE OF A BREAST MASS DISCOVERED ON ROUTINE MAMMOGRAPHY Tinuola B. Ajayi¹; Alyse Wheelock¹; Sondra S. Crosby^1,2

¹General Internal Medicine, Boston Medical Center, Boston, MA; ²Health Law, Bioethics, and Human Rights, Boston University School of Public Health, Boston, MA. (Control ID #3874142)

CASE: A 65-year-old woman was scheduled for annual breast cancer screening. Mammography revealed a focal asymmetric mass in the lower right breast and follow up ultrasound confirmed a 0.5x 0.5 x0.6 cm round heterogeneous mass. Mammogram results from 2 years prior was BIRADS- 1 with no abnormalities. Ultrasound-guided core biopsy was performed. Pathology revealed sections of parasitic worm species with surrounding granulomatous inflammation. No in-situ or invasive carcinoma was seen. Geographic and histomorphologic features were suggestive of a parasitic worm. The CDC confirmed Onchocerca species, a filarial nematode. Antifilarial IgG and IgG4 were positive. Peripheral blood microscopy was negative for microfilariae. Review of the absolute eosinophil counts showed a range of 100 to 400 (Normal < 500/mcL). The patient was subsequently referred to Infectious Diseases and was initiated on treatment for onchocerciasis with Ivermectin and Doxycycline with a plan to monitor the mass on serial ultrasounds.

IMPACT/DISCUSSION: Onchocerciasis is caused by a filarial worm called Oncocerca volvulus that is transmitted through the female black fly (Simulium damnosum). It is mainly found in sub-Saharan Africa. The most common clinical manifestations include rash, pruritus, unilateral extremity swelling, or cutaneous nodule and these findings may present years to decades after infection. Ocular lesions can progress to vision loss, giving the condition its colloquial name River Blindness. Onchocerciasis presenting as a breast mass is relatively rare. The patient immigrated from southwest Cameroon 10 years ago as an asylum seeker and had returned for a month-long visit 5 years prior to her diagnosis. Initial refugee health screening was unremarkable, including an absolute eosinophil count of 400. Absolute eosinophil count may serve as a marker of certain parasitic infections especially among migrants from low-resource settings. However, as eosinophilia only accompanies some parts of the life cycle in a subset of parasites (more often helminths), the absence of eosinophilia does not exclude disease. It is important to emphasize that some parasitic infections have very long latent periods and it is imperative to know country of birth and travel history to assess the need for screening and treatment. For this patient from Cameroon, Loa loa was excluded prior to treatment given the risk for precipitating dangerous encephalopathy with anti-helminthics in the setting of co-infection. For this reason, Infectious Diseases consultation is recommended when considering parasitic treatment for a patient from areas endemic for Loa loa (West and Central Africa).

CONCLUSION: A detailed migration and travel history should be obtained in all patients to guide appropriate Infectious Disease screening and treatment as recommended by the CDC. Though atypical, onchocerciasis can present as a breast mass or other soft tissue nodule. Tissue biopsy confirmation should be followed by referral to Infectious Diseases.

A RARE CASE OF COVID-19-RELATED INSOMNIA AND ITS MANAGEMENT

Rafael Rivera Sepulveda, Luis Paulino, Lucy Guerra

Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL. (Control ID #3875759)

CASE: A healthy 38-year-old female presented to our clinic due to new onset insomnia for 10 days after a positive COVID-19 test. She developed an inability to fall asleep despite feeling tired. The patient reported minimal to no sleep for 5 consecutive days. She initially tried melatonin with no resolution. She presented to her primary care physician (PCP) who initiated hydroxyzine 25mg. The dose was subsequently doubled due to poor response. She had mild improvement in her sleep reporting 4 hours of sleep for the following two nights, but symptoms recurred thereafter. Her PCP then added doxepin with no improvements to her symptoms. She then presented to our clinic for a second opinion. Her COVID-19 symptoms before her insomnia included muscle aches, headaches, nausea, tiredness, mild cough, and loss of taste. All these symptoms resolved after completion of a 5-day course of Paxlovid. She never required supplemental oxygen, and never developed respiratory distress. She was vaccinated with Johnson and Johnson vaccine 1 year before presentation. She has 2 kids, lives with her husband, and denied recent social stressors or family issues. She denied a prior history of psychiatric conditions. She denied symptoms of loss of interest in daily activities, loss of energy, feelings of guilt, lack of concentration, loss of appetite, weight loss, or psychomotor retardation or agitation before her insomnia. Her new onset insomnia has been very distressing to herself and her family. The patient is not a smoker and has no recent alcohol use or illicit drug use. She denied a change in diet and does not drink coffee, tea, or energy drinks. She has no prior history of insomnia.

IMPACT/DISCUSSION: Among the various symptoms reported due to the long-term effects of COVID-19, up to 11% of patients experienced sleep disorders following recovery from COVID-19 infection. Although the mechanism of action is not fully understood, previous studies have demonstrated cytokine dysregulation as a potential cause. Cytokine dysregulation has been shown in patients with COVID-19, which could explain many of the psychiatric symptoms associated with the long-term effects of COVID-19. A combination of pharmacotherapy and cognitive behavior therapy is recommended as first-line treatment for insomnia. However, there is currently limited data on COVID-19-related insomnia and treatment of such. Our patient had no improvement after trials of melatonin, hydroxyzine, doxepin, diazepam, and low-dose trazodone.

CONCLUSION: Identification and treatment of insomnia are important given the association with anxiety, depression, and suicidal behavior. Given that the patient was not responsive to many first-line treatment options, a decision to trial high-dose trazodone and diazepam as needed was made. Additionally, we added molnupiravir, as it has been tried with rebound COVID-19 and long-hauler symptoms within a short time post-COVID-19 illness. She reported a great response on follow-up 2 weeks later.

A RARE CASE OF SCLEROMYXEDEMA IN A PATIENT WITH MGUS

Joud Enabi, Muhammad Waqar Sharif, Kyle McDaniel, Roman Karkee, Barath Rangaswamy

Internal Medicine, Texas Tech University Health Sciences Center, Permian Basin, Odessa, TX. (Control ID #3873330)

CASE: A 50-year-old female with a history of MGUS and morbid obesity presented to an oncologist clinic from a dermatology referral for progressively worsening pruritic acanthosis on her forearms and nose. A review of systems was notable only for skin complaints. Physical examination showed diffuse skin involvement of the forearm, nose, and bilateral legs. Skin biopsy showed fibroblastic proliferation in the superficial and deep dermis along with dermal mucin deposition. Bone marrow biopsy showed normal cellularity of marrow, and flow cytometry suggestive of a small(0.03%) population of Kappa-restricted monoclonal plasma cells. Fluorescence in situ hybridisation demonstrated 13q deletion and t(14;16) translation with a normal karyotype. Laboratory work-up prior to treatment was notable for albumin 3.3g/dL, globulin 4.5g/dL, and albumin/globulin ratio of 0.7. The patient was treated with cycles of intravenous immunoglobulin therapy 400mg/kg lasting five days and completed six cycles of Intravenous Immunoglobulin(IVIG) therapy over the course of 8 months. Repeat laboratory testing after treatment showed albumin and globulin decreased to 3.1g/dL and 4.2g/dL,respectively, while the albumin/globulin ratio remained at 0.7. The patient reported improvement of the facial skin lesion and resolution of the lesions on the proximal thighs.

IMPACT/DISCUSSION: Scleromyxedema is a rare medical condition that should be differentiated from other localized forms of lichen myxedematosus with specific diagnostic and therapeutic approaches. The pathogenesis of scleromyxedema and the etiology behind the increased collagen deposition, dermal mucin deposition, and hyperproliferation of the dermal fibroblasts are still unclear. Most patients have features of either generalized or localized Lichen myxedematosus(LM). On the other hand, some patients may present with mixed forms with features between generalized and localized LM. Clinically, it is characterized by indurated erythematous, waxy papules disseminated on the face, chest, and extremities that coalesce and develop into plaques yielding extensive skin thickening. The diagnosis of atypical scleromyxedema cases is established with the correlation of the histopathological findings and the patient's clinical presentation with systemic manifestations that might be related to the disease. Multiple treatment regimen have been used to treat scleromyxedema. IVIG is the first-line treatment option used in recent case reports. This treatment strategy has become more popular due to its efficacy in treating scleromyxedema cases. Our case report supports the hypothesis of adopting high-dose IVIG in treating scleromyxedema.

CONCLUSION: Scleromyxedema is considered one of the rare chronic conditions of the Lichen myxedematosus family. Patients with scleromyxedema present with confluent papular eruptions with other potential systemic symptoms. Histology slides commonly show dermal fibroblast proliferation with fibrosis, monoclonal gammopathy, and dermal mucin deposition.

A UNIQUE CASE OF UNDETECTABLE BLOOD PRESSURE

Max X. Wei¹; Nicoleta Rus²

¹Internal Medicine, HCA Healthcare, Nashville, TN; ²Rocky Vista Health center, Rocky Vista University, Parker, CO. (Control ID #3872933)

CASE: A 42 year old female born in Serbia with past medical history of hypotension, factor V leiden, failed in vitro fertilization,presents for abnormal BP reading at home. She took her BP at home one month ago on her left arm and it was undetectable. She tried three total machines with the same message. BP was normotensive on her right arm. All 3 machines worked for her husband and a family friend for both arms. She endorses frequent syncope when she was a child. She was infected with COVID one month ago. She endorses some localized stabbing pain under the L breast that started three weeks ago. She rates it a 4/10, does not radiate, lasts only a few seconds at a time. Review of systems in negative for numbness, skin discoloration, weakness in her left arm.

Family history is significant for her father passing away at age 60 from heart failure complications. Her mother has hyperlipidemia, hypertension, and an unspecified arrhythmia.

Social history is significant for a 25 pack year smoking history, quit around five years ago. Has around 3-5 alcoholic drinks weekly.

On exam, left brachial and radial pulses are not palpable. Left carotid pulse is slightly diminished. No sensory deficits in the arm, normal capillary refill bilaterally. Strength is 5/5. Heart is regular rate and rhythm on auscultation, no murmurs appreciated. Lungs are clear to auscultation bilaterally.

Initial lipid panel was significant for an LDL of 176, total cholesterol of 276. Arterial ultrasound findings of the left upper extremity compatible with L subclavian stenosis. Computed tomography with angiography and intravenous contrast revealed intimal thickening versus noncalcified atherosclerotic plaque causing severe luminal stenosis of the proximal subclavian artery and mild/moderate stenosis of the brachiocephalic artery origin. She was started on aspirin 81mg and atorvastatin 40mg and referred to vascular surgery for further management.

IMPACT/DISCUSSION: We must realize abnormal presentations for common risk factors are almost inevitable. In this case a relevant past medical, family, and social history led not to cardiovascular or stroke complications but rather, an isolated, significant stenosis of a major artery. Complete occlusion of an upper extremity is a dire consequence and certainly unwanted. This case must serve as a reminder that in medicine, we are always students.

CONCLUSION: Abnormal presentations for common risk factors are bound to happen and should not be missed.

A detailed history and physican examination is an important part of practice despite advances in modern medicine.

Typical risk factors can often lead to atypical results.

A VICIOUS LOOP OF CELLULITIS AND DEEP VENOUS THROMBOSIS IN THE LOWER EXTREMITY

Lakshmi Priyanka Pappoppula, Sarasija Natarajan, Muhammad Hassan Shakir, Khadijah Sajid, Ravleen Kaur

Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA. (Control ID #3876749)

CASE: The description follows a 47-year-old male with past medical history significant for seizure disorder on phenytoin, morbid obesity with BMI 61.1 over multiple hospitalisations, outpatient and emergency room visits for recurrent left lower extremity cellulitis and deep venous thrombosis (DVT). The patient’s initial episode of DVT was diagnosed in the left common femoral and popliteal veins following severe COVID infection. He was started on warfarin. On follow up, warfarin was replaced with apixaban due to subtherapeutic INR. Despite INR reaching therapeutic values subsequently, he developed acute on chronic DVT and was switched back to warfarin. Evaluation for alternate causes of hypercoagulability including genetic workup was negative. Recurrence of lower extremity pain and erythema 6 months later prompted a CT scan that was suggestive of cellulitis which was treated with amoxicillin clavulanate . Recurrence of similar symptoms in the next month prompted a course of doxycycline. 3 months later, an ultrasound repeated for persistent symptoms revealed acute on chronic DVT. Anticoagulation was changed to LMWH. He was simultaneously treated with cephalexin for possible cellulitis. Over the course of the next 6 months, he was treated twice for cellulitis and once again diagnosed with acute on chronic DVT despite therapeutic INR. Current therapeutic options being explored are the initiation of fondaparinux and role of daily suppressive antibiotic therapy for cellulitis.

IMPACT/DISCUSSION: Venous stasis, endothelial dysfunction and the hypercoagulable state factor into the Virchow’s triad for thrombosis. Despite the absence of genetic and autoimmune predispositions to hypercoagulability, our patients' obesity is a risk factor for DOAC failure. Phenytoin use could have contributed to reduced bioavailability of warfarin. However, the recurrence of DVT despite therapeutic INR levels with LMWH in the setting of recurrent cellulitis holds biological plausibility for association consistent with the Virchow's triad. Review of literature suggests that the coexistence of DVT and lower limb cellulitis occurs rarely with meta analyses estimating rates of 0%-15%. They therefore recommend against the routine use of prophylactic anticoagulation and systematic paraclinical investigations to rule out DVT in low risk patients with cellulitis. Use of the Wells score in these situations overestimates the likelihood of DVT due to overlapping clinical signs. The studies however suggest keeping a higher threshold to rule out DVT in patients at elevated risk for the same. Similarly, the occurrence of DVT resulting in lymphedema is a predisposing factor to cellulitis of the lower extremity.

CONCLUSION: Cellulitis and deep venous thrombosis may predispose the patient to further episodes of the either disease. Aggressive lymphedema therapy, wound care and a tailored anticoagulation regimen may reduce the risk of cellulitis in DVT and vice versa.

BIOTIN - AN INFLUENCER OF NOT ONLY HAIR, SKIN AND NAILS

Alexa M. Pope, Megan M. Alexander

Internal Medicine, Wake Forest University School of Medicine, Sandy Ridge, NC. (Control ID #3856381)

CASE: A fifty-three year old female with a history of type 1 diabetes mellitus (T1DM) status post pancreas- kidney (SPK) transplantation, chronic pulmonary Mycobacterium avium complex (MAC) infection, iron deficiency anemia and hypothyroidism presented with one day of worsening fatigue and somnolence. On arrival to the emergency department, the patient was found to be hypothermic and bradycardic. On exam, she was easy to arouse but fell asleep quickly. During periods of wakefulness, she was oriented without other focal exam findings and could provide adequate medical history. Initial laboratory work up was remarkable for TSH 45.7, T4 0.7, Total T3 0.4. Endocrinology was consulted and discovered the patient’s levothyroxine dose had been progressively down-titrated in the setting of supplemental biotin use. She had also been taking her oral levothyroxine supplementation in the morning following breakfast with her other morning medications. The patient received IV levothyroxine with improvement of symptoms and her oral daily dose of levothyroxine was increased.

IMPACT/DISCUSSION: Hypothyroidism is a common disorder of thyroid deficiency with clinical manifestations that range from asymptomatic to life threatening myxedema coma. Thyroid deficiency is evaluated by TSH and free T4 laboratory assays, where elevated TSH and low free T4 levels indicate deficiency. Supplemental biotin use can influence these assays, and most commonly causes falsely low levels of TSH and falsely elevated levels of T4 and T3. This can lead to an incorrect initial diagnosis of hyperthyroidism or falsely indicate levothyroxine doses are supratherapeutic with subsequent incorrect titration in those with known hypothyroidism. Additionally, levothyroxine has a narrow therapeutic index impacted by concurrent food ingestion or defects in gastrointestinal absorption.

CONCLUSION: In conclusion, our patient presented with severe hypothyroidism secondary to incorrect dose titration of levothyroxine in the setting of biotin use and suboptimal timing of levothyroxine intake. Patients should be biotin supplement free for at least 48 hours prior to laboratory testing to prevent assay interference and levothyroxine should be taken with water, separate from other medications or supplements, at least 30 minutes prior to a patient’s morning meal.

BRAIN CHECKED OUT: A CURIOUS CASE OF RELAPSING PEMBROLIZUMAB-INDUCED LIMBIC ENCEPHALITIS

Jordyn A. Feinstein, Pedro C. Barata, Christopher R. Trevino, Albert Jang

Internal Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #3872640)

CASE: A 68-year-old man with metastatic, papillary renal cell carcinoma treated with pembrolizumab and axitinib for eight months presented with progressive emotional lability, memory loss, apraxia and visual hallucinations concerning for limbic encephalitis. His dose of pembrolizumab was adjusted from 200 mg every three weeks to 400 mg every six weeks five weeks prior to symptom onset. MRI brain showed mesial temporal inflammation, but EEG had no pathognomonic supportive features. A lumbar puncture showed elevated white blood cell count of 25 cells/mm³ with 76% lymphocytes and negative CSF antibodies. After ruling out infection, the encephalitis was attributed to pembrolizumab. Symptoms were refractory to IV methylprednisolone but rapidly responded to plasmapheresis (PLEX) and returned to baseline cognition and personality. Pembrolizumab was permanently discontinued.

Over the next ten months, the patient had two recurrences of encephalitis, one occurring one week following his second Moderna mRNA COVID vaccine and the most recent five days after developing pneumonia despite tacrolimus. In both instances, his encephalitis rapidly resolved after PLEX, and mentation returned to baseline. He was initiated on rituximab-abbs with the goal of preventing future episodes by inhibiting B-cell function.

IMPACT/DISCUSSION: Immune checkpoint inhibitor (ICI) therapy is becoming popular in treating solid tumor malignancies. Pembrolizumab upregulates the immune system to fight tumor cells. This can disrupt immune tolerance, leading to various autoimmune-like syndromes. Through rare, neurologic sequalae have been reported, including limbic encephalitis. Reversibility of these neurologic immune-related adverse events (irAEs) is variable even with aggressive treatment, and rapid reversibility with PLEX suggests an antibody- mediated encephalitis which carries a better prognosis for recovery than cell-mediated encephalitides. Many neuromuscular irAEs can be fatal, though encephalitides with rapid treatment are less likely to lead to death. Our patient’s relapsing condition was always preceded by an immune activating event.

Multi-disciplinary care from neurologists, rheumatologists and oncologists is critical when treating these patients. It is crucial for internists to be cognizant of patients on current or previous treatment of immunotherapy when evaluating for new symptoms of possible autoimmune disease, even if treatment was completed in the past. Therefore, ICI therapy should always be noted in the chart. Early recognition and intervention are important for expediting recovery, so internists should know the early signs and symptoms of irAEs.

CONCLUSION: ICIs are being used more regularly as cancer treatment. Acknowledgement of a patient’s previous treatment with ICI is imperative when evaluating any new symptoms that appear autoimmune in nature. Of the known irAEs, those in the neurologic category remain rare but potentially fatal. Early recognition is thus critical for patient recovery.

CALCIUM CALCIUM EVERYWHERE AND NOT A DROP TO USE

Joel W. Wright, Danielle J. Pope, Sofia Terner, Donjeta Sulaj

Internal Medicine, Englewood Health, Englewood, NJ. (Control ID #3875524)

CASE: A 60 year old man with poorly controlled Hypoparathyroidism presented with one month of difficulty concentrating, slurred speech and imbalance. Examination revealed dysarthria, dysdiadochokinesia, ataxia, impaired concentration, and difficulty with short term recall and calculation.

His medications were Calcitriol 1mcg twice daily, Calcium Carbonate 2g twice daily, Cholecalciferol 1000 units daily, Recombinant Parathyroid Hormone (PTH) 100mcg daily and Ergocalciferol 50,000 units twice weekly. He was hypercalcemic at 12.1mg/dL, and had low PTH 5.4 pg/mL (15-65 pg/mL). Phosphorus, 25- vitamin D, 1,25-vitamin D and PTH-related peptide were normal. Magnetic resonance imaging (MRI brain) revealed dense bilateral cerebellar, basal ganglia, thalamic and subcortical calcifications. Upon re-evaluation, he admitted to overdosing on calcium supplements as he thought his symptoms were related to hypocalcemia. With his presentation and MRI findings, he was diagnosed with Fahr’s Syndrome secondary to hypoparathyroidism.

IMPACT/DISCUSSION: Hypoparathyroidism can result in many well-known complications including nephrocalcinosis as well as the sequelae of hypocalcemia - namely arrhythmias, seizures and tetany. Internists must be aware of rarer complications such as Fahr’s Syndrome.

Fahr’s syndrome, is a neurodegenerative disorder in which abnormal calcium deposition occurs in the basal ganglia, thalamus, hippocampus, cerebral cortex and cerebellum. It may present with choreoathetosis, seizures, ataxia, personality changes, dementia and psychosis.

While Fahr’s Disease, a phenotypically identical yet separate entity is genetic, the syndrome may be secondary to central nervous system infections, vasculitis, toxins and endocrinopathies. Although poorly elucidated, the pathophysiology may be linked to long-standing hyperphosphatemia which downregulates basal ganglia phosphate transporters leading to colloid deposition within the cerebral blood vessels. Paradoxically, chronically low calcium levels correlate to having a greater volume of calcification. Besides hypoparathyroidism itself, supplementation with large amounts of vitamin D and calcium, has been associated with Fahr’s Syndrome by way of potentiating ectopic soft tissue calcification.

This case highlights the importance of a thorough neurologic exam with close attention to behavioral changes in patients with hypoparathyroidism to detect early signs of Fahr’s Syndrome. Identification and treatment of hypoparathyroidism promptly is critical to reduce the risk of developing Fahr’s Syndrome. Goal serum calcium levels should be maintained within the lower range of normal and calcium phosphate product < 55 mg²dL² with efforts to avoid large doses of calcium and Vitamin D, by utilizing recombinant PTH.

CONCLUSION: Uncontrolled hypoparathyroidism can result in neurologic sequelae such as Fahr’s Syndrome. It can be prevented or delayed by avoiding large doses of calcium and vitamin D as well as strictly controlling calcium homeostasis.

CAROTID SINUS HYPERSENSITIVITY: A NOVEL AND MINIMALLY-INVASIVE TREATMENT Alyssa Kahl, Paul Schurmann, Jeffrey T. Bates, Addison A. Taylor

Baylor College of Medicine, Houston, TX. (Control ID #3869000)

CASE: A 62-year-old man with hypertension, type 2 diabetes mellitus, benign prostatic hyperplasia (BPH), and history of cerebellar stroke syndrome secondary to a remote vertebral artery dissection presented for positional lightheadedness. Four months prior to presentation, he developed positional lightheadedness associated with standing that forced him to widen his gait for steadiness; these episodes lasted for several minutes before self-resolving. He also noted extreme lightheadedness upon turning his head while supine to either side; these episodes lasted for approximately 60 minutes before resolving. He reported adequate fluid intake; he denied emesis, cough, alcohol, illicit drug use or other triggers prior to these episodes. He was not taking any beta-blockers or calcium channel blockers; he was taking tamsulosin for BPH, which was discontinued without resolution of his symptoms. He underwent autonomic testing which revealed an abnormal baroreceptor reflex response to Valsalva maneuver, including an exaggerated fall in blood pressure (BP) and the lack of hypertensive overshoot post-Valsalva. Parasympathetic modulation of heart rate with slow deep breathing showed exaggerated parasympathetic response. Right but not left carotid sinus massage reproducibly resulted in a 2-3 second pause in heart rate associated with a 15-30 mmHg fall in systolic BP. These findings were consistent with right carotid hypersensitivity and adverse parasympathetic autonomic influence. He underwent minimally-invasive cardioneuroablation (CNA) in the electrophysiology lab. He noted immediate improvement, reporting minimal episodes of dizziness and no syncope, which persisted up to his most recent follow-up four months post-procedure. An implanted loop recorder (ILR) has monitored the effectiveness during the post-treatment period, showing no evidence of sinus pauses or ventricular block for 5 months.

IMPACT/DISCUSSION: Carotid sinus hypersensitivity (CSH) can be associated with significant impairment in the quality of life (QoL) of affected patients. The treatment of cardioinihibitory CSH usually includes pacemaker insertion for those most severely affected. A new and less invasive treatment, CNA, has been used extensively in selected patients with vasovagal syncope but has not been frequently employed in patients with cardioinhibitory CSH. In fact, successful use of CNA in the patient reported here is, to our knowledge, only the third case reported in the literature. However, we report the use of continuous ECG monitoring with ILR for 5 months, suggesting treatment durability performed with right atrial approach only

CONCLUSION: In this case, we presented a patient with cardioinhibitory CSH treated with a novel and minimally invasive procedure; CNA. CNA remains a promising new intervention for selected patients with cardioinhibitory CSH and its application should be further investigated. Patients who remain symptomatic following CNA can always be considered for pacemaker insertion.

CHALLENGES IN THE DIAGNOSIS OF HODGKIN LYMPHOMA IN A YOUNG FEMALE

Analisa Taylor, David Kaplan

Internal Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #3868101)

CASE: A 19-year-old female presented to an internal medicine clinic for another opinion on 6 months of fatigue and tachycardia. Other symptoms included syncope, night sweats, body odor, exertional dyspnea, eructation, and abdominal fullness. Labs ordered by her primary care provider were remarkable for anemia, thrombocytosis, and low serum iron. The patient was instructed to start an oral contraceptive and an iron supplement. She was diagnosed with anxiety and started an SSRI. Holter monitor results were normal. Tilt table testing demonstrated postural tachycardia prompting the diagnosis of postural orthostatic tachycardia syndrome and treatment with propranolol and midodrine. Her symptoms and lab abnormalities did not improve, so she was given intravenous iron and referred to a gastroenterologist. An upper endoscopy with esophageal biopsy and a colonoscopy were normal. She was then evaluated by a functional medicine provider who ordered labs showing elevated inflammatory markers, anemia, and thrombocytosis. At that time, an appointment was made at an internal medicine clinic. The patient had no medical, surgical, social or family history. Vital signs and physical exam were normal, including lymph node and breast exams. Repeat labs were notable for a white blood cell count of 11.67 k/uL, hemoglobin 11.2 g/dl, platelets 850 k/uL, ESR 128 mm/hr, ferritin 374 ng/ml, and iron 25 ug/dl. Rheumatoid factor, ANA, and anti-CCP Ab were negative. CT scan revealed mediastinal, hilar, and axillary lymphadenopathy. An excisional lymph node biopsy showed Classic Hodgkin Lymphoma Nodular Sclerosis subtype. PET scan revealed diffuse adenopathy in the neck, chest, and abdomen. She was referred to oncology and successfully treated with chemotherapy.

IMPACT/DISCUSSION: This case demonstrates the challenge of making a unifying, accurate diagnosis when a patient presents with numerous signs and symptoms. Multi-organ system involvement did not initially suggest a unifying diagnosis and complicated her clinical evaluation. She had one of three B symptoms and no palpable lymphadenopathy that typically raise suspicion for hematologic malignancy. However, persistent abnormalities in multiple cell lines were a key diagnostic clue. Her evaluation was fragmented with multiple specialty referrals which delayed recognition of a systemic illness. She was given inaccurate diagnoses and continued on treatments despite lack of effectiveness. It is possible her mostly normal specialty testing, young age, and outward appearance of good health reassured providers that further evaluations were either not required or outside their scope of practice. Unfortunately, this caused a functional decline and a delay in a life-threatening diagnosis.

CONCLUSION: Systemic illness must be considered early in the diagnostic process when a patient presents with multi-organ dysfunction. A holistic approach to patient care can lead to a more accurate and timely diagnosis of systemic illness, especially with an atypical disease presentation.

CHRONIC OSTEOMYELITIS IN A 21-YEAR-OLD WITH NO RISK FACTORS

Danielle Urman¹; Matthew H. Tan²; Melissa Wing²; Bernice Ruo²; Ruth Abeles²

¹School of Medicine, University of California San Diego School of Medicine, La Jolla, CA; ²Medicine, University of California San Diego, La Jolla, CA. (Control ID #3873408)

CASE: A 21-year-old female presented to urgent care with two weeks of worsening right upper extremity swelling, redness, and localized pain. She denied fever, chills, and history of trauma. The patient’s medical history was notable for mild eczema and no prior surgeries. She denied any history of intravenous drug use, recent travel, or new medications. Vitals were within normal limits. Physical examination was notable for localized edema and erythema around the right, middle upper arm with some firmness and tenderness to palpation but no fluctuant mass.

Complete metabolic panel showed normal electrolytes, kidney and liver function. Complete blood count showed no leukocytosis. C-reactive protein was within normal limits. Sedimentary rate was 28 mm/hr. An X-ray of the right upper extremity revealed a cortical thickening of the middle/proximal humerus with a lytic focus with surrounding soft tissue calcification. A follow-up MRI with contrast of the right upper extremity showed chronic osseous remodeling of the posterolateral cortex of the humerus with a superimposed defect measuring 4.6 mm x 1 cm as well as endosteal remodeling with focal discontinuity. CT of the right upper extremity showed changes of chronic osteomyelitis of right proximal humerus with cloaca and extruded sequestrum within soft tissues with surrounding edema and subcutaneous edema. Patient was referred to infectious disease and underwent IR-guided biopsy of the humerus. Gram stain was negative and cultures only grew rare candida albicans, which was suspected to be a contaminant. Patient underwent incision and debridement of the right humerus, and the culture grew methicillin sensitive Staphylococcus aureus. She was treated successfully with a 6-week course of amoxicillin and clavulanate after debridement.

IMPACT/DISCUSSION: We report a case of a young women with osteomyelitis and no risk factors. This is the first case report of its kind.

Chronic osteomyelitis is characterized by a long-standing infection of the bone. It typically presents with pain flares, swelling, and erythema at the site as seen in this patient. Fever may be present. Usually signs of chronic inflammation can be seen radiographically. It is often the result of hematogenous spread from a neighboring infection or introduction of bacteria from a trauma or surgery. The most commonly isolated organism is Staphylococcus aureus. In a young patient with no inciting event, other entities on the differential include: 1) chronic non-infectious osteomyelitis, an inflammatory bone disorder in children and 2) Brodies abscess, a subacute form of osteomyelitis characterized by pus in the bone. Definitive treatment is surgical debridement with culture collection from the site followed by 4-6 weeks of antibiotics depending on the causative organism.

CONCLUSION: Chronic osteomyelitis is possible in a patient with no traditional risk factors

Mimics to chronic osteomyelitis in young patients include chronic noninfectious osteomyelitis and Brodies abscess

CLEAR CELL RENAL CELL CARCINOMA PRESENTING IN A NOT SO CLEAR WAY

George T. Kalapurakal, Yoonho Park

Advocate Christ Medical Center, Oak Lawn, IL. (Control ID #3869147)

CASE: Renal Cell Carcinoma (RCC) is the eighth most common malignancy in the United States of America (USA), accounting for over 64,000 reported cases and 14,000 deaths annually. Of the types of RCC, Clear Cell Renal Cell Carcinoma (ccRCC) is the most common, accounting for over 80% of cases. Given the high prevalence and malignant potential of ccRCC, it is important for clinicians to be aware of its variety of presentations. We present a case of metastatic ccRCC presenting as a scalp lesion.

Patient Presentation

A 58-year-old male with no significant past medical history presented for a growth on the back of his neck. He endorsed symptoms of discomfort associated with the mass, but denied recent fevers, night sweats, chills, unintentional weight loss, hematuria, and flank pain. Family history was notable only for his father having passed from an unknown cancer. Social history was notable for one pack per day smoking history.

Clinical Course

Physical examination of the right occipital scalp displayed a firm, immobile, painless mass measuring 1.7 centimeters (cm) x 1.4 centimeters (cm). The lesion was subsequently biopsied and sent to pathology. While awaiting these results, the patient underwent a CT of the neck which demonstrated multiple subcentimeter lymph nodes scattered in the neck, none of which were pathologically enlarged or abnormally enhancing. His pathology report returned as Clear Cell Neoplasm concerning for Renal Cell Carcinoma metastasis. Subsequent CT chest, abdomen, pelvis demonstrated a mildly exophytic isoattenuating left upper pole renal mass measuring 3.7 cm x 2.7 cm, concerning for Renal Cell Carcinoma.

IMPACT/DISCUSSION: Clear Cell Renal Cell Carcinoma can be a difficult disease to recognize. The classic triad of flank pain, hematuria, and a palpable abdominal renal mass is present in about 9% of cases. ccRCC is known for its metastatic capability, with the most common areas being lungs, lymph nodes and bones. Skin lesions have been documented as the seventh most common site for metastasis. Typically, cutaneous lesions present six months to five years after initial diagnosis with the most common sites being the trunk, followed by the scalp. Skin findings as a presenting sign for ccRCC is generally associated with poor prognosis as there are often multiple areas of metastasis by the time of diagnosis. This case emphasizes the need for clinicians to maintain a broad differential for cutaneous skin mass evaluation. These lesions must be carefully examined with the consideration for biopsy if further clarification is required. Prompt diagnosis and treatment may play a key role in patient outcome.

CONCLUSION: Given the high prevalence and malignant potential of ccRCC, it is important for clinicians to be aware of its variety of presentations. Skin lesions present in the setting of RCC must be carefully examined with the consideration for biopsy, especially when imaging findings are incongruent.

COGAN’S SYNDROME IN THE RARE SETTING OF SJORGEN’S SYNDROME

Kejal Shah¹; Kristina M. Cross¹; Aimen Asim Dar²; Samhitha Gonuguntla³; Barath Rangaswamy¹; Srikanth Mukkera¹

¹School of Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; ²Research, Texas Tech University Health Sciences Center Permian Basin Campus, Odessa, TX; ³Internal Medicine, Texas Tech University Health Sciences Center- Permian Basin, Odessa, TX. (Control ID #3872228)

CASE: 67-year-old female with a history of Raynaud’s syndrome and two first-trimester miscarriages presented with chronic dry eyes. A year ago, she was evaluated for floaters in her left eye and found to have vitreous detachment and opacities. Interestingly, her Lyme Polymerase chain reaction was positive at the time and treated with doxycycline for concerns of intermediate uveitis secondary to Lyme’s disease. Now she complains of persistent dry eyes and a facial rash. Physical exam revealed normal vitals, bilateral conjunctival injection, and an erythematous macular rash on her face. She also had hypopigmented patches on the left shin consistent with vitiligo. She was initially diagnosed with undifferentiated connective tissue

disease and started on hydroxychloroquine 400 mg daily. Laboratory work-up including ANA, anti-dsDNA and lupus anticoagulant were negative, but was positive for Sjogren’s syndrome A (SSA) and an elevated erythrocyte sedimentation rate. During follow up visits, she endorsed new onset hearing loss. On exam, tympanic membranes were normal, Rinne’s test was positive in the left ear and negative right ear. The weber test lateralized to the left. She was found to have sensorineural hearing loss in the right ear and then diagnosed with Cogan’s syndrome in the setting of with Sjogren’s disease. High-dose steroids, Methotrexate 12.5 mg weekly were initiated along with folic acid daily.

IMPACT/DISCUSSION: Cogan syndrome is a rare autoimmune disease involving the inner ear and eye, that often occurs in the third decade of life. The hallmarks of the disease include non-syphilitic interstitial keratitis and vestibulo-auditory dysfunction, that manifests as Meniere-like episodes with fluctuating severity of hearing loss. Systemic disease occurs in approximately 70% of the patients, with a pathological mechanism like vasculitis. Although the pathogenesis is unclear, it is believed to occur due to lymphocyte and plasma cell infiltration of the spiral ligament, loss of cochlear neurons, endolymphatic hydrops, degenerative changes in the organ of Corti. Demyelination and atrophy of the vestibular and cochlear branches of the eighth cranial nerve also occurs. Treatment depends on severity, including High-dose corticosteroids, immunosuppressive therapy, disease-modifying anti-rheumatic drugs, and biologics. Cogan syndrome has been reported in patients with autoimmune diseases like rheumatoid arthritis and inflammatory bowel disease, but rarely reported in Sjogren’s syndrome. A thorough workup is warrented in patients suspected of suffering from Cogan’s Syndrome including a transthoracic echo, to rule out aortic or valvular involvement, which can be life-threatening.

CONCLUSION: We report Cogan syndrome, a rare autoimmune disease, in a patient with Sjogren's syndrome. With less than 250 cases reported so far, only three cases of Cogan’s with Sjogren’s syndrome have been reported. Raising clinical awareness is key for improved diagnosis.

CUTANEOUS MANIFESTATIONS OF CHRONIC LYMPHOCYTIC LEUKEMIA

Krishna Desai¹; Sabah Iqbal¹; Akhil Jain¹; Sohiel Deshpande¹; Harsha Sai Sreemantula¹; Vidhi Mehta¹; Mahvish Renzu¹; Manzoor Rather¹; Rajesh Thirumaran²

¹Internal Medicine, Mercy Fitzgerald Hospital, Darby, PA; ²Hematology/Oncology, Mercy Fitzgerald Hospital, Darby, PA. (Control ID #3874629)

CASE: A 71-year-old male with past history of CLL (diagnosed twenty years back), treated with Rituximab and Bendamustine (in remission), presented with fatigue, night sweat, and generalized multiple painful swellings for many months. On examination, several subcutaneous nodules were noted on the arms, chest, trunk, and back.

Given the history of CLL, a PET scan was done which showed innumerable subcutaneous soft tissue nodules with moderate FDG uptake. The largest ones measured 2.2 x 2.4 cm in the midline back, 1.5 x 1.5 cm in the left anterior chest wall, 1.8 x 1.2 cm in the right anterior abdominal wall, and a lymph node superficial to the left mandibular condyle measuring 2.2 x 1.3 cm. A biopsy of the left lower back lesion showed CLL with plasmacytic differentiation (Figure 2) and peritumoral amyloid deposition.

He was started on daily Ibrutinib for CLL of the extranodal site, along with Allopurinol to prevent tumor lysis syndrome. The lesions started to shrink, but in two weeks, he endorsed severe eye dryness and blurred vision, so it was discontinued. Four weeks later, after the complete resolution of symptoms, the patient was started on Obinutuzumab for six months, which he tolerated well and remained in remission.

IMPACT/DISCUSSION: Cutaneous manifestation of CLL is very rarely encountered. The biopsy is the mainstay to establish the diagnosis. CLL is usually not treated unless the patient is symptomatic or has anemia or thrombocytopenia. Ibrutinib, a burton-kinase inhibitor, is the first line of treatment.

Although CLL is a well-established malignancy secondary to plasma clonal expansion of B lymphocytes, its cutaneous manifestations are uncommon and seldom reported in the literature. Skin infiltrates can be solitary, groups, plaques, papules, or large tumors. The prognosis is unchanged in skin involvement unless there is Richter syndrome (high-grade CLL). Ibrutinib is the initial choice of the standard of treatment in CLL, including in cases of 17p deletion. In cases of inadequate response or side effects, such as in our patient, regimens including obinutuzumab, chlorambucil, and rituximab, have also proven effective.

CONCLUSION: Cutaneous manifestation of CLL is very rarely encountered. The biopsy is the mainstay to establish the diagnosis. CLL is usually not treated unless the patient is symptomatic or has anemia or thrombocytopenia.

DELAYED DIAGNOSIS OF NONTUBERCULOUS MYCOBACTERIAL INFECTION IN A PATIENT WITH CHRONIC COUGH

Hema Pingali^1,2; Carolina Geadas^3,2; Sigal Yawetz^3,2

¹Medicine, Brigham and Women's Hospital, Boston, MA; ²Harvard Medical School, Boston, MA; ³Infectious Diseases, Brigham and Women's Hospital, Boston, MA. (Control ID #3870190)

CASE: A 56-year-old female with granulomatosis with polyangiitis (on rituximab) and a remote history of treatment for tuberculosis (TB) presented to her new primary care doctor with a chief complaint of non- productive cough for 15 years. Chest computerized tomography (CT) from five years prior had revealed bilateral bronchiectasis and nodules that were attributed to prior TB. Further investigation elicited an additional history of fatigue, dyspnea, and a 15-pound weight loss over the past year. Due to concern for recurrent TB, induced sputum samples were obtained. These revealed Mycobacterium fortuitum within 7-14 days. While this particular NTM more commonly causes skin infections, repeat growth on respiratory samples suggested clinically significant pulmonary disease in a patient with underlying bronchiectasis. She was referred to Pulmonology and Infectious Diseases for consideration of treatment. Given her systemic symptoms, therapy was initiated. First-line treatment for M. fortuitum pulmonary infection is not well defined, but typically involves an aminoglycoside and two other agents - a beta-lactam, imipenem, and/or fluoroquinolone. The patient’s renal function precluded the use of aminoglycosides, so a regimen of linezolid (with vitamin B6), imipenem, and levofloxacin was used. At a 2-month follow-up, she reported significant improvement in symptoms. Repeat CT revealed decreased nodular infiltrates. Her course was complicated by peripheral neuropathy secondary to linezolid and tenosynovitis attributed to fluoroquinolone use. Based on susceptibility testing, treatment was changed to trimethoprim-sulfamethoxazole and a tetracycline.

IMPACT/DISCUSSION: The case illustrates the importance of considering pulmonary NTM in the evaluation of patients with chronic cough, especially the elderly and those with chronic lung disease or immunosuppression. Diagnosis requires radiographic findings (typically pulmonary nodules on chest CT) and positive sputum samples. Non-specific symptoms, the logistics of specialized testing, and long incubation periods all complicate the evaluation. Once a diagnosis is made, treatment should be discussed with Pulmonology or Infectious Diseases specialists. The decision to treat will depend on the host, clinical progression, symptom severity, drug susceptibility profile, drug interactions, and shared discussions regarding potential risks and benefits, as treatment courses are lengthy (months to years) and often poorly tolerated.

CONCLUSION: 1) NTM is an increasingly common cause of chronic cough in the US but can be easily missed due to low provider suspicion and challenging diagnosis.

2) Diagnosis of pulmonary NTM requires both radiographic and microbiological (sputum) evidence.

3) The treatment for pulmonary NTM is often poorly tolerated and of a long duration, so the decision to treat should be made in consultation with Pulmonology or Infectious Diseases.

DIALYSIS ACCESS ASSOCIATED STEAL SYNDROME: A CASE REPORT

Sarah Elsayed, Jaskaranpreet Kaur, Manish Wadhwa, Ishita Mehra, Rajesh Boorgu

Internal Medicine, North Alabama Medical Center, Florence, AL. (Control ID #3872932)

CASE: A 54-year-old male with uncontrolled insulin-dependent diabetes mellitus, a peripheral vascular disease with multiple toe amputations, and end-stage renal disease on hemodialysis was admitted for uremic encephalopathy secondary to hemodialysis noncompliance. He was afebrile with a pulse of 89 beats/min, respirations of 18 breaths/min, BP 163/65 mmHg, and saturating 98% on room air. On examination, his left hand had several gangrenous ischemic lesions in the three medial fingers that developed a few weeks after the establishment of a left arterio-venous (AV) fistula and did not improve after the brachial artery bypass procedure. His hospital stay was complicated by the malfunctioning of the AV fistula which the vascular surgeon evaluated. The fistula was unsalvageable because of extensive ischemia of the left arm caused by steal syndrome. A right-internal jugular vein tunneled dialysis catheter was inserted for hemodialysis access. The patient was discharged with a plan to follow up with a vascular surgeon for left-hand amputation. IMPACT/DISCUSSION: Dialysis access-associated steal syndrome (DASS) is a serious complication of dialysis access, it can cause significant limb ischemia or even limb loss. It affects 10% of high-risk patients. Risk factors include age > 60 years, diabetes mellitus, coronary artery disease, cerebrovascular disease, female gender, peripheral arterial disease, and history of DASS. Diabetes mellitus is the strongest predictor for DASS regardless of the presence of other risk factors. Assessing the risk of DASS requires a preoperative examination of all upper extremity pulses, bilateral upper extremity blood pressures, full duplex ultrasound mapping of bilateral upper extremity vessels, and the digital-brachial index. Patients at risk for steal syndrome are those with a digital brachial index of less than 0.6. Revascularization procedures such as ligation, open surgical banding, distal revascularization-interval ligation (DRIL), revascularization using distal inflow, and proximal invasion of arterial inflow and minimally invasive limited ligation endoluminal- assisted revision (MILLER) may aid in symptom improvement.

Optimizing medical management of hypertension and diabetes mellitus can be sufficient for patients with mild symptoms who do not require surgery. Hypotension should be avoided during hemodialysis and warming gloves might be of benefit. This is besides close monitoring of symptoms and patient education concerning the prevention of hand injuries and the reporting of symptom deterioration.

CONCLUSION: Early referral to a nephrologist for planning good vascular access reduces the risk of AV access complications such as DASS and the need for a tunneled catheter.

DITCH THE ITCH: TREATMENT AND MALIGNANCY WORKUP IN PATIENTS WITH CHRONIC SPONTANEOUS URTICARIA

Shira H. Yellin¹; Shyam Sundaresh²

¹Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Department of Medicine, Mount Sinai Health System, New York, NY. (Control ID #3872108)

CASE: A 66 year old male with no medical history presents to clinic for three months of transient pruritic welts. Each welt lasts for less than a day and occurs in various locations like eyes and lips. He is unable to identify any dietary or environmental triggers. He takes no medications. He has no family history of autoimmune disorders or malignancy. Physical examination reveals a 1cm solitary erythematous blanching raised wheal on his right inner arm, as well as a 4cm poorly marinated violaceous induration on his scalp. He is treated with a daily dose of a second generation antihistamine, which prevents further wheals. He is referred to dermatology who obtains a biopsy of his scalp lesion and diagnoses basal cell carcinoma, pending Mohs surgery.

IMPACT/DISCUSSION: This case illustrates a usual presentation of CSU. Treatment with antihistamines is the mainstay of therapy for this condition and is escalated in a stepwise fashion, listed below. Patients should be counseled to avoid NSAIDs at all stages of treatment, due to their ability to worsen hives. Step 1. Once daily dosing of a non-sedating second generation antihistamine.

Step 2. Four times a day dosing of antihistamine and increase dose until symptoms improve (2018 International guidelines, The international EAACI/GA2LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria). If there is continued lack of response, step two allows for the addition of further medications such as an additional second generation antihistamine

(2014 American guidelines, The diagnosis and management of acute and chronic urticaria: 2014 update), leukotriene-receptor antagonist, or a first generation antihistamine at bedtime. Step 3. Increasing the dose of the first generation antihistamine given at bedtime.

Step 4. Patients who are still symptomatic after the first three steps of treatment are said to have refractory CSU. These patients move on to step four, which involves a combination of biologics, anti-inflammatory, and immunosuppressive agents.

CONCLUSION: Antihistamines can be used up to several times a day in the treatment of CSU.

Emphasize age-appropriate cancer screening in patients with CSU due to the increased risk of malignancy.

DOCTOR, I UNDERSTAND MY ILLNESS, BUT I WILL NOT TAKE ANY MEDICATIONS-PECULIAR MANAGEMENT OF FAMILIAL HYPERCHOLESTEROLEMIA (FH).

Letisha Mirembe

Medicine, Texas Tech University System, Lubbock, TX. (Control ID #3876620)

CASE:

Case Presentation A 43 year old female was referred to the cardiology clinic for further management of FH. Her BMI was in a normal range of 19-20, she has an active lifestyle and exercises regularly. 4 years prior to this referral, her lipid panel revealed elevated total cholesterol of greater 300mg/dl, LDL-C greater than 200mg/dl. She was advised to start statins but declined and opted to stick to a strict plant based diet and regular exercises. Her total cholesterol and LDL-C have been reducing markedly in the past 2 years and at her most recent visit , total cholesterol was 239mg/dl and LDL-C was 127mg/dl.

IMPACT/DISCUSSION: FH is the most common autosomal dominant genetic disease. Homozygous FH is rare and fatal but Heterozygous FH is estimated to occur in about 1 in 200 to 250 individuals in the USA.When genetic testing is not available or not felt to be necessary, the Dutch Lipid Clinic Network criteria, which assigns points based on low-density lipoprotein cholesterol (LDL-C) levels, personal history

of early atherosclerotic cardiovascular disease (ASCVD), family history of early ASCVD, or high cholesterol in a first-degree relative, and physical examination findings.

This patient did not have genetic testing done but scored high on the Dutch lipid Clinic Network criteria as her father and grandfather had elevated total cholesterol and LDL-C and an ASCVD at the ages of 39 and 50 respectively, and had several younger siblings and cousins with elevated total cholesterol and LDL-C. The steps recommended in management of FH are; setting LDL-C goal of <70mg/dl, initiating a high-dose statin therapy, measuring LDL-C in 6 to 12 weeks. If the patient is not at LDL-C goal after statin, start ezetimibe 10 mg daily and repeat LDL-C in 6 to 12 weeks. If the patient remains above the goal, a PCSK9 inhibitor such

as Inclisiran may be added.

This case is peculiar due to her young age at presentation, physical fitness and a normal BMI for which many health providers would argue that she did not require lipid panel testing. However her family history was key and is a reminder that exhaustive history taking contributes a great percentage to the diagnosis. She declined medication and opted for a strict plant based diet. Her total cholesterol and LDC-C significantly reduced. Although this is not part of the traditional guidelines, it was successful in this patient and is worth a try in all patients with FH.

CONCLUSION: Conclusion Familial hypercholesterolemia (FH) is an autosomal dominant genetic disease. Previously undiagnosed heterozygous FH patients present with symptoms of cardiovascular disease or adverse cardiovascular disease events in early middle age. Health care providers should recommend lipid profiles for all first-degree relatives of patients with FH in order to identify other individuals at risk. The main stay of treatment is Statins, Ezetimibe and PCSK9 inhibitors but this case has revealed that a strict plant based diet acoul be considered as a first line option.

DOWN IN THE DUMPS

Kyle Luo¹; Joesph R. Sweigart²

¹College of Medicine, University of Kentucky, Lexington, KY; ²Hospital Medicine, University of Kentucky, Midway, KY. (Control ID #3872017)

CASE: An 84-year-old woman with previous Roux-en-Y gastric bypass in 2005 presented to the ER for evaluation of altered mental status. The day prior, she became somnolent at home so her family notified EMS who found her to be hypoglycemic. Her symptoms resolved with dextrose and she declined further evaluation. Her confusion returned that evening and she was difficult to rouse the following morning. Her family brought her to the ER where she was persistently hypoglycemic. She was started on a D5 drip and admitted.

At the time of admission, she reported feeling well and denied fever, nausea, vomiting or abdominal pain. She was not diabetic and not taking any outpatient hypoglycemic medications. On examination, she was morbidly obese with normal cardiovascular, pulmonary and GI exams. Labs at admission included glucose of 52 mg/dL while on a D5 drip, C-peptide of 17.9 (reference range: 1.1 – 4.4) and normal CBC and comprehensive metabolic panel. The following morning, cortisol was 14.2, TSH was 1.25 and A1C was 5.4. During her hospitalization, her blood glucose levels remained stable overnight followed by episodes of hypoglycemia 60-90 minutes after breakfast, consistent with post-prandial hypoglycemia. She was discharged with instructions to follow a high protein diet, avoid simple sugars, and intermittently monitor her blood glucose.

IMPACT/DISCUSSION: Recognizing and correctly diagnosing delayed complications of bariatric surgery is important for internists as these surgeries have now been in use for decades. Postprandial hyperinsulinemic hypoglycemia, or late dumping syndrome (LDS), is associated with debilitation and significant decline in quality of life. LDS must be considered for patients with a prior history of bariatric surgery. Patients often develop significant fatigue, the need to lie down, and other neuroglycopenic symptoms such as confusion and weakness 1-3 hours after meals. This syndrome may not manifest until several years after bariatric surgery.

The pathophysiology of late dumping syndrome is related to a hyperinsulinemic response to a carbohydrate load. Dietary modification with smaller meals, high-protein and high-fiber foods, and avoidance of rapidly absorbable carbohydrates is first-line in management. In patients who do not respond adequately to dietary modifications, pharmacotherapy may be considered. Acarbose, an alpha-glucosidase inhibitor, decreases carbohydrate digestion and has been used for treatment of LDS. Somatostatin analogues may also provide benefits through the slowing of gastric emptying, inhibition of insulin secretion and decreased release of postprandial GI hormones. In severe or refractory cases, surgical management with gastrostomy tube placement or gastric bypass reversal may also be considered.

CONCLUSION: - Late dumping syndrome (hyperinsulinemic hypoglycmia) may present years after baratric surgery.

- Treatment options for late dumping syndrome include dietary modifications (first line) and medications if needed.

EXTENSIVE INTRACARDIAC CEMENT EMBOLISM IN A PATIENT UNDERGOING WORKUP FOR BONE MARROW TRANSPLANT

Gavisha Waidyaratne¹; Caitlin Bennett¹; Elvira Umyarova²; Naresh Bumma²

¹Internal Medicine, The Ohio State University, Columbus, OH; ²Hematology/Oncology, The Ohio State University, Columbus, OH. (Control ID #3867594)

CASE: A 64-year-old male with multiple myeloma status-post induction therapy presented with foreign body (FOB) incidentally seen on echocardiogram during stem cell transplant (BMT) workup. Despite no prior history of central line placement or cardiac catheterization, the echo noted a linear density concerning for a wire extending from the inferior vena cava (IVC) to the right ventricle (RV). He did however have a kyphoplasty six weeks prior to presentation.

The patient was asymptomatic. CT Chest and PET confirmed foreign body originating from L2-3 and extending superiorly in the IVC to the proximal RV. Cardiac surgery did not recommend surgical intervention. Interventional radiology (IR) confirmed that the FOB was likely a cement embolism from prior kyphoplasty.

IR recommended IVC venography with cement retrieval and possible deployment of temporary embolic protection device. Risks of not proceeding with retrieval were discussed including embedding of the cement or thromboemboli. The patient elected to forego the procedure and was discharged. The case was discussed at tumor board, and the committee recommended that transplant workup be put on hold until embolus removal. The patient sought a second opinion and was recommended to continue maintenance therapy due to the risks of BMT.

IMPACT/DISCUSSION: Intracardiac and intrapulmonary cement embolisms are well-documented complications of percutaneous vertebroplasty, a procedure that stabilizes compression fractures by injecting bone cement into the vertebral body. While largely safe, cement leakage into the paravertebral veins, azygous venous system, or vena cava with subsequent migration is a major complication; the incidence of pulmonary cement embolisms is 4.6-26.9%. Cement embolisms are also easily mistaken for wires on imaging. A detailed history is necessary to diagnose cement embolisms.

We present the case of a large, asymptomatic intracardiac cement embolism in a patient undergoing BMT workup. There is limited data on cement embolisms in solid organ transplant and BMT candidates. Though most cement embolisms are asymptomatic, complications include tamponade, valvular damage, cardiac perforation, and death. Management strategies include conservative management, anticoagulation, percutaneous retrieval, and surgery, but invasive options can be dangerous. BMT patients are already at high risk of infection, cardiotoxicity, and bleeding. It is difficult to assess how the risk of complication from cement embolisms should be weighed in a patient undergoing BMT evaluation. We recommend an individualized and multidisciplinary approach. Our case suggests that while cement embolisms may not be an absolute contraindication to BMT, the long-term implications are not clear.

CONCLUSION: Cement embolisms are an important complication of vertebroplasty that can be easily mistaken for FOB and have major risks. The significance of these risks in patients undergoing BMT requires further investigation.

FATAL CANCER REVEALS A FETAL ANOMALY: A CASE OF A PERSISTENT LEFT SUPERIOR VENA CAVA

Falah I. Abu Hassan, Andrea J. Zapata, Anass Dweik, Md Rockyb Hasan, James ". Walker

Internal Medicine, Texas Tech University Health Sciences Center School of Medicine, Amarillo, TX. (Control ID #3861517)

CASE: A 59 -year-old male patient presented to our hospital for diffuse cramping abdominal pain and obstructive jaundice. These symptoms were preceded by two months of nausea, vomiting, anorexia and a 60- pound weight loss. CT scan showed complete encasement of the origin of the superior mesenteric artery and vein. ERCP with sphincterotomy, stent placement, and brush biopsy were performed, and the patient was diagnosed with inoperable stage IV pancreatic cancer and was offered palliative chemotherapy, via implantable port placement. During trials to insert a port-a-cath, right and left sided trials via the internal jugular (IJ) and subclavian (SC) veins to insert a guidewire with fluoroscopy showed the wire lodging in the left side of the heart, and when the left IJ access was used, the wire terminated below the diaphragm and was thought to be lodging in the inferior vena cava. CT angiography of the chest confirmed the absence of a right- sided superior vena cava (SVC), with the brachiocephalic veins draining to a persistent left-sided SVC which drains to the coronary sinus and right atrium. Echocardiogram confirmed the SVC anomaly and ruled out the presence of an unroofed coronary sinus, ASD or VSD. Eventually, the patient had a femoral port-a-cath placed and was discharged shortly after to continue palliative care.

IMPACT/DISCUSSION: Embryologically, the caudal part of the right cardinal veins (CV) along with the common CV form the right superior vena cava normally. It is thought that the right CV develops into the SVC due to the preferential blood flow to the right CV. When the caudal part of the left superior CV and the left common CV persist, they form the LPSVC. Similarly, the absence of the right SVC is a rare occurrence, making the drainage of the head and neck completely dependent on the PLSVC. The drainage of the PLSVC usually terminates into the coronary sinus. In this case, the need for a port was for the administration of chemotherapy, and this raises the concern that a port placed in such an anomaly could theoretically irrigate the coronary arteries with the infused solutions. There was a concern that there was an unroofed coronary sinus, in which the CS would be communicating with the left atrium but that was refuted by the angiography study. Additionally, port placement in CS, atrial septal defects, and ventricular septal defect is relatively contraindicated due to risk of air embolism introduction into systemic circulation during port use.

CONCLUSION: LPSVC and absent right-sided SVC are both rare embryologic anomalies that can have several considerations to our practice. Despite having a good prognosis, there may be implications on central line placement, pacemaker placement, and cardiopulmonary bypass procedures.

FIXING THE LEAK: A CASE OF MENINGITIS SECONDARY TO MENINGOENCEPHALOCELE Jeremy T. Stephan¹; Michelle Sweet²; Natalie B. Otto¹; Mohit Uppal¹

¹Internal Medicine, Rush University Medical Center, Chicago, IL; ²Internal medicine, Rush University Medical Center, Chicago, IL. (Control ID #3875529)

CASE: The patient is a 40-year-old female with hypertension who presented with fever, nasal congestion, cough, body aches, and confusion. Ten months before presentation, the patient presented with pharyngitis associated with pooling of “spit” in her throat and choking when lying flat. CT imaging at the time demonstrated a sphenoid sinus mass, but the patient was lost to follow-up. Initial vitals on presentation were significant for fever (102F), tachycardia (HR 110), and hypertension (BP 176/82). Glasgow Coma Scale was 9 with eye movement to pain, moaning incomprehensible sounds, and localization of pain with movement. Exam was significant for right nasal sinus filled with solid white-gray secretions. Admission labs were significant for elevated WBC (22.06). CT brain and soft tissue neck revealed expansile hypodense polypoidal lesion in the R nasal cavity and sphenoid sinus with bony skull erosion. Lumbar puncture and cerebrospinal fluid analysis demonstrated cloudy fluid with cell counts > 10000 WBC, 350 RBC, 99% neutrophils, and growth of gram-positive cocci in chains.

Cultures diagnosed strep pneumoniae meningitis and bacteremia as complications from the imaged transsphenoidal meningoencephalocele. The patient responded to IV ceftriaxone with resolution of her bacteremia and meningitis, upon which otolaryngology and neurosurgery performed endoscopic endonasal resection of the meningoencephalocele with repair of right middle fossa skull base defect. The patient was discharged in good condition 25 days after admission.

IMPACT/DISCUSSION: We present a case of a patient with a meningoencephalocele from skull defects that led to meningitis after presenting ten months earlier with symptoms of CSF leak. A meningoencephalocele is an uncommon structural anomaly characterized by herniation of brain matter and CSF through a skull defect. The etiology of these defects is typically unclear but is separated into primary congenital and acquired, including trauma, tumor, infection, or elevated intracranial pressure. Meningoencephaloceles classically present in the third or fourth decade of life with symptoms of nasal obstruction, polyps, or CSF leak, which may include headache, nasal drainage, or ear drainage.

Meningoencephaloceles may develop in numerous locations, including occipital and frontoethmoidal. Transsphenoidal locations account for fewer than 10% of meningoencephaloceles. Skull defects such as meningoencephaloceles are occasional causes of cerebrospinal fluid leaks and meningitis making them important to recognize as a potential etiology for individuals presenting with those symptoms. Treatment typically involves endoscopic repair of the skull defect in an interdisciplinary approach with neurosurgery and otolaryngology.

CONCLUSION: Meningoencephalocele is an infrequent but important etiology of CSF leak and meningitis.

Surgical correction is critical to prevent recurrent symptoms of CSF leak and recurrent episodes of meningitis.

GLIOBLASTOMA MULTIFORME AND ALPHA-1-ANTITRYPSIN DEFICIENCY

curtis ober¹; Rojin Esmail²; Damian Casadesus³

¹Medicine, Ross University School of Medicine, Miramar, FL; ²internal medicine, Jackson Memorial Hospital, Miami, FL; ³Internal Medicine, Jackson Memorial Hospital, Miami, FL. (Control ID #3875327)

CASE: A woman in her 70s with a history of A1ATD presented to the emergency department with altered mental status. The son described that she started with shaking and seizure-like activity but became unresponsive and transferred to our institution. Upon presentation the patient was lethargic. Vital signs were heart rate of 129/minute and blood pressure of 169/119 mmHg. The patient was oriented to person and time and followed commands.

Laboratory studies were abnormal for lactic acid 6.3 mmol/L and leukocytosis with neutrophilic predominance. CT of the brain revealed a 1.1 cm heterogenous slightly hyperdense intra-axial lesion in the

high left frontal lobe with surrounding vasogenic edema and mass effect. A CTA of the chest was completed, with findings of mucous plugs consistent with her long-term history of bronchiectasis, as well as bilateral small hilar lymph nodes concerning for metastatic disease. MRI of the brain to better characterize the cranial lesion showed a brain mass measuring 2.0 x 1.7 x 2.7 cm. There was a debate about neurosurgical excisional biopsy, CT-guided core needle biopsy, or mediastinoscopy with lymph node biopsy. Ultimately due to the small target of the 8 mm hilar lymph node, and the poor pulmonary status of the patient, it was decided to perform a brain excisional biopsy by neurosurgery. Pathology studies of the biopsy were consistent with GBM WHO grade IV, isocitrate dehydrogenase 2 negative.

Due to the patient's age and comorbidities, options of treatment with systemic oral chemotherapy and radiotherapy as well as a discussion of palliative care were communicated with the patient and her family. Our patient chose to approach treatment with concomitant radiotherapy and systemic chemotherapy.

IMPACT/DISCUSSION: A1AD is a genetic disease with a large prevalence and wide distribution of phenotypic expression. There are well-documented sequelae of A1ATD most notably bronchiectasis and liver cirrhosis. The only well-demonstrated cancer indirectly caused by A1AT is hepatocellular carcinoma. A1AT may potentially increase the risk of other cancers such as lung, colorectal, gastric, and bladder cancer may lead to poor prognosis or can be associated with a negative impact on invasiveness and metastatic capacity. Only one study describes the relationship between A1ATD and central nervous system cancer. Hiller and coworkers described the presence of non-liver cancers in 14 patients with A1ATD. Only one of the patients has central nervous system cancer of the meninges. To our knowledge, this is the first patient with GM and A1ATD that is reported in the literature. In countries with a high incidence of A1ATD, further studies should be done to identify the association between these two medical conditions.

CONCLUSION: A1ATD is a risk factor for non-liver cancers Glioblastoma multiforme is a brain tumor that can be associated with A1ATD

Physicians need to be aware that toxic metabolic encephalopathy in a patient with A1ATD can be associated with glioblastoma multiforme

GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONIST FOR TREATMENT OF OBESITY Nicole Kochman, David A. Feldstein, Linda Baier Manwell, Samantha Pabich

Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI. (Control ID #3872424)

CASE: A 29-year-old female with non-alcoholic fatty liver disease, obstructive sleep apnea and chronic back pain presented to endocrinology in 2017 for weight loss management. She requested an anti-obesity medication because her Obera intragastric balloon had been removed due to severe nausea. From 2017-2018 she tried bupropion-naltrexone and phentermine-topiramate, with minimal results. By May 2020, she weighed 315 lbs (BMI 48) and liraglutide was initiated. She lost 65 pounds (21% body weight) in one year. In June 2021, she requested a switch to semaglutide because weight loss progress had stalled. She stopped liraglutide and gained 15 pounds in one month while waiting for insurance approval for semaglutide. One year after starting semaglutide, she was seen by Cardiology for lightheadedness and a fainting spell. She was switched to tirzepatide after cardiology raised concern for orthostatic hypotension from semaglutide.

IMPACT/DISCUSSION: Obesity is a major public health issue. It affects mortality risk and chronic conditions such as type II diabetes (T2D) and cardiovascular disease. Adjunctive pharmacotherapy is warranted for patients with obesity if lifestyle modifications are unsuccessful. GLP-1 agonists, originally developed to treat T2D, are effective for weight loss. They work by mimicking a hormone that slows gastric emptying, resulting in increased feelings of satiety and potential weight loss. A recent trial, Semaglutide Treatment Effect in People with Obesity (STEP 1), randomized 1961 adults without diabetes and a BMI ≥30 to placebo or once-weekly semaglutide for 68 weeks. The semaglutide group experienced greater reduction in weight compared to placebo ( -14.9% vs -2.4%). However, the metabolic effects are likely not maintained after medication discontinuation. An extension of STEP 1 showed that treatment withdrawal after 68 weeks of therapy led to a mean regain of two-thirds of lost weight by 120 weeks.

Higher cost and tolerability are significant barriers to prescribing GLP-1 agonists. The most frequent side effects include nausea, vomiting and diarrhea. Studies have shown that these effects generally improve over time and could be reduced by dose titration. GLP-1 agonists are also associated with a slight reduction in systolic blood pressure, which may play a role in the drugs’ beneficial effects on cardiovascular disease as well as this patient’s lightheadedness.

This case highlighted that GLP-1 agonists are effective weight loss agents but must be continued to maintain reduction. Their use may be limited by side effects and cost. This case taught me to ensure that patients understand the risk of weight regain when stopping a GLP-1 agonist.

CONCLUSION: 1. Semaglutide, causes significant weight loss in obese individuals without diabetes.

2. Discontinuation of GLP-1 agonist therapy can lead to most of the weight loss regained within 1 year.

3. Nausea, vomiting, and diarrhea are major side effects of GLP-1 agonists.

HEYDEING IN PLAIN SITE

Hania N. Shahin¹; Omar Shahin²

¹School of Medicine, University of California Riverside School of Medicine, Riverside, CA; ²Riverside Community Hospital, Riverside, CA. (Control ID #3875193)

CASE: A 74-year-old man presented to the emergency department with large volume melenic stools that had begun within 12 hours of presentation. He did not endorse a history of concomitant chest discomfort, dyspnea, or hematemesis.

The patient reported a medical history of hypertension, type II diabetes mellitus, atrial fibrillation, and his medications included therapeutic anticoagulation with rivaroxaban. In the 14 days prior to presentation, he was admitted to the hospital for similar complaints of melenic stools. At that time, upper and lower gastrointestinal endoscopic evaluation revealed no active source of bleeding. Transthoracic echocardiography was conducted and identified a left ventricular ejection fraction estimate of 35% and an aortic valve area of 0.4cm², findings consistent with severe aortic stenosis. During the patient’s readmission, video capsule endoscopy revealed multiple angiodysplastic lesions in the jejunum and ileum which were identified as the probable source of his gastrointestinal bleeding. The patient was then referred to an outpatient cardiologist to undergo evaluation for transcutaneous aortic valve replacement.

IMPACT/DISCUSSION: A multisystem disorder characterized by aortic stenosis, acquired von Willebrand Factor (vWF) dysfunction, and gastrointestinal bleeding was first characterized in 1958 and given the name “Heyde syndrome”. Because of the increasing prevalence of aortic stenosis (AS) and gastrointestinal bleeding with advanced age, Heyde syndrome is often diagnosed in older patients. Many patients with aortic stenosis have a significantly reduced level of vWF multimer, and there appears to be an inverse correlation between the severity AS and the degree of vWF serum levels. Red blood cells that transverse a stenotic aortic valve are subject to increased shear forces, which is hypothesized to contribute conformational changes in large vWF multimers that allows enzymatic cleavage of the multimers, thereby interfering with the inhibition of angiogenesis. The resultant increase in vessel formation can manifest as angiodysplastic malformations on mucosal surfaces. Most sources of gastrointestinal bleeding in Heyde syndrome arise from angiodysplasias in the small bowel. Video capsule endoscopy or push enteroscopy can be utilized as diagnostic modalities, especially when standard upper and lower gastrointestinal endoscopic evaluations are non-diagnostic. Aortic valve replacement has demonstrated high rates of cessation of recurrent gastrointestinal bleeding and is offered as a first-line curative treatment strategy for patients with Heyde syndrome.

CONCLUSION: Heyde syndrome should be considered in patients with unexplained melenic stools as patients may have otherwise asymptomatic severe aortic stenosis. Transthoracic echocardiogram is appropriate to rule in aortic stenosis, and thus Heyde syndrome as a cause of gastrointestinal bleeding.

HYPEREOSINOPHILIC SYNDROME: A CASE OF HYPOXIC RESPIRATORY FAILURE

Rage Geringer

Pulmonary and Critical Care, Creighton University School of Medicine, Omaha, NE. (Control ID #3875370)

CASE: 41 year old male with history of alcohol abuse initially presented for chest pain. He had a chest x-ray completed that showed concern for viral pneumonia. He tested positive for COVID and was discharged to quarantine. At that time, he was noted to have a peripheral eosinophilia of 4,200 mcL. The patient then returned two weeks later with altered mental status, chest pain, and respiratory distress. Peripheral eosinophilia was 7,500 mcL. He was evaluated by critical care in the emergency department where he was intubated. CT showed peripheral sparing ground glass opacities. A broncheoalveolar lavage was completed showing a cell differential of 84% eosinophilia without features of alveolar hemorrhage. He had a troponin of 2,200ng/L. Cardiology was consulted calling it demand ischemia. Neurological status felt to be altered due to alcohol withdrawal. Weaning from ventilator was difficult because of this. When weaned, he still had chest pain so cardiology reconsulted, again contributing pain and tropenemia to demand. Patient was treated with steroids for concern of eosinophilic pneumonia, resolving all symptoms. He was able to be extubated and discharged, following up with cardiology who did cardiac MRI showing myocarditis, presumed eosinophilic. Gastroenterology did upper endoscopy finding eosinophilic esophagitis. HES then diagnosed.

IMPACT/DISCUSSION: Peripheral eosinophilia is a common finding on labs with a broad differential. Most of the time this eosinophilia is found on routine lab work in primary care clinics. The differential can range from benign to pending catastrophe. Though asthma is often seen with peripheral eosinophilia, it is important to remember asthma mimics. In our case, mimics that we considered were acute eosinophilic pneumonia, e-cigarette/vaping indulced lung inujury, and alveolar hemmorhage.

HES is over production of eosinophils that can be set off by either infection (most commonly helminth), cancers (most commonly lymphoma), genetic dispositions, or unknown factors. A patient must have greater than 1,500 cells/microL at least one month apart with signs of organ damage. Common organs involved are gastrointestinal, pulmonary, integumentary, and cardiac.

In our patient, he was found to meet criteria based on blood draws multiple months apart, as well as involvment of gastrointestinal system with esophagitis, pulmonary with eosinophilic predominant bronchoscopy, and cardiac with myositis. He responded well to steroids which would be expected in HES.

CONCLUSION: Though peripheral eosinophilia can be seen with relative frequency, HES is a rare cause of multiorgan failure. Symptoms are often attributed to other causes rather thank linked together. Our patient met the diagnostic criteria of peripheral eosinophilia greater than 1,500 mcL, lack of other cause of eosinophilia (i.e parasites), and signs of multiorgan involvement. Steroids are the treatment, with most patients needing further immunosuppression.

HYPOVITAMINOSIS D AS A RED HERRING IN A CASE OF RISING ALKALINE PHOSPHATASE

Julia Brown, Beenish Ahmed

Internal Medicine, Christiana Care Health Services Inc, Wilmington, DE. (Control ID #3875321)

CASE: A 71-year-old male with a past medical history of obesity was seen outpatient and underwent a routine Comprehensive Metabolic Panel (CMP). Results showed a marginally elevated alkaline phosphatase (ALP) to 120 IU/L (ref. 39-117). Eight months later, a repeat CMP revealed an ALP of 204 IU/L. Vitamin D level was 6.7 ng/mL (ref. 30-100). Parathyroid hormone (PTH) was ordered but not completed. He was initiated on vitamin D supplementation, and it was suspected that his ALP elevation was secondary to vitamin D deficiency. Five months later, the patient returned with a 40lb weight loss. Labs showed ALP of 322 IU/L. Subsequent gamma-glutamyl transferase (GGT) was 255 IU/L (ref. 0-65), PTH 24 pg/mL (ref. 15-65), and vitamin D 31.8 ng/mL. A liver ultrasound showed nodular lesions. Follow up MRI showed numerous masses obliterating the bile ducts and peri-portal lymphadenopathy. The patient was referred to Oncology. CA 19-9 was elevated to 281U/mL (ref. 0-35) and AFP to 2684 ng/mL (ref. 0-8.3). Pathology from CT guided liver biopsy was consistent with cholangiocarcinoma with hepatic and lymphatic metastasis. The patient started palliative chemotherapy with cisplatin and gemcitabine. He developed abdominal ascites, which has required weekly paracenteses.

IMPACT/DISCUSSION: Cholangiocarcinoma is a cancer of the biliary epithelial cells. Currently accounting for 15% of all primary liver cancers, its incidence has been rising.^1,3 Due to its insidious symptoms, cholangiocarcinoma often does not present until advanced and carries a median survival of < 12 months.² Diagnostic features include an elevated ALP with normal bilirubin levels and biliary duct masses on imaging.¹ There is a significant difference in survival rates between patients with advanced vs. local disease.³

Early detection is critical.

The differential diagnosis for an elevated ALP is typically disease of the liver or bone. Hepatobiliary origin is established by an elevated GGT, whereas bone origin is often associated with low serum calcium, serum phosphorus, and vitamin D level and elevated PTH. Our patient’s elevated ALP was initially presumed to be associated with bony resorption in the setting of hypovitaminosis D. Follow up GGT or PTH may have led to earlier diagnosis of his biliary disease.

CONCLUSION: An undifferentiated, elevated ALP should be thoroughly investigated.

Early diagnosis of cholangiocarcinoma is likely to influence survival.

References

1. Lazaridis KN, Gores GJ. Cholangiocarcinoma. Gastroenterology. 2005;128(6):1655-1667. doi: https://doi.org/10.1053/j.gastro.2005.03.040

2. Zhang C, Wang H, Ning Z, et al. Serum liver enzymes serve as prognostic factors in patients with intrahepatic cholangiocarcinoma. Onco Targets and Ther. 2015;10:1441-1449. doi: 10.2147/OTT.S124161

3. Koshiol J, Yu B, Kabadi SM, Baria K, Shroff R. Epidemiologic patterns of biliary tract cancer in the United States: 2001–2015. BMC Cancer. 2022; 22(1178). doi: https://doi.org/10.1186/s12885-022-10286-z

IMMUNE CHECKPOINT INHIBITOR INDUCED AUTOIMMUNE DIABETES

Mariya Kononenko, Eric Woods

Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #3875486)

CASE: A 64-year-old woman with a history of infiltrating ductal carcinoma status post chemotherapy and bilateral mastectomy complicated by triple-negative lymph node recurrence was sent to her primary care physician for hyperglycemia on routine monitoring blood work. The patient denied any new symptoms including polyuria, polydipsia, fatigue, or weight changes. She had been receiving neoadjuvant chemotherapy with a combination of carboplatin, docetaxel, and pembrolizumab for over 9 months. She has not received any steroids for over two years. Her serum glucose was 412 mg/dL and hemoglobin A1c was 8.6%. Her urine was negative for ketones. Anti-GAD-65 antibodies were elevated to 523 U/mL and her C-peptide was low

(1.0 ng/mL). Islet-cell antibodies, zinc transporter 8 antibodies, and anti-insulin antibodies were negative. She was initiated on long-acting basal and short-acting meal-time insulin with normalization of blood sugars, and she was continued on her chemotherapy regimen.

IMPACT/DISCUSSION: Internists are increasingly likely to encounter immune-related adverse effects of pembrolizumab like autoimmune diabetes mellitus because the use of this medication is becoming more common. Pembrolizumab is a monoclonal antibody and immune checkpoint inhibitor (ICI) that binds to the programmed cell death protein 1 (PD-1) receptor and allows for improved T-cell mediated killing of tumor cells. However, in up to 2% of patients treated with pembrolizumab, T-cells may also contribute to the destruction of beta islet cells in the pancreas leading to diabetes mellitus.

ICI-induced autoimmune diabetes usually develops acutely, with over 60% of patients first presenting with diabetic ketoacidosis. This immune-related adverse effect appears more common with pembrolizumab compared to other immune checkpoint inhibitors. There has been no association found between the number of treatments of pembrolizumab received and the onset of diabetes. There have been no reported remissions of autoimmune diabetes despite cessation of PD-1 inhibitor treatment and insulin has been the only effective treatment of ICI-induced diabetes. Certain HLA types may be used as biomarkers to identify patients with a predisposition to developing autoimmune diabetes.

General internists play an important role in recognizing initial symptoms of diabetes, routinely monitoring glucose levels in patients on immune checkpoint inhibitors, and maintaining a high index of suspicion for ICI-induced autoimmune diabetes to prevent adverse outcomes.

CONCLUSION: - ICI-induced autoimmune diabetes frequently presents with DKA and is characterized by a more rapid progression to insulin deficiency as compared to other forms of type 1 diabetes.

- ICI-induced diabetes can occur anytime after starting therapy and does not appear to undergo remission even after discontinuing the associated medication.

IMMUNE CHECKPOINT INHIBITOR INDUCED EXACERBATION OF TYPE II DIABETES

Angelina Lo¹; Janteshpreet Sandhu¹; Akash Patel²; Dang Khoa Duong²

¹School of Medicine, University of California Irvine, Irvine, CA; ²Internal Medicine, University of California Irvine Medical Center, Orange, CA. (Control ID #3873827)

CASE: A 74-year-old woman with history of type II DM (T2DM) and melanoma on cycle 11 of nivolumab presented to the ED due to home blood glucose measurements in the 300s. For 25 years, her diabetes had been under adequate control on mixed insulin, 26 units/day. HbA1c from 6 months prior was 5.9%. However, despite no change in diet, her diabetes became poorly controlled for several weeks prior to ED presentation, with home blood glucose as high as 525. She gradually increased insulin dosage to 95 units/day, but still could not achieve glucose control.

In the ED, she was stable with a benign physical exam and no evidence of DKA or hyperosmolar hyperglycemic state. Work-up was significant for blood glucose of 328, HbA1c of 12%, and elevated GAD-65 antibody (0.1 nmol/L). Complete T1DM autoimmune panel was recommended, but the patient wanted to be discharged before it could be sent. Overall impression was that the patient was suffering a nivolumab-induced exacerbation of baseline T2DM. She was discharged with endocrinology follow-up. In the endocrinology clinic, she was switched from premixed insulin to glargine/aspart regimen with instructions for further titration based on blood glucose level. Upon follow-up with her oncologist, her endocrine irAE (immune-related adverse event) was considered to be grade 2, and she was continued on the same dosage of nivolumab therapy.

IMPACT/DISCUSSION: Immune checkpoint inhibitors (ICI) may cause a host of irAEs which are unique in their presentation and management. Endocrine irAEs include autoimmune thyroid disease, hypophysitis, adrenal insufficiency, and diabetes.

Nivolumab is a PD-1 inhibitor which can cause new-onset T1DM or worsening of known T2DM in 1.8% of patients. Differentiating between new-onset T1DM and worsening T2DM is important to anticipate clinical manifestation and to devise management strategy. It is more likely that our patient has worsening of T2DM, but there are features to support both possibilities. New-onset T1DM cases often have an abrupt onset with higher degree of hyperglycemia and DKA occuring in 50-75% of cases at initial presentation, while worsening T2DM is typically more gradual. In our patient, HbA1c was quite elevated compared to previous levels, indicating a chronic change in glycemic control. However, our patient also had an elevated anti-GAD level, which is an autoimmune antibody associated with T1DM. The presence of autoantibodies in ICI- induced diabetes is not consistent among studies. Some studies indicate most patients have negative autoantibodies, while others show that at least one autoantibody is present.

CONCLUSION: Patients with known T2DM on ICI for oncologic treatment may have worsening glycemic control. Diabetes is a common diagnosis and it is crucial for medical providers to be aware of this irAE to ensure early recognition and to coordinate care between endocrinologists and oncologists for optimal management.

LARGE SUBCLINICAL ABSCESS OF A FORGOTTEN FAILED RENAL ALLOGRAFT

Parul Kochhar, Luis F. Ng Sueng

Internal Medicine, Henry Ford Health System, Detroit, MI. (Control ID #3848396)

CASE: 39 year old female with a history of left nephrectomy in 2009, end-stage renal disease due to obstructive uropathy from neurogenic bladder, status post kidney transplant in 2016 with subsequent failure in 2020. She started peritoneal dialysis that year. She had residual urine production, for which she used intermittent straight catheterization. She was admitted for severe symptomatic anemia. Vitals were within normal limits. The examination was remarkable for subtle pain in the right lower quadrant. Complete blood count revealed a white count of 14.2 and hemoglobin of 6.0 mg/dL. Incidentally, the nursing staff noted cloudy urine with a very dense consistency during her straight catheterization. Dipstick urinalysis was unable to be fully processed due to the dense consistency of her urine but showed 149 RBCs, 182 WBCs, and many bacteria. Computed Tomography Abdomen showed a 7 cm large gas and fluid collection with no normal identifiable renal parenchyma consistent with necrosis of her kidney allograft. Abscess culture grew Actinomyces species and she was started on Ertapenem. The transplant surgery team was consulted but did not recommend transplantectomy due to poor surgical candidacy. A percutaneous drain was placed to achieve source control. She was eventually discharged with long-term oral antibiotic therapy with Augmentin.

IMPACT/DISCUSSION: 1 in 5 patients with renal transplantation will have allografts that fail in 5 years, and more than one in two will have graft failure by 10 years. Potential complications of failed allografts include infections, malignancy, bone disease, and cardiovascular disease. Among these, infections remain the leading cause of complications following a kidney transplant. These can occur early post-transplant, during peak immunosuppression, and late onset. The latter occurs 6-12 months following transplant and includes community-acquired pneumonia, upper respiratory infections, and urinary infections, which are by far the most common. In patients with urinary infections, the clinical presentation can range from asymptomatic bacteriuria or pyuria to pyelonephritis and sepsis. In patients with failed transplants and recurrent urinary tract infections or sepsis, transplantectomy should be considered. This patient had multiple previous episodes of pyelonephritis with positive cultures for ESBL and VRE organisms. Patient could not recall if transplantectomy was discussed during her prior infection episodes. Her presentation was subtle despite the large abscess in the graft. This patient’s symptoms were initially attributed to severe anemia and she did not exhibit any clear infectious symptoms.

CONCLUSION: This case illustrates potential infectious complications of a failed kidney allograft. Transplantectomy should be discussed in patients with failed allograft and recurrent bacterial infections, and immunosuppression should be weaned accordingly. Diagnosis of renal allograft complications can be challenging due to atypical or subclinical presentations.

LIT UP WITH LIGHT CHAINS: PULMONARY AMYLOID PRESENTING AS HYPERMETABOLIC LUNG NODULES

Samuel C. Ficenec, Erica Tate

Department of General Internal Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #3868863)

CASE: A 76-year-old Haitian woman with a past medical history of GERD, diabetes, hypertension, and no smoking history presented to the Emergency Department (ED) with a chief complaint of chronic cough, chest pain, and shortness of breath. The patient’s workup for acute coronary syndrome including a troponin trend and EKG was negative. Tuberculosis testing was negative. Due to suspicion of a pulmonary embolus a chest CT was obtained that demonstrated multiple bilateral nodules and a previously known right upper lobe pulmonary nodule that had increased in size from 5 to 14 mm in comparison to exams from a year prior. Given a concern for a pulmonary malignancy the patient was referred to pulmonology, and an Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan was obtained. This imaging study again demonstrated the 14 mm right upper lobe pulmonary nodule with hypermetabolic activity (SUV_max = 3.3). The patient was subsequently scheduled for CT guided needle biopsy. The biopsy specimen displayed abundant eosinophilic substance with multinucleated giant cells, histiocytes, and plasma cells, no carcinoma was seen. Congo Red staining was also performed and showed green birefringence under polarized light, which highlighted amyloid deposits and confirmed the diagnosis as amyloidosis. Additional workup also revealed the lack of other organ involvement or other plasma cell dyscrasias further differentiating the diagnosis to focal pulmonary amyloidosis.

IMPACT/DISCUSSION: This case highlights the broad differential of pulmonary nodules and the diagnostic uncertainty of lesions with increased metabolic activity. FDG-PET scanning is a technology that is commonly used to differentiate benign and malignant lesions and to stage patients with lung cancer. This imaging modality has high a sensitivity and specificity of approximately 80-90% for pulmonary malignancy. However, this technique is not infallible and positive results are possible in benign cases such as infection, pneumoconiosis, sarcoidosis, and uncommon diseases such as amyloidosis. Focal pulmonary amyloidosis is a rare disorder that typically presents with non-specific symptoms and does not require treatment. Several studies have been conducted to evaluate the role of FDG-PET scans in focal and systemic amyloidosis and found that the majority of focal cases demonstrate positive findings while systemic amyloidosis does not. This is thought to be due to the number of giant cells present in focal lesions which participate in the metabolism of soluble full-length light chains into insoluble fibrils. In addition, the finding of pulmonary amyloidosis has also been associated with underlying adenocarcinoma. However, this relationship is unclear and further study is needed.

CONCLUSION: In conclusion, the finding of metabolically active pulmonary nodules by FDG-PET imaging is associated with a broad differential diagnosis. Astute clinicians would do well to maintain benign diseases on their differential diagnosis.

LOW-DOSE NALTREXONE AS A NOVEL TREATMENT OPTION FOR FIBROMYALGIA

Sara Li

General Internal Medicine, The Ohio State University, Columbus, OH. (Control ID #3875061)

CASE: A 57-year-old female with a past medical history of irritable bowel syndrome, chronic back pain, migraine headache, occipital neuralgia, and anxiety disorder, presented to primary care clinic with debilitating whole-body arthralgia, myalgia, and paresthesia for many years. Significant laboratory workup included a negative complete blood count, complete metabolic panel, thyroid function test, inflammatory markers (ESR and CRP), Lyme antibody, antinuclear antibody, double-stranded DNA antibody, and rheumatoid factor. Evaluation for small fiber neuropathy was negative, and minor salivary gland biopsy was negative for Sjogren’s disease. She had previously been evaluated by multiple specialists, including a rheumatologist, endocrinologist, and neurologist, and was diagnosed with fibromyalgia. Following diagnosis, all attempted treatments including Tylenol, NSAIDs, neuropathic pain medications (gabapentin, pregabalin), muscle relaxants, SSRI (fluoxetine), SNRI (duloxetine), TCA (amitriptyline), trigger point injections, occipital nerve blocks, cognitive behavioral therapy, physical therapy, and escalating doses of narcotics and benzodiazepines were unsuccessful in relieving her symptoms and resulted in excessive daytime somnolence. At our initial clinic visit, all pain medications and benzodiazepines were discontinued, and she was started on low-dose naltrexone at 5 mg once daily. At one month follow-up, she reported improvement in whole-body myalgia and paresthesia. At six month follow-up, she reported complete resolution of all previously reported symptoms. She did not report any side effects.

IMPACT/DISCUSSION: Naltrexone is an FDA-approved treatment for opioid and alcohol use disorder, but its role in chronic pain and fibromyalgia is underreported and underutilized. Low-dose naltrexone (LDN) is an off-label treatment option for chronic pain disorder and has been studied in the context of patients with fibromyalgia. At dose of 1-5 mg daily, LDN has been shown to significantly improve baseline pain scores compared to placebo without the sedating side effects associated with other pain medications[1]. At doses between 1-5 mg daily, naltrexone does not reach the affinity threshold for opioid receptor antagonism and has been hypothesized to have an anti-inflammatory effect on the central nervous system[2]. For our patient, LDN markedly improved her daily pain, functionality, and quality of life without significant side effects. Primary care physicians should consider LDN in fibromyalgia patients who have continued systemic symptoms despite maximal supportive and traditional pain management.

CONCLUSION: 1. Low-dose naltrexone uses naltrexone at a dose of 1-5 mg daily and is hypothesized to have alternative properties compared to full-dose naltrexone that may be beneficial for chronic pain treatment.

2. Low-dose naltrexone is underutilized and should be considered for patients with fibromyalgia and chronic pain refractory to other treatments

LOW DOSE ORAL MINOXIDIL CAUSING PERIPHERAL EDEMA AND RAPID WEIGHT GAIN

Kunj Patel, Jasmine Omar

Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #3866407)

CASE: 54 year old female with history of hepatic hemangioma, migraines and recently diagnosed alopecia presented to clinic with bilateral upper and lower extremity swelling. She was seen by Dermatology one month prior to presentation and was started on oral Minoxidil 1.25 mg daily for her alopecia. Since then, she has noticed rapid weight gain of 20 pounds over one month, increased peripheral swelling bilaterally with associated leg pain. She has also had intermittent headaches that are different than her usual migraines. She denied chest pain, shortness of breath, palpitations. BNP was mildly elevated. Other lab work including TSH, urinalysis and liver profile was unremarkable. Imaging including CT head, CT PE, lower extremity dopplers, and echocardiogram were also unremarkable. She was trialed with a loop diuretic without improvement in symptoms despite sufficient urine output. Minoxidil was held and her symptoms improved significantly.

IMPACT/DISCUSSION: Lower extremity edema is a common complaint that can have profound clinical impact on a patient. A chronic presentation is typically more common in the outpatient setting and is often the result of venous insufficiency. Less common is an acute to subacute presentation of which the most common etiologies typically include acute heart failure exacerbation, acute nephrotic syndrome, and bilateral deep vein thrombosis. Newly initiated medications should always be considered as a cause with dihydropyridine calcium channel blockers being the most commonly seen culprit. Side effects are often seen with a dose dependent relationship. Minoxidil produces vasodilation mediated by cyclic AMP, primarily effecting arteriolar smooth muscle. Although Minoxidil is indicated for use in hypertension, it is more commonly used for dermatological conditions such as androgenetic alopecia. Topical minoxidil is the most frequent formulation but oral minoxidil can also be used. Side effects are minimal but the most common include hypotension, headaches, and hypertrichosis. Peripheral edema is rare, particularly with low doses but is reversible with discontinuation and can be further aided by concurrent diuretic use.

CONCLUSION: Rapid onset peripheral edema is often related to acute heart failure, nephrotic syndrome or DVT. Although life-threatening causes should be quickly ruled out, a clinician should also consider medication side effects that could be contributing.

Oral minoxidil is less frequently used than topical but significant side effects such as headaches, hypertrichosis, hypotension, and more rarely peripheral edema can occur.

Discontinuation reverses the peripheral edema and a low dose loop diuretic can provide additional benefit.

LUNG CANCER WITH OLIGOMETESTATIC DISEASE TO THE PROSTATE

Josette M. Kamel¹; Simran Arjani²; Kateryna Fedorov^2,3; Ioannis Mantzaris^1,3

¹Internal Medicine, Montefiore Medical Center, Bronx, NY; ²Montefiore Medical Center, Bronx, NY; ³Oncology, Albert Einstein College of Medicine, Bronx, NY. (Control ID #3875004)

CASE: A 72-year-old man with a 20-pack-year smoking history presented with a painless right neck mass and axillary lymphadenopathy. Computed tomography (CT) of the neck showed multiple right cervical nodes, right axillary lymphadenopathy, and a 1.4 cm right middle lobe (RML) spiculated nodule. Excisional biopsy of the neck lymph node revealed mature CD4+, CD8-, CD30+, CD7-, CD25+ T cell lymphoma. He tested HTLV+ and was diagnosed with Adult T Cell Leukemia/Lymphoma (ATLL). Staging PET/CT and bone marrow biopsy did not show additional sites of disease. He underwent endobronchial ultrasound-guided biopsy of the right middle lobe (RML) pulmonary nodule, which revealed lung adenocarcinoma without nodal involvement. Lung adenocarcinoma was regarded as Stage IA2 (cT1bN0M0) and was treated with 54

Gy of stereotactic body radiation therapy (SBRT). ATLL was treated with Interferon and Zidovudine. Repeat PET/CT showed interval decrease of RML nodule but progression of ATLL prompting change of treatment to brentuximab vedotin (BV). Repeat PET/CT 6 months later showed resolution of lymphadenopathy and previously seen RML nodule but identified an ill-defined right lower lobe (RLL) opacity attributed to post- radiation changes. Subsequent PET/CT showed increase of RLL opacity and a new hypermetabolic focus in the left prostate concerning for malignant process at both locations. Prostate Specific Antigen testing was negative. A prostate biopsy identified metastatic lung adenocarcinoma in 6/6 core samples. Given oligometastatic low burden disease he was treated with SBRT at both sites, 45 Gy and 24 Gy to RLL and prostate, respectively. He completed 16 months of BV with continuous complete metabolic response on post- treatment PET/CT. Previously seen hypermetabolic pulmonary and prostate foci have improved but most recent surveillance PET/CT identified a new presacral left mesenteric density, concerning for malignancy. The new lesion is small and not amenable to biopsy and is managed with serial imaging.

IMPACT/DISCUSSION: Over half of lung adenocarcinoma cases are metastatic at diagnosis, commonly involving liver, adrenal glands, bone, and brain. Lung cancer metastasis to prostate is uncommon, with most cases found incidentally during autopsy. A study reporting 1,474 autopsy cases of prostate malignancy identified only 18 cases with metastatic prostatic lesions, only 5 (0.34%) of which were from primary lung malignancy. No details are available on extent of metastatic disease in these patients or histologic type of lung malignancy. Two other case reports describe lung neuroendocrine tumors metastatic to prostate in patients albeit with known metastatic disease at that time.

CONCLUSION: The prostate is a rare but possible site of metastasis of primary lung adenocarcinoma. This is the first described case of biopsy confirmed lung adenocarcinoma with oligometastatic disease. Prompt work-up of unusual locations in patients with lung adenocarcinoma allows for appropriately tailored therapeutic intervention.

MANAGEMENT OF LABILE BLOOD PRESSURE DUE TO COVID-19 INFECTION AND RADIATION INDUCED BARORECEPTOR DYSFUNCTION

Timothy Nguyen¹; Stephen Wanjala¹; Mona Brake²

¹Internal Medicine, University of Kansas School of Medicine Wichita, Wichita, KS; ²Nephrology, Robert J. Dole VA Medical Center, Wichita, KS. (Control ID #3874632)

CASE: A 76-year-old male with a history of hypertension, tonsillar cancer with radiation therapy, orthostatic hypotension (OH), and recent COVID-19 infection presented for severe chest pain. He was found to have a blood pressure (BP) 226/109, but his other vital signs, physical exam, blood work (besides elevate troponins) and EKG were unremarkable. Patient stated that his BP was manageable between 100-130 systolic prior to his COVID-19 infection. Since then, his BP significantly fluctuates between 80-210 causing him to have symptomatic OH. He was admitted for hypertensive emergency given his chest pain and elevated troponins. We increased home lisinopril and started Clonidine. This patient’s peaks BP became controlled, but had episodes of OH with BP in the 80’s. His workup for secondary hypertension were unremarkable: cardiac dysfunction, adrenal insufficiency, Cushing syndrome, pheochromocytoma, and renal artery stenosis were negative. Nephrology recommended to stop clonidine, start Amlodipine, elevate head of his bed to 30 degrees, and start physical therapy. With these changes, the patient’s systolic BP remained in the range of 100-160.

IMPACT/DISCUSSION: Management of labile BP due to baroreceptor failure is difficult as baroreflex lesions can cause drastic changes in bp. Our patient demonstrated his dangerous volatility as his BP would range between 90-230’s within 20 minutes. For this patient, we determined a regimen of pharmacologic and nonpharmacologic treatments that allowed better control of his BP. For pharmacological management, we stopped clonidine, started amlodipine and increased lisinopril. Clonidine was effective in controlling his BP peaks, but exacerbated his OH. Amlodipine was able to control his BP and has been shown to have protective affects against OH. Lisinopril was increased it is not highly associated with OH and has protective affects attributed by improving baroreceptor sensitivity and vascular compliance. For nonpharmacological management, we recommended elevation of the head of his bed by 30 degrees and to begin physical therapy. Bed elevation has been shown to decrease nocturnal hypertension and physical therapy prevents deconditioning which decreases OH. Comparing this patient’s BP ranges during prior admissions to after contracting COVID-19 revealed worsened lability of his BP after infection. His baseline autonomic dysfunction began 5 years ago due to neck radiation for his tonsillar cancer. We postulate that COVID-19 worsened his baroreceptor dysfunction based on temporal associations. We recommended regular follow-ups with his primary and nephrologist for monitoring and adjustment of medications as his baroreceptor reflex may improve overtime.

CONCLUSION: The goal for this patient is to maintain his BP in a range that would avoid OH and hypertensive crises with an understanding that we do not expect his BP to be in a normal range. This pharmacologic and nonpharmacologic regimen allowed us to control his BP within an acceptable range.

MERKEL CELL CARCINOMA IN A LIVER TRANSPLANT PATIENT

Rabab S. Isa¹; Emily Clarke¹; Hanna Fanous¹; Anokhi Jambusaria-Pahlajani²

¹Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; ²Internal Medicine, Division of Dermatology, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #3852230)

CASE: A 47-year-old woman with diabetes and remote liver transplant for hepatitis C presented for recurrent, rapidly advancing Merkel Cell Carcinoma (MCC) of the left forearm, diagnosed 7 months prior. She previously underwent radical primary tumor resection and axillary lymph node dissection, revealing 5 nodes with MCC. She was switched from tacrolimus to sirolimus to decrease recurrence risk, but ultimately required radiation and a second tumor resection. She presented to the hospital for a third recurrence.

On exam, there was a 2.5cm ulcerated, firm, pink nodule on the extensor surface of her left forearm and a large, ulcerated plaque with yellow sclerotic margins on the flexor surface. Labs demonstrated mild leukopenia and transaminitis. Contrast-enhanced CT of the chest, abdomen, and pelvis was negative for metastasis. Hematology-oncology recommended etoposide and cisplatin every 3 weeks, which the patient tolerated well.

Due to multiple gaps that delayed presentation, a multidisciplinary care plan was created with hematology- oncology and transplant gastroenterology prior to discharge, including decreasing her sirolimus dose to minimize recurrence risk.

IMPACT/DISCUSSION: MCC presents as a rapidly progressive, painless pink to violaceous indurated nodule. Risk factors include older age, male sex, Fitzpatrick skin type, sun exposure, active malignancy, and immunosuppression. MCC’s presentation can be varied, making diagnosis difficult.

Lesions are commonly found in the head and neck (43%) and upper extremities (24%). Most patients (65%) have local MCC, but 26% have nodal involvement and 8% have metastases. MCC has a high 5-year mortality rate (30%), twice that of malignant melanoma. The National Comprehensive Cancer Network (NCCN) has published clinical practice guidelines for MCC management.

NCCN recommends a complete skin and lymph node examination, labwork, biopsy, and imaging for suspected metastatic or unresectable MCC. Sentinel lymph node biopsy (SLNB) is recommended for MCC and ≥1 risk factors (primary tumor >1cm, chronic T-cell immunosuppression, HIV, malignancy, transplant, head/neck primary site, or lymphovascular invasion). If SLNB is positive, imaging, lymph node dissection, and radiotherapy can be considered. NCCN recommends screening exams every 3-6 months for 3 years and every 6-12 months thereafter.

Skin cancer risk is greatest for lung (3.52%) and heart (1.63%) transplants. Calcineurin inhibitors like tacrolimus cause a 200-fold increase in skin cancer risk; thus, studies advocate for use of mTOR inhibitors like sirolimus. Dose reduction strategies can be utilized to decrease risk of skin cancer and recurrence. Further, the Skin and Ultraviolet Neoplasia Transplant Risk Assessment Calculator (SUNTRAC) provides a risk-stratified approach for skin cancer in transplant patients.

CONCLUSION: Within 10 years of transplant, 14% of patients will develop a form of skin cancer, underscoring the importance of monitoring for skin cancers by a dermatologist in this population.

NECROBIOSIS LIPOIDICA: A CASE REPORT ON VASCULAR INSUFFICIENCY AS A PRIMARY PATHOGENIC FACTOR

Avisha D. Amarnani, Radhika Sood, Ereny Demian

College of Medicine, Penn State College of Medicine, Hershey, PA. (Control ID #3871925)

CASE: A 54-year-old male presented to a VA Medical Center in the Mid-Atlantic region for management of a chronic, recurring, and non-healing left lower extremity wound with onset one year ago. The patient had no history of diabetes, hypertension, or other immunodeficiencies. He reported this began as a superficial laceration that became infected, which significantly worsened until he required hospitalization in March and received a cadaver skin graft. Follow-up with wound care was difficult due to health system limitations and the skin graft failed, promoting readmission. At this time, his wound was a sizable ulcerated lesion on the tibia with serous drainage and a visibly exposed tendon. An MRI of the site showed early osteomyelitis, and the patient was started on broad spectrum antibiotics. Vascular surgery was consulted and CT angiography showed multiple significant occlusions of the left femoral, popliteal, and peroneal arteries suggestive of peripheral artery disease. Skin biopsy was obtained and ruled out vasculitides and malignancies; however, the pathology report suggested the presence of necrobiosis lipoidica.

IMPACT/DISCUSSION: Necrobiosis lipoidica (NL) is a chronic idiopathic granulomatous disease associated with collagen degeneration. NL typically presents as lower extremity well-demarcated yellow- brown plaques with erythematous borders that may also have ulcerations. Histology helps rule out other diagnoses such as pyoderma gangrenosum, erythema nodosum, and necrobiotic xanthogranuloma. While the exact pathogenesis has yet to be determined, previous research has identified vascular insufficiency, immunodeficiency, and microvascular dysfunction as pathogenic factors leading to NL. Thus, NL has been associated with a combination of diabetes mellitus, venous insufficiency, inflammatory diseases such as sarcoidosis or Crohn’s, thyroid disorders, and hyperlipidemia. This case is particularly interesting since the patient only presented with vascular deficiencies, and not with a concurrent immunodeficiency as is typically seen.

Further research should be conducted on how vascular deficiencies alone can serve as the pathogenic factor for NL. The venous stasis that results from venous insufficiency can lead to hypoxia. One theory is hypoxia damages blood vessels, leading to the evolution of NL. However, this remains debatable as prior studies have both supported and refuted this claim. While the true pathogenesis of NL continues to be investigated, this case report serves as a unique instance of a NL patient solely with vascular deficiencies with no other pertinent medical history.

CONCLUSION: - NL is a chronic granulomatous disease whose pathogenesis is largely unknown, but commonly presents in patients who have several vascular and immunodeficient-related comorbidities.

- This case represents an instance of NL where only vascular factors were present in a patient’s history, prompting the need for further research into the pathophysiology of this disease process.

PLENTY TO CRYO AND PUTREFY ABOUT: DELAYED DIAGNOSIS OF CRYOGLOBULINEMIC VASCULITIS

Rudiona Hoxhaj¹; Diana Toro²; David R. Haburchak¹

¹Internal Medicine , WellStar Health System, Marietta, GA; ²Augusta University, Augusta, GA. (Control ID #3869138)

CASE: A 57-year-old female with hypothyroidism and newly diagnosed peripheral arterial disease presented as a new patient to clinic after suffering agonizing bilateral lower extremity ulcerations of 5 months duration.

Previous management included a biopsy demonstrating gangrenous necrosis with mixed inflammation, a stent to her left femoral artery, as well as escalating numbers of cadaveric and autologous skin grafts. These interventions proved frustratingly futile, with new ulcers protruding through the skin grafts, leading to opioid dependence. Further inquiry led to a history of concealed intravenous drug use with an ensuing lacy netlike pattern of skin discoloration five years prior to the ulcerations. Physical exam disclosed a dispirited, chronically ill-appearing female displaying conspicuous livedo reticularis interspersed with large, deep and raw, yellow and bleeding necrotic ulcers within bilateral lower extremities. Ulcers were non-confluent and had no purple undermined edges. HEENT, musculoskeletal and lymph node exams were negative. Workup was negative for HIV, Sjogren’s, and SLE. ANCA screen was normal. Her rheumatoid factor was elevated (37 IU/mL). Her renal function and urinalysis were normal. She had transiently elevated AST (94 U/L) and ALT (58 U/L), decreased IgG (284 mg/dL), diminished C4 (2 mg/dL), reactive Hepatitis C Ab with viral load (432,000 IU/mL) with Genotype 2 and positive cryoglobulin. Repeat punch biopsy depicted superficial and deep perivascular and interstitial dermatitis with purpura and focal intravascular fibrin denoting small vessel vasculitis. There was no evidence of pyoderma gangrenosum. She was swiftly started on prednisone 60 mg daily to address the underlying vasculitis while awaiting approval for sofosbuvir/velpatasvir (Epclusa) to treat the principal chronic Hepatitis C.

IMPACT/DISCUSSION: Our case exposes unrecognized and untreated Hepatitis C as a significant cause of CryoVas, here manifesting as severe and debilitating painful necrotic skin ulcerations. While typically presenting with palpable purpura, livedo reticularis should alert physicians to the possibility of vasculitis, prompting appropriate evaluation for chronic antigenemia.

CONCLUSION: Widespread screening for history of drug use and Hepatitis C is likely to unveil further subclinical and mild cases of CryoVas. The importance of a thorough skin examination and laboratory testing for cryoglobulins will aid in appropriate treatment as the prognosis is related to supervening infection and liver failure.

PLOP GOES MY HEART: A CASE OF RECURRENT ATRIAL MYXOMA

Omair A. Syed, Scott Lynch

Internal Medicine, Alameda Health System, Oakland, CA. (Control ID #3875573)

CASE: A 69-year-old female with a complex history including prior left atrial myxoma status post resection in 2019, heart failure with reduced ejection fraction (20-25%), mitral valve repair, patent foramen ovale closure, heparin-induced thrombocytopenia (HIT), and atrial fibrillation presented to the hospital with congestive heart failure exacerbation. She was found to have a large echogenic mobile mass in the left atrium on transthoracic echocardiogram, which was initially treated as a thrombus with argatroban in lieu of heparin due to history of HIT. Later, transesophageal echocardiogram showed a 3x3cm mass attached to the posterior high wall of the atrium, consistent with recurrence of the atrial myxoma. Dense smoke was also noted indicating a high risk for thrombosis and argatroban was continued. Oncology and cardiology recommended surgical resection and was transferred for evaluation by cardiothoracic surgery. The patient was deemed high risk for surgical resection due to multiple prior cardiothoracic surgeries involving sternotomies and other co- morbidities. Ultimately she was accepted for transfer to a facility capable of performing salvage AngioVac, a minimally invasive means of removing the mass

IMPACT/DISCUSSION: Atrial myxomas are the most common primary cardiac tumor accounting for 50% of all cardiac neoplasms. They are benign tumors that arise from multipotent mesenchymal cells, and only 10% are considered genetic. Despite effective treatment with surgical resection, there is a 3-13% recurrence rate in nonfamilial cases. A retrospective study of primary cardiac tumors over 40+ years has shown the highest rates of recurrence in the 4 years following resection of the initial tumor. The authors of this study recommended serial screening for recurrence every 6 months with echocardiogram. Given the plethora of complications that may result, such as arrhythmias, valvular defects, heart failure, and thromboembolic events, it is important to recognize atrial myxomas and screen for recurrence.

CONCLUSION: This case of recurrent atrial myxoma demonstrates the importance of noting a history of atrial myxoma resection and understanding the risk of recurrence to prevent the many possible complications mentioned above. This patient’s medical history demonstrates many of these complications, particularly decompensated cardiomyopathy and the potential for thromboembolic events. Literature has shown varying reported recurrence rates from 3% to 13% for non-familial and 22% for familial cases. Though there are no formal guidelines on recurrence surveillance, one study has suggested that with an increased risk of recurrence in the first 4 years after successful removal, semiannual screening echocardiograms should be performed. This patient was within the window of 4 years but did not have routine screenings. It can be inferred that if her atrial mass was detected on echocardiogram at an earlier stage, it may have been more amenable to earlier and less invasive resection.

POSACONAZOLE INDUCED TORSADES DE POINTES LEADING TO VT ARREST

Samir Mehta, Beenish Ahmed

Internal Medicine, Christiana Care Health Services Inc, Wilmington, DE. (Control ID #3874805)

CASE: 65-year-old female with a history of T-cell immunodeficiency on chronic suppressive azole therapy for recurrent mucocutaneous candidiasis and Wolff-Parkinson White (WPW) syndrome presented to the emergency department for fatigue and syncope. In the waiting room, the patient developed Torsades de Pointes, which evolved into ventricular tachycardia (VT) arrest. She required multiple rounds of CPR and amiodarone due to persistent VT. On presentation her potassium was 2.9 and magnesium was 1.1.

Her multifactorial arrest was driven by these severe electrolyte disturbances likely driven by chronic posaconazole use as well as underlying congenital channelopathies. She was aggressively repleted by intravenous potassium and intravenous magnesium.

In the ICU she was initiated on a beta blocker and amiodarone for suppression of her ventricular arrythmia. Due to her history with recurrent and complicated infections we had to continue her posaconazole with close laboratory monitoring of her electrolytes. Coronary angiogram revealed multivessel disease not amenable to percutaneous intervention. The patient was not a candidate for coronary artery bypass grafting given her multiple risk factors. The decision was made to medically manage her coronary artery disease. Due to her risk for recurrent cardiac arrest, she underwent placement of a dual-chamber implantable cardiac defibrillator device (ICD). Following placement of the ICD, the patient was discharged and maintained on posaconazole.

IMPACT/DISCUSSION: Our patient had multiple unique predisposing factors which cumulatively resulted in VT arrest. She had inherited channelopathy and significant coronary artery disease, both of which increased her risk for cardiac arrest. However, in addition, she was on chronic suppressive antifungal therapy with posaconazole, which has been shown to cause significant electrolyte abnormalities like hypomagnesemia and hypokalemia, further predisposing her to Torsades and VT arrest.

Posaconazole has been reported to cause hypomagnesemia with studies indicating 18% incidence. The cause is due to complex interplay of cation channel receptors which mediate intestinal absorption and facilitate urinary excretion.

In patients who have inherited channelopathies it would be beneficial to closely monitor serial EKGs when prescribing medications which can further prolong QT segments. In addition, there should be ongoing discussion and reevaluation of the need to continue these high-risk medications.

CONCLUSION: VT arrest is a byproduct of multiple risk factors including ischemia, medications, electrolyte disturbances, and channelopathies

Posaconazole induces hypokalemia and hypomagnesemia. This risk can be reduced by routine monitoring of electrolytes, in addition to EKGs, for high-risk individuals

RECURRENT ACUTE INTERMITTENT PORPHYRIA (AIP) ATTACKS IN A MALE - UNLUCKY ODDS

Taylor Crist¹; Rehan Choudhury¹; Maggie Kuusinen⁴; Irmina J. Swiostek³; Maria G. Frank²; Emily Lowe³

¹School of Medicine, University of Colorado, Denver, CO; ²Hospital Medicine, Denver Health Hospital Authority, Denver, CO; ³Internal Medicine, University of Colorado, Denver, CO; ⁴Internal Medicine - Pediatrics, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #3870910)

CASE: A 26-year-old male, recently diagnosed with Acute Intermittent Porphyria (AIP), presented with 3 days of sudden onset severe periumbilical pain exacerbated by eating. He reported 20 episodes of non-bloody emesis accompanied by bilateral facial numbness and right-sided chest pain in the 3 days prior to admission, as well as subjective fever, chills, and diarrhea. Patient sustained 8 similar episodes in the prior 18 months with associated weight loss. Patient reported facial paresthesia with an otherwise unremarkable neurological exam. Laboratories at admission showed hypokalemia and elevated creatinine. Total bilirubin was 2.6 with a normal liver echotexture in ultrasound. Urine porphobilinogen and aminolevulinic acid labs were elevated (206 and 192 respectively) and consistent with an AIP attack. Patient received an extended course of 6 doses of hemin due to persistent symptoms and was discharged with an off-label prescription of givosiran to help prevent future attacks.

IMPACT/DISCUSSION: Acute Intermittent Porphyria (AIP) is a rare autosomal dominant disorder characterized by a deficiency of porphobilinogen-deaminase, an enzyme in heme synthesis. Attacks occur due to upregulation of the enzyme ALA synthase, and are characterized by episodes of abdominal pain, peripheral neuropathies, and constipation. During attacks, hepatic heme is depleted, resulting in induction of delta-aminolevulinic acid synthase (ALAS1). This leads to an accumulation of delta-aminolevulinic acid (ALA) and porphobilinogen (PBG); an elevation of both in urine is the only diagnostic test for API. Hence, AIP can only be diagnosed during an attack. Furthermore, this disease is more common in people of Swedish descent and biologic females, with only 3-8% of AIP patients experiencing recurrent attacks (>3 attacks/year). Our patient is a male of Italian and French descent who experienced an average of 8 attacks a year before diagnosis. The recommended treatment is 4 doses of IV hemin, which downregulates ALAS1 transcription and decreases levels of ALA/PBG. While awaiting hemin infusion, carbohydrate loading via dextrose should be started to assist with downregulation of ALAS1 transcription. More recently, givosiran, an RNA interference therapy that inhibits ALAS1 expression and is FDA approved for Acute Hepatic Porphyria, has been successfully used in the treatment of AIP.

CONCLUSION: Due to its vague presentation and diagnostic logistical challenges, a diagnosis of AIP is commonly elusive, and many patients are frequently misdiagnosed in emergency departments. A careful neurological exam revealing peripheral neuropathy can lead a clinician to consider AIP. This case reinforces the significance of conducting a thorough history and examination, as well as considering a broad differential diagnosis, particularly in young patients presenting with severe abdominal pain and unremarkable complementary testing. A high index of suspicion is key to diagnosing AIP as testing will only be diagnostic during an attack.

RENAL SARCOIDOSIS CAUSING ACUTE RENAL FAILURE– UNUSUAL FORM OF PRESENTATION OF SARCOIDOSIS IN A YOUNG ADULT.

Roman Karkee¹; Roman Karkee¹; Barath Rangaswamy⁴; Namratha Pallipamu⁵; Syed Hasan Raza Abidi²; Pranav S. Ganta³

¹Internal Medicine, Texas Tech University Health Sciences Center, Permian Basin, Odessa, TX; ²The Aga Khan University Medical College Pakistan, Karachi, Sindh, Pakistan; ³Permian Basin Kidney Center, Odessa, TX; ⁴Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ⁵Siddhartha Medical College, Vijayawada, Andhra Pradesh, India. (Control ID #3875555)

CASE: A previously healthy 36 years female presented with 6 weeks history of fatigue, generalized body aches, nonproductive cough, loss of appetite and weight loss (7lbs). No significant family history noted. Vitals signs and physical exam were unremarkable. Labs showed normocytic anemia ,Hb 9.5 gm/dl, elevated creatinine 7.8 mg/dl. Low levels of 25-OH vitamin D, normal 1,25 -dihydroxy vitamin D and elevated serum PTH were noted. Calcium and phosphate were normal. Urinalysis revealed mild leukocytes, elevated leukocyte esterase along with mild glucosuria, hematuria and proteinuria. Infection workup was negative. Iron panel showed anemia of chronic disease. Total 24-hour urine protein was elevated 486.5 mg, protein creatinine ratio was 532. Urine light chains were mildly elevated. Serum electrophoresis showed no M spike. Autoimmune panel was normal. Imaging studies including chest X-ray, renal ultrasound, CT abdomen and pelvis were normal. Due to unexplained renal failure, renal biopsy was performed revealing severe acute interstitial nephritis with acute tubular injury and necrosis, noncaseating granulomas with multinucleated giant cells. Diagnosis of sarcoidosis was established. IV Steroid therapy was initiated and subsequently switched to oral prednisone on discharge. On follow up, she underwent a bronchoscopy guided lung biopsy

which showed non-necrotizing granuloma and scattered lymphocytes confirming the diagnosis of sarcoidosis.

IMPACT/DISCUSSION: Sarcoidosis is a multisystem granulomatous disease usually affecting young adults and is characterized by the formation of non caseating granulomas. Intrathoracic involvement is the most common type [>90%]. Other systemic involvement may include the skin, reticuloendothelial system, eyes, central nervous system, kidneys, and heart. Renal involvement of sarcoidosis is extremely rare ( around 0.7%). Renal injury can occur in various forms which may include hypercalcemia, hypercalciuria, nephrolithiasis, nephrocalcinosis, interstitial nephritis ( most common ) with or without granuloma, glomerular or tubular dysfunction. Renal Biopsy is essential for diagnosis, non-granulomatous tubulointerstitial nephritis is the most common histological presentation. Steroid therapy remains the mainstay of treatment with good success rates. Alternative therapies include methotrexate, azathioprine, or tumor necrosis factor antagonists.

CONCLUSION: Renal involvement of Sarcoidosis is extremely rare thus making it an underestimated cause of AKI leading to diagnostic delays. Clinicians should have a high index of suspicion especially for young patients presenting with unexplained AKI, mild to moderate proteinuria with or without systemic involvement. Early renal biopsy and and timely administration of steroids can prevent irreversible renal damage.

ROLE OF UREA IN THE TREATMENT OF CHRONIC HYPONATREMIA SECONDARY TO SIADH: A CASE REPORT

Melvin Joy¹; Atul Sinha¹; Tulika Saggar¹; Bair Cadet²; Prachi Anand¹

¹Internal Medicine, Nassau University Medical Center, East Meadow, NY; ²Nephrology, Nassau University Medical Center, East Meadow, NY. (Control ID #3876942)

CASE: A 91-year-old male with past medical history of chronic hyponatremia secondary to SIADH, dementia, hypertension and benign prostatic hypertrophy presented to the emergency department after an unwitnessed fall. CT was negative for intracranial bleed and the patient was at his baseline with no focal neurologic deficits. His sodium level on admission was 141 mmol/L. On Day 2 of hospitalization, his sodium dropped to 131 mmol/L despite starting his oral medication oral NaCl tablets 3gm TID. Hyponatremia work up showed Urine osmolality 899 mOsm/kg, Urine sodium 199 mmol/L; Serum osmolality 274 mOsm/kg, Serum cortisol 2.76 ug/dl, TSH 23.06 IU/mL. The rest of the biochemical analysis were within normal range. Serum sodium was trended twice daily. His sodium level did not improve and ranged between 130-134mmol/L; Nephrology was consulted on Day 5 of hospitalization and recommended continuing the oral sodium chloride tablets with free water restriction. On Day 6, we contacted his daughter who informed us that the patient has been on urea 15 mg/d since the diagnosis of hyponatremia secondary to SIADH. On Day 7, urea was restarted. His sodium levels improved to 138 mmol/L on day 8 and were stable between 137-142 mmol/L till the time of discharge.

IMPACT/DISCUSSION: Hyponatremia is the most common water and electrolyte balance disorder encountered in clinical practice and is especially prevalent in the elderly. Conditions associated with hyponatremia require hospitalization in 15–20% of cases. Common causes of hyponatremia are dehydration, SIADH, hypothyroidism, and volume-overloaded states. SIADH accounts for one third of all hyponatremia cases. SIADH is an example of a euvolemic hyponatremia state in which ADH secretion is not dependent on volume loss or a hyperosmolar state. Laboratory criteria for diagnosis include Urine osmolality >150 mOsm/kg, Urine sodium >20-30 mmol/L. Urea works as an effective osmole in nephron segments with high water permeability and low urea permeability in the connecting tubule, cortical collecting duct, and outer medullary collecting duct. This property of urea favors free water excretion. Urea in SIADH has been shown to decrease natriuresis and creates a state of positive sodium balance which also contributes to the improvement of plasma sodium level. Urea 0.5 to 1.0 g/ kg/day or higher may be used as an osmotic diuretic agent in patients with chronic hyponatremia due to SIADH.

CONCLUSION: Urea salt tablets is an over-the-counter medication that some practitioners have used to treat hyponatremia. This unique case report shows the effectiveness of urea for the treatment of chronic hyponatremia secondary to SIADH and that is safe and well tolerated.However, randomized trials that assess the efficacy in larger numbers of patients are needed to establish the precise therapeutic role of this agent for the management of hyponatremia.

SECONDARY ADRENAL INSUFFICIENCY DUE TO PEMBROLIZUMAB THERAPY PRESENTING WITH FOCAL WEAKNESS

Brigid Jacob, Mallory Brosious, Elizabeth Lewis, Megan Dekker

Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #3874074)

CASE: Middle age female with a history of cerebral palsy and triple negative non-metastatic breast cancer of the left breast on three months of pembrolizumab therapy and status post localized lumpectomy and partial mastectomy presented with subacute lower back pain, decreased appetite, and bilateral lower extremity weakness. Patient previously ambulated with a walker but now was unable to ambulate.

Physical exam was significant for intact sensation in all four extremities, intact cranial nerves, 3/5 strength on all lower extremity maneuvers bilaterally and 5/5 strength on all upper extremity maneuvers bilaterally. Venous dopplers, computed tomography (CT) of chest, CT of head, CT of cervical spine, and X-rays of lower extremities did not reveal any significant findings. Magnetic resonance imaging (MRI) of brain and whole spine showed degenerative changes in the spine with disc protrusion at C3-C4 and T8-T9. Spinal cord, conus medullaris, and cauda equina roots were otherwise normal. Random serum cortisol on admission was low with an otherwise unremarkable initial laboratory work up. Patient had positive cosyntropin stimulation test, consistent with adrenal insufficiency. Adrenocorticotropic hormone and dehydroepiandrosterone sulfate were also low. Findings suggested she had developed secondary adrenal insufficiency.

Patient was started on a short-acting glucocorticoid, hydrocortisone, with two-thirds of the total dose in the morning and one-third in the afternoon to stimulate normal cortisol circardian rhythm per endocrinology recommendations and returned to baseline within days. Neurology workup including MRI was negative for neurologic cause for her symptoms. Oncology held pembrolizumab therapy and treated with radiation therapy. Although endocrinology eventually cleared resumption of pembrolizumab if necessary for breast cancer treatment, an alternative chemotherapy regimen was elected per patient and caregiver preference.

IMPACT/DISCUSSION: Adrenal insufficiency can have a variety of etiologies. Pembrolizumab-induced adrenal insufficiency is a rare immune-related adverse event. With treatment, patients can achieve a complete response with reversal of symptoms. Early recognition is essential in improving a patient’s functional status and can be fatal if diagnosis is delayed given the possibility of adrenal crises. ¹

Sonehara K, Tateishi K, Araki T, et al. Pembrolizumab-Induced Adrenal Insufficiency in Patients with Untreated Advanced Non-Small Cell Lung Cancer: A Case Series. Case Rep Oncol. 2021;14(3):1561-1566. Published 2021 Nov 5. doi:10.1159/000519597

CONCLUSION: Pembrolizumab chemotherapy can cause secondary adrenal insufficiency during treatment or late onset. Adrenal insufficiency can present with focal neurologic symptoms. Early identification and initiation of treatment will contribute to positive patient outcomes.

SEVERE THROMBOCYTOPENIA IN A 30-YEAR-OLD AFRICAN AMERICAN MALE WITH NEWLY DIAGNOSED SARCOIDOSIS: A CASE REPORT

Melisa Pasli¹; Katie Lovell¹; Sai Vulasala²; Marsha Hairr¹; Revanth Reddy Bandaru²; Mohammad Khalilullah²; Leonard Johnson²

¹School of Medicine, East Carolina University Brody School of Medicine, Greenville, NC; ²Department of Internal Medicine, ECU Health, Greenville, NC. (Control ID #3867725)

CASE: A 30-year-old African American male presented with sudden onset of buccal, mucocutaneous bleeding and severe thrombocytopenia. ROS was significant for shortness of breath, nosebleeds, and skin rash. He received malaria prophylaxis prior to recent travel to Ghana and on return developed dyspnea and bilateral hilar adenopathy. After bronchoscopy, he was prescribed doxycycline and prednisone. Onset of bleeding and deteriorating condition prompted him to seek medical attention. Preliminary diagnosis of ITP was made with differentials including drug induced, autoimmune, malignancy, lymphoma, and sarcoidosis. Severe thrombocytopenia led patient to receive 2 units of platelets and be admitted. Platelet counts declined to 1000uL. Steroids were withheld due to suspicion of mediastinal lymphoma. Platelet count remained at

1000uL on days 2-3 despite 7 platelet transfusions. 1g/kg of IVIG and second line therapy with romiplostim were given. Platelet counts improved to 6000uL on day 4. Whole-body PET scan, CT chest abdomen pelvis, CT-guided bone marrow biopsy and bronchoscopy/lymph node biopsy were performed. Bone Marrow Aspirate showed megakaryocyte proliferation with no definitive evidence of marrow involvement by non- Hodgkin lymphoma or metastatic carcinoma, and results did not meet criteria for myelodysplastic syndrome. Lymph nodes revealed non-caseating granulomatous inflammation with no cells diagnostic of malignancy. Diagnosis of ITP was made, likely secondary to sarcoidosis, and therapy with prednisone improved platelet count.

IMPACT/DISCUSSION: Severe ITP secondary to sarcoidosis has not been reported in an African American male younger than age 32. One case report presents severe thrombocytopenia with similar values, but the patient was older with super-imposed focal segmental glomerulosclerosis, and a 5-year history of sarcoidosis. Our patient was younger with newly diagnosed sarcoidosis and no evidence of end-organ damage. Most patients with pulmonary sarcoidosis may not need intervention, or therapy may be withheld due to the nature of the pathology. Sarcoidosis may undergo spontaneous regression in up to 80% of patients with stage 1 disease. Conversely, systemic therapy is deemed necessary for those with progressive disease or in patients with symptoms or lung function deterioration. Significant improvements in both pulmonary function and symptoms are reported in patients who received glucocorticoids. Our patient was prescribed steroids following hospital discharge after his platelet levels had stabilized with second-line therapies

CONCLUSION: Confounding factors that caused diagnostic uncertainty in our patient were travel history with prophylactic anti-malarial medications, use of doxycycline, slightly elevated angiotension-converting enzyme (ACE) levels, and imaging features concerning metastatic disease vs. lymphoma. The clinical diversity of sarcoidosis often leads to diagnostic uncertainty and treatment delays due to its resemblance to other, more common disorders.

SGLT2 INHIBITOR ORTHOSTATIC EFFECTS ARE UNDERESTIMATED DURING ACUTE INFECTIOUS ILLNESSES.

Joseph Markey, Aakash Hans, Mitchell Keel, Gilbert-Roy Kamoga

Internal Medicine, White River Health System Inc, Batesville, AR. (Control ID #3873083)

CASE: 63M s/p 4 vessel CABG 10/1/22 presented with a history of well-controlled diabetes mellitus on pioglitazone and insulin glargine (basaglar) 20 units each morning. A1C was 7.4 as of 10/13/22; empagliflozin was added thereafter for cardiovascular protection. Several weeks later the patient noted fatigue, cough with clear sputum 2 days after influenza virus exposure, and he reported 2 syncopal events Friday evening 11/25/22. He presented to his primary care physician 11/28 for re-evaluation. The workup revealed orthostatic blood pressure measurements notable for 195/93 lying, 182/92 sitting, and 157/88 standing consistent with an orthostatic change, and detectable beta-hydroxybutyrate confirmed ketosis. The patient was instructed to hold the empagliflozin, which he complied with until his hyperglycemia worsened with point of care glucose in 210s at home, and again he took another dose of empagliflozin which preceded a recurrent syncopal episode 7 hours later. The following day he was seen at his cardiologist's office and his prescribed blood pressure medications carvedilol 12.5 mg twice daily and lisinopril 10 mg daily were discontinued after blood pressure was noted to be 108/56. He also returned to his primary care physician for repeat beta-hydroxybutyrate testing which was again detectable in the serum.

IMPACT/DISCUSSION: SGLT2 inhibitors have significantly changed the landscape for the management of diabetes, kidney disease, and heart failure since their advent, with the first FDA approval in this class being canagliflozin in 2013. Established adverse effects of members of the SGLT2 class include hyperglycemic and euglycemic ketoacidosis, hypovolemia, increased risk of fractures, increased risk of limb amputations, hyperlipidemia, complicated and uncomplicated urinary tract infections occasionally leading to acute renal failure requiring dialysis. This case helps to highlight the increased risk for ketoacidosis, hypovolemia, and orthostasis if a patient has viral syndrome and is on an SGTL2 inhibitor.

CONCLUSION: Clinicians should consider more liberal screening for beta-hydroxybutyrate levels in the serum and orthostatic vitals in patients on SGLT2 inhibitors who demonstrate signs and symptoms of an acute infectious illness. A low threshold for discontinuation of SGTL2 inhibitors in patients with clinical features suggestive of an infectious illness is prudent. This could prevent hypovolemia presenting as orthostatic syncope due to the diuretic effect of the SGLT2 inhibitor and euglycemic ketoacidosis. Antihypertensive and orthostatic effects of SGLT2 inhibitors are underestimated particularly in patients who present with an acute infectious illness.

STATIN-INDUCED NECROTIZING MYOPATHY

Besim Ademi¹; William B. Rothwell²

¹Internal Medicine, Tulane University School of Medicine, New Orleans, LA; ²Internal Medicine & Pediatrics, Tulane University School of Medicine, New Orleans, LA. (Control ID #3874863)

CASE: A 47-year-old man presented from an outside hospital for further evaluation and treatment of rhabdomyolysis and progressive weakness. The patient reported onset of lower extremity weakness months prior to evaluation, which slowly worsened and soon affected all his extremities. At the time of hospital evaluation, he was unable to walk and restricted to a bed with an associated thirty-pound weight loss. His outpatient medications included atorvastatin, started roughly two years ago. Vitals included blood pressure of 128/86, pulse of 90, respiration rate of 18, oxygen saturation of 97 on room air and temperature of 98.5 Fahrenheit. Physical exam demonstrated 2/5 strength in all four of his extremities with limited mobility while lying in bed. Lab work was notable for a creatine kinase (CK) elevation greater than 14,000 units/L. Creatine was at baseline of 0.7 mg/dL. Urinalysis was positive for 3+ red blood cells and a myoglobin of 5953 ng/mL. Subsequent ANA, anti-Jo, rheumatoid factor, hepatitis and HIV testing were all negative. However, HMG- CoA Reductase antibodies were present, and an associated muscle biopsy revealed chronic necrotizing myopathy. With direction from rheumatology, treatment consisted of prednisone at 1mg/kg/day and extensive physical therapy. Further treatment of methotrexate and either intravenous immunoglobulin or rituximab was recommended. At time of discharge to inpatient rehabilitation, the patient regained the ability to independently sit up in bed and walk with assistance.

IMPACT/DISCUSSION: Statin therapy is a mainstay option for treatment of primary and secondary prevention of cardiovascular adverse events. Patients with a known cardiac event are almost always reflexed to the drug, resulting in nearly 25% of the United States adult population receiving a form of statin. Although well-tolerated, general myalgias remain the most reported side effect. More concerning is drug related myonecrosis and rhabdomyolysis. Directly immune-related statin induced myopathies are exceedingly rare, evident in even hospitalization rates for rhabdomyolysis for patients treated with a statin (0.44 per 10,000 patients). The diagnosis can solely be made with HMG-CoA Reductase antibodies. If positive, the muscle biopsy becomes redundant and should not delay treatment. In review of the few case reports for immune- mediated myonecrosis from statin therapy, the treatment course is prolonged and typically does not respond immediately to steroids in a fashion similar to other myositis. Patients may never regain full strength or take multiple years to reach their prior baseline. Poor prognostic factors include younger age of onset, African- American descent and profoundly elevated serum markers such as CK.

CONCLUSION: Immune related statin induced myopathies can be debilitating and often require prolonged treatment for clinical improvement. Shared decision-making must be incorporated into the initiation of statins, even if generally well tolerated.

STAYING ALIVE: A CASE OF MYOCARDIAL INFARCTION, CARDIAC ARREST, HEART FAILURE, AND ATRIAL FIBRILLATION

Benjamin Hull¹; Alina Popa²

¹Medical Student, Penn State College of Medicine, Hershey, PA; ²Academic Hospitalist, WellSpan York Hospital, York, PA. (Control ID #3865269)

CASE: A 73-year-old male, with a history of multivessel CAD s/p PCI and CABG, HFrEF secondary to ICM, and HTN, presents from an outside hospital after having an NSTEMI at home complicated by VTACH and cardiac arrest achieving ROSC after 45 minutes. At the outside hospital, he was nonresponsive. Troponins were elevated. EKG showed AFIB with RVR and no ST elevations. He was intubated and started on amiodarone and heparin. He cardioverted into NSR, was extubated, and his mentation approached his baseline. TTE showed an EF of 30-35% with mild lateral wall hypokinesis and severe global hypokinesis of the remaining LV. CAG showed an unpassable RCA lesion. He was then transferred to a referral center for complicated PCI. At admission, he was normotensive with regular heart and respiratory rates, saturating in the high 90s on room air. Heart was RRR with no JVP or lower extremity edema. Lung exam was normal. He was A&Ox4. Cardiac PET/CT showed multivessel CAD with a partially reversible filling defect in the RCA territory. Cardiac MRI showed an EF of 24% with viable myocardium in the RCA territory and 29% nonviable total myocardium. He had an AICD placed and underwent a successful PCI of the RCA. He was discharged home on losartan 12.5mg, metoprolol succinate 100mg, spironolactone 12.5mg, clopidogrel 75mg, rosuvastatin 40mg, and warfarin 5mg.

IMPACT/DISCUSSION: This case highlights GDMT for HFrEF, AICD for secondary prevention, and the nuances of antiplatelet therapy for patients who also have an indication for anticoagulation. Medication regimens for HFrEF with an angiotensin receptor-neprilysin inhibitor (ARNi), beta-blocker (BB), mineralocorticoid receptor blocker (MRB), and SGLT2 inhibitor show the greatest decrease in all-cause and cardiovascular mortality. Other combinations, such as an angiotensin receptor blocker, BB, and MRB also reduce mortality and combination therapies have higher survival benefits compared to single-agent therapy. In situations where patients with ischemic heart disease survive VTACH, AICDs are indicated as secondary prevention. Patients who undergo PCI after NSTEMI require DAPT to prevent stent thrombosis. Unfortunately, patients may also have indications for chronic anticoagulation. It is well known that DAPT with anticoagulation (triple therapy) increases the risk of bleeding. Studies have demonstrated that a single antiplatelet therapy with anticoagulation has similar all-cause and cardiovascular mortality, rates of recurrent MI, stent thrombosis, and stroke, with significantly less bleeding events compared to triple therapy.<span style="font-size:10.8333px"> </span>Ultimately, this case adds to the literature as it demonstrates the multimodal treatment needed after NSTEMI complicated by HFrEF, VTACH, and AFIB.

CONCLUSION: 1) The best GDMT for HFrEF is an ANRi, BB, MRB and SGLT2 inhibitor.

2) Single antiplatelet therapy with anticoagulation has similar efficacy and lower bleeding risk compared to triple therapy in patients who undergo PCI and have AFIB.

THE ADDITION OF TELEHEALTH TO VA TRANSITIONAL CARE OPTIONS

Jeannette F. Stein¹; Charlyne M. Carmichael²; Daniel Burleson²

¹Department of Internal Medicine, Duke University Medical Center, Durham, NC; ²VA Healthcare-VISN 6, Durham, NC. (Control ID #3868780)

CASE: 66 yo female with kidney disease on hemodialysis, diabetes on insulin, heart failure with preserved EF, recurrent deep venous thrombosis, hypertension, and bipolar disorder was recently hospitalized for chronic thromboembolic disease complicated by pulmonary hypertension.

Due to COVID 19 restrictions on home visits, as well as distance to the patient’s residence, the patient could not be admitted to the existing VA Transitional Care (TLC) program, but an evaluation was done by the TLC team via telephone and recommendations made. The patient’s medication regimen was reviewed with attention to polypharmacy and high-risk medications. Specific medication and non-pharmacologic recommendations were made, as well as assistance provided with efforts on tobacco cessation. Attempts were also made to re-engage with the patient’s psychiatrist for treatment.

IMPACT/DISCUSSION: The COVID-19 pandemic required clinicians to adapt practice for our most vulnerable patients. Efforts of the VA TLC team to adapt care delivery using a telehealth option, “TLC Plus” are discussed. The goal was to address the needs of vulnerable Veterans living outside of the VA TLC service area and those who would not have had access to post discharge transitional care services due to illicit drug use, COVID, or geographic location. TLC Plus used telehealth, enabling referrals from inpatient teams without excluding those living outside of the service area; distance qualifications were suspended.

This program provided education, medication reconciliation, appointment reminders and post discharge support to Veterans via telephone. The TLC clinicians reviewed symptoms, falls, medications, activities of daily living, and provided individualized health education.

Chronically ill older patients have an increased risk of readmission within 30 days of hospital discharge, often preventable. The Transitional Care Model (TCM) introduced by Naylor and colleagues improves the transition between hospital and home while decreasing readmissions[1]. This is an evidence-based intervention that has been proven in multiple clinical trials to improve the care and outcomes of chronically ill older adults transitioning from hospitals to home[2]. A telehealth option was created by the VA TLC team, aiming to improve the health and well-being of our patients during the vulnerable hospital to home period.

[1] J Am Assoc Nurse Pract. 2017 Dec. 2017 Dec;29(12):773-790. Nurse practitioner-led transitional care interventions: An integrative review. Kathlyen Mora et al.

[2] J Am Geriatr Soc. 2017 Jun; 65(6): 1119–1125. Components of Comprehensive and Effective Transitional

Care. Mary Naylor et al.

CONCLUSION: Adaptations have been made to the TCM; there are diverse reasons for this[1]. Efforts were made by the VA TLC team to include key components of the TCM while providing care and outreach via telephone.

[1] Soc Sci Med. 2018 Sep;213:28-36. Adaptations of the evidence-based Transitional Care Model in the U.S. Mary D Naylor et al.

THE BROAD DIFFERENTIAL OF VENTRICULAR TACHYCARDIA

Eileen Yu¹; Debra S. Leizman^2,1

¹School of Medicine, Case Western Reserve University, Cleveland, OH; ²Internal Medicine, University Hospitals, Cleveland, OH. (Control ID #3877731)

CASE: A 58 year old male with no known past medical or family history presented to the trauma bay following a motor vehicle accident after a syncopal episode while driving. He endorsed shortness of breath, diaphoresis, light headedness, and blurry vision prior to the accident. Notable findings on presentation included heart rate in the 200s, blood pressure 93/56, and EKG showing sustained monomorphic VT with no ischemic changes. High sensitivity troponin was elevated (6481 ng/L) and began to downtrend ten hours after presentation. Amiodarone infusion was initiated and synchronized cardioversion was successfully performed.

Echocardiogram and cardiac MRI revealed ejection fraction of 27%, hypokinesis of the lateral ventricular wall, left ventricular scar size of 13%, and mild eccentric left ventricular hypertrophy. Left and right heart catheterization showed no occlusion of the coronary vessels. PET demonstrated no evidence of cardiac sarcoidosis, but did incidentally reveal metastatic prostate cancer. Lipid panel was within normal limits. A dual chamber ICD was placed for secondary VT prevention and patient was initiated on goal-directed medical therapy.

IMPACT/DISCUSSION: This case demonstrates the workup for VT and the accompanying broad differential. Because the patient did not have electrolyte abnormalities, any family history of heart conditions or sudden cardiac death, or any medication or illicit drug use, our evaluation began with identification of structural heart defects, which are the most common culprits of VT. Myocardial scarring, a nidus for reentrant circuitry, was discovered on echocardiogram and pointed to ischemic heart disease. Interestingly, this patient did not have any history of acute coronary syndrome or atherosclerotic disease, no risk factors for coronary artery disease, and no evidence of obstructive artery disease on cardiac MRI. He worked as a personal trainer and endorsed excellent health prior to this hospitalization. Therefore, less common causes of scarring were considered. Negative cardiac PET results made infiltrative disease unlikely. Myocardial infarction with non- obstructive coronary arteries (MINOCA) is present in 5-15% of patients with STEMI/NSTEMI and is a possible working diagnosis for our patient who may have previously suffered a silent MI. Few studies have also linked arrhythmias with cancer and shown there are possible pathophysiologic associations between the two. These possibilities should be considered during the workup of VT in patients with unremarkable or unknown past medical histories.

CONCLUSION: -Following acute management of monomorphic VT, diagnostic workup should focus on determining the etiology of VT, identifying reversible causes, and implementing secondary prevention.

-Workup should start with elucidating most common causes, which include structural and ischemic heart diseases.

-Less likely causes, such as infiltrative disease, MINOCA, and prior silent MI are farther down the list, but should still be considered.

THE CRUCIAL ROLE OF GENERAL INTERNISTS IN FAMILY PLANNING FOR PATIENTS WITH END STAGE RENAL DISEASE

Archanna Radakrishnan, Patricia Ng

Internal Medicine, Stony Brook University Hospital, Stony Brook, NY. (Control ID #3874631)

CASE: Ms. B is a 25 year-old female with C3 Glomerulonephritis on hemodialysis (HD) who reported to her primary care physician (PCP) that she was trying to conceive but had not shared her pregnancy plans with her nephrologist or gynecologist (GYN). Her PCP provided education about her risk for pregnancy complications and the importance of coordinating care with her specialists. She was advised to start folate 5mg daily and follow up with GYN. One month later, she had a positive pregnancy test and was urgently referred to

maternal-fetal medicine (MFM).

At 21 weeks gestation, she shared with her PCP that she stopped taking folate because it was not mentioned at her specialists’ appointments. Her PCP provided additional education on pregnancy complications and the importance of taking prenatal vitamins.

At 23 weeks gestation, Ms. B presented to the hospital with chest pain, headache, and blood pressures (BP) above 200/100. Exam was notable for bilateral lower extremity edema and normal neurological exam. CT head showed bilateral subarachnoid hemorrhage in the frontal lobes and parietal sulci. Labs were significant for Cr 4.97 and Hgb 10.7. Testing was negative for preeclampsia and HELLP syndrome. She was admitted for hypertensive emergency and received daily hemodialysis, nicardipine infusion, and levetiracetam for seizure prophylaxis. Her clinical course improved but her BP could not be maintained below 140/90 with oral medications. Additional imaging revealed abdominal ascites and moderate pericardial effusion with possible early tamponade. Given these complications, Ms. B underwent emergent C-section and pericardiocentesis with pericardial drain placement. After these procedures, her BP stabilized and she was transitioned to oral medications.

IMPACT/DISCUSSION: Managing pregnancy in patients with ESRD is challenging. Although consultant input is important, PCPs have a unique opportunity to regularly assess reproductive goals and optimize care plans, such as ensuring chronic conditions are controlled prior to conception or reminding patients to take prenatal vitamins.

For pregnant patients with ESRD, higher doses of folate (5mg) are recommended due to increased clearance after HD. Internists should adjust chronic medications to avoid teratogenic agents and closely monitor for signs of hypertensive emergency, preeclampsia, and HELLP syndrome. Pericardial effusion in the setting of uncontrolled hypertension is a rare complication in patients with ERSD and reduction in dry weight via HD decreases this risk (Adam et al 2016). Although our patient and her baby were thankfully discharged home, earlier family planning and interdisciplinary care coordination may have prevented the aforementioned adverse events.

CONCLUSION: ●General internists play a critical role in family planning counseling and care coordination in patients with ESRD

●Patients with ESRD are at high risk for multiple pregnancy complications including neural tube defects, hypertensive emergency, pre-eclampsia, and HELLP syndrome

THE GREAT IMITATOR STRIKES AGAIN: A CURIOUS CASE OF HEADACHE

Anne Arnason²; Rachel Vanderberg¹

¹Internal Medicine, UPMC, Pittsburgh, PA; ²Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #3872669)

CASE: A 32-year-old man presented via telemedicine with five weeks of a new, constant, progressive right sided headache and associated sensation of a protrusion. He endorsed right-sided sensitivity to touch, worse pain in the morning and with bending over, and blurred vision. A normal neurologic exam was documented in an urgent care visit a few weeks prior. Magnetic resonance imaging (MRI) showed a right frontal bone lesion with pachymeningeal enhancement. A positron emission tomography scan showed increased uptake in the right frontal calvarium and diffuse, symmetric lymphadenopathy. Axillary lymph node biopsy was negative for neoplasm. Rapid plasma reagin titer (RPR) was 1:128 and serum fluorescent treponemal antibody was positive. HIV test was negative. He reported current monogamy with a female partner. CSF had had 6 white blood cells and negative venereal disease research laboratory test. He received a 14-day course of continuous penicillin VK for late secondary versus tertiary syphilis with suspected neurosyphilis. His RPR titer decreased to 1:32, headaches resolved, but osseous findings remained unchanged on 3-month interval MRI.

IMPACT/DISCUSSION: Osseous involvement of syphilis can occur at any stage but is most common in tertiary and congenital infection. Recent studies suggest that the incidence of bone involvement in secondary syphilis, as suspected in this case, may be seen in up to 8.7% of cases (previously thought to affect only 0.15%). Osseous syphilis typically affects the long bones and skull. There are no treatment guidelines for syphilitic bone lesions, though intramuscular penicillin G for 2-4 weeks appears to be effective. Imaging findings can persist for up to 11 months after therapy.

Syphilis reached a nadir of new cases in 2000, but has been increasing since. In 2022, the United States Preventive Services Taskforce reaffirmed its grade A recommendation to screen for syphilis in persons with risk factors including geographic incidence. One study showed screening in low-risk individuals in a high- risk area is effective at identifying new cases. Another study suggested that screening patients at increased risk more frequently is an effective mitigation strategy. At a visit two months prior to his diagnosis, sexually transmitted infection screening was ordered but did not include an RPR. The patient did not have a personal risk factor for syphilis; however, the incidence of syphilis was rising in this patient’s county. Curbing the resurgence in syphilis will require diligence in screening among clinicians and recognition of syphilis’s many manifestations

CONCLUSION: - Bony involvement is a rare manifestation of syphilis, but may be more common in early syphilis than previously thought, seen in as many as 8.7% of cases of secondary syphilis.

-With the recent increase in the incidence of syphilis, physicians should adhere to the 2022 USPSTF recommendation, considering screening high risk populations every 3-6 months and low risk populations in high-risk areas.

THE YIN AND THE YANG OF THYROID AUTOIMMUNITY

Raul Lopez Fanas

Internal Medicine, Montefiore Wakefield Campus, Bronx, NY. (Control ID #3875284)

CASE: A 44-year-old Jamaican woman with recurrent/remitting Graves’ disease and Myasthenia gravis presents with palpitations for 1 day. As per clinical record review, she had a similar episode when she was diagnosed with Graves’ at age 26; she was treated with methimazole (MMI) which she self-discontinued. Hyperthyroidism recurred with a TSH<0.01 mIU/mL (n 0.50-5.0) and FT4 3.6 ng/dL (n 0.6-1.5 ng/dL) after 6 years. She was not treated and hyperthyroidism remitted for two years until she was admitted with myasthenia crisis and hyperthyroidism recurrence. MMI was resumed but she self-discontinued it. She was readmitted for myasthenia flair and hyperthyroidism recurrence three years later. On further workup noted a thyroglobulin 163 ng/mL (n <60 ng/mL), thyroglobulin antibody (TgAb) 83 IU/mL (n <10 IU/mL), thyroid- stimulating immunoglobulin (TSI) 286% (n <140%) and thyroid peroxidase antibody (TPO) 140 IU/mL (n <5.0 IU/mL). Thyroid ultrasound suggested autoimmune thyroiditis. MMI was resumed and was referred for radioactive iodine (RAI) scan with plan for RAI therapy. RAI uptake on scan was 36.3% consistent with Graves' disease. However, TSH returned to normal range. RAI therapy was postponed and MMI was discontinued for more than three years.

During this admission, laboratory data were consisting with significant Hashimoto's thyroiditis with a TSH 9.58 mIU/mL, FT4 0.6 ng/dL, TPO>1000 IU/mL; TSI and TgAb were negative. Patient was started on Levothyroxine 25 mcg daily. A year after discharge, patient have remained stable with Levothyroxine 75 mcg daily.

IMPACT/DISCUSSION: Oscillating autoimmune thyroiditis is a relatively uncommon phenomenon. It can be caused by a disbalance in two types of thyrotropin receptor autoantibodies that can coexist in immune disorders of the thyroid stimulating antibody (TSAb) and TSH-stimulation blocking antibody (TBAb). The balance between these antibodies can fluctuate over time. Most data available exhibit that treatment with antithyroid medications reduces thyroid autoimmunity and TSAb secretion, switching to predominately TBAb, and leading to hypothyroidism. However, less data is available regarding the mechanism by which patients with Grave’s switch to hypothyroidism several years after the cessation of antithyroid medications. In addition, although it is well known that there is crossover between autoimmune diseases, it is not clear if myasthenia gravis could precipitate the oscillatory phenomenon. Moreover, other studies have hypothesized that there could be an immune dysregulation developed after using alemtuzumab and interferon for multiple sclerosis. This patient was taking Pyridostigmine before admission, and no relationship has been established with Pyridostigmine.

CONCLUSION: This case report highlights an atypical phenomenon of thyroid autoimmunity triggered by a poorly understood mechanism. As internists, it is important to be aware of this phenomenon, how to monitor it, and potentially treat it.

TRADING BLINDNESS FOR DYSPNEA, A CASE OF MEDICATION INDUCED METABOLIC ACIDOSIS OR HOW I LEARNED TO LOVE THE ABG

Zachary Meili¹; Jaime Fineman²

¹Internal Medicine, Temple University, Philadelphia, PA; ²Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA. (Control ID #3867715)

CASE: A 44-year-old female with a past medical history of pulmonary embolism and multiple venous thromboembolisms on chronic anticoagulation, large uterine fibroids complicated by blood loss anemia, and a recent diagnosis of dural sinus venous thrombosis leading to grade IV papilledema presents to establish care. She has been following with neuro-ophthalmology for her intracranial hypertension (ICH) leading to vision loss, headaches, and tinnitus, and is currently being treated with acetazolamide 3000 mg daily with favorable effect. At her initial visit, she reports worsening exertional dyspnea over the last month. She is only able to walk a block before needing to rest. She underwent extensive workup with CT angiography, echocardiogram, pulmonary function tests, and anemia evaluation, all of which were normal. She returned to clinic a few months later with persistent symptoms limiting her daily activities. At this point, notice was taken to multiple metabolic panels ordered by other providers with low bicarbonate levels (14-16 mmol/L) without an anion gap. An arterial blood gas was ordered, showing a pH of 7.33 and pCO2 of 30 mmHg, consistent with metabolic acidosis with inadequate respiratory compensation. It was posited that with increased physical activity, she was unable to fully compensate for the significant metabolic acidosis caused by acetazolamide, leading to dyspnea on exertion. Neuro-ophthalmology was contacted to adjust medications in light of this side effect. She was switched to a different medication class for her papilledema with subsequent resolution of her dyspnea and metabolic acidosis.

IMPACT/DISCUSSION: Acidosis resulting in activity-limiting dyspnea is an uncommon side-effect of acetazolamide. Acid-base physiology can be challenging in the outpatient setting given the infrequency of presentation and difficulty obtaining blood gases. In this case, the bicarbonate levels on prior labs were not acknowledged and connected with the patient's dyspnea for a prolonged period. The PCP’s role in coordination of care is paramount when considering new symptoms and how they may relate to specialist- prescribed medications. Even in the absence of symptoms, PCP’s should address lab abnormalities during routine monitoring for medication side-effects, even ones they may not prescribe themselves. This involves balancing risks and benefits, and the possible need to discuss alternative treatment options with specialists when patients are faced with challenging side-effects.

CONCLUSION: Primary Care Physicians should recognize medication-induced metabolic acidosis and its potential contribution to symptomatic dyspnea. Avoid anchoring bias by maintaining a broad differential diagnosis for dyspnea. PCP’s have an important role in ensuring specialist-prescribed medications are being monitored with appropriate lab testing, for drug-drug interactions, and recognizing medication side-effects.

TREATING CHRONIC PAIN AND COMPLEX PERSISTENT OPIOID DEPENDENCE WITH BUPRENORPHINE/NALOXONE IN A PRIMARY CARE INTERDISCIPLINARY CLINIC

Stacy T. Charat^1,2; Serena Cheng¹; Ashley Emami¹

¹VA San Diego Healthcare System, San Diego, CA; ²University of California San Diego, La Jolla, CA. (Control ID #3874621)

CASE: The Complex Pain Clinic is an interdisciplinary program embedded within a VA primary care clinic with a primary care doctor, a psychologist, and a clinical pharmacist practitioner. This referral clinic was established to address the needs of patients with chronic pain on prescribed opioids with complex persistent opioids dependence (CPOD) who would benefit from multi-modal pain management and a transition to buprenorphine. Here we describe a case that demonstrates protocols and outcomes: MP is a 55 year-old male with HIV-associated neuropathy, fibromyalgia, and CPOD. PMH includes type 2 diabetes, PE on anticoagulation, well-controlled HIV, and depression. He describes throbbing pain and pins and needles throughout his body. Exam is notable for diffuse weakness and muscle atrophy. He lives alone, uses a motorized wheelchair, and has limited social supports. He does not use alcohol, vapes THC daily, and denies other non-prescribed drugs. His starting opioid regimen was tapentadol XR 100mg twice daily and tapentadol IR 50mg QID PRN (160 mg morphine equivalents daily dose/MEDD.) His initial PEG scores were 5-7, 7-8, and 9. He was given the following buprenorphine/naloxone 2mg/0.5mg SL initiation protocol: Day 1: 1mg (1/2 tablet) Qday, Day 2: 1mg (1/2 tablet) BID, Day 3: 1mg (1/2 tablet) TID, Day 4: 2mg (1 tablet) BID and stop tapentadol XR, Day 5: 2mg (1 tablet) TID, Day 6: 2mg (1 tablet) TID and stop tapentadol IR. He tolerated the transition without withdrawal symptoms but did not stop tapentadol IR until day 15 due to his preference. His buprenorphine/naloxone was slowly titrated to 4mg/1mg TID due to initial increased pain. After 2 months, he reported that the total-body pins and needles had significantly reduced and he was able to spend more time out of bed. PEG scores over 10 months ranged from 4-8, 5-7, and 5-7.

IMPACT/DISCUSSION: Patients with non-malignant chronic pain are often managed in primary care, but providers struggle to help patients meet functional goals while reducing the risks of opioids. CPOD is a clinical diagnosis that describes patients with features of OUD, but for whom opioids are prescribed rather than illicit, and the driver for opioid use is pain control rather than euphoria. This case is an important addition to the limited body of literature demonstrating the use of buprenorphine/naloxone to treat pain and CPOD, with potential benefit for opioid-induced hyperalgesia. It uniquely demonstrates that patients with CPOD can be treated in the primary care setting by an interdisciplinary team.

CONCLUSION: 1. The off-label use of a low dose initiation of buprenorphine/naloxone is a safe and effective way to transition patients with complex persistent opioid dependence off full mu-agonist opioids without precipitating withdrawal or compromising pain control and functional status.

2. Working in interdisciplinary teams within primary care is an effective way to address chronic pain and complex persistent opioid dependence, emphasizing a multi-modal approach.

VASCULITIS IN THE SETTING OF CHRONIC HEPATITIS B INFECTION

Danielle Urman¹; Vandan Patel²; Bernice Ruo²

¹School of Medicine, University of California San Diego School of Medicine, La Jolla, CA; ²Medicine, University of California San Diego, La Jolla, CA. (Control ID #3872708)

CASE: A 58 year-old Vietnamese-born female with no significant past medical history presented with 2 months of hemorrhagic bullous lesions and synovitis of the left elbow and bilateral knees. She first noticed lower extremity blisters that progressed to bloody blisters. She also described joint pain with warmth and redness along with tingling in bilateral feet and hands. She denied any new medications, recent travel, and personal or family history of autoimmune disease. Her physical exam was notable for left elbow and bilateral knee joint effusion with overlying erythema and warmth. Her skin exam showed 1x1 cm hemorrhagic lesions on the scalp, lower eyelid, and bilateral fingers. Her neurological exam showed changes in sensation in bilateral ulnar nerve territories and feet.

Initial work-up showed a rheumatoid factor of 452, white blood count of 19, c-reactive protein of 19, erythrocyte sedimentation rate of 85, normal anti cyclic citrullinated peptide, and normal complement levels. Blood cultures grew methicillin-sensitive Staphylococcus aureus. During her hospital stay, labs were notable for anemia, thrombocytosis, leukocytosis, and positive hepatitis B (Hep B) core antibody and surface antigen. Electromyography and nerve conduction studies were consistent with mononeuritis multiplex. Other lab results showed cryoglobulin with no precipitate, myeloperoxidase antibody (MPO) of 2, anti-proteinase 3 antibody of 13, and antineutrophil cytoplasmic antibodies (ANCA) positive at 1:80. Skin biopsies showed evidence of vasculitis with tissue eosinophilia pronounced mainly in the superficial venules. The patient developed acute abdomen 8 months later from a perforated gastric ulcer. Gastric and omental biopsies showed markedly increased eosinophils with chronic inflammation. Repeat labs showed ANCA positive 1:640, MPO 67, and peripheral eosinophilia as high as 6400. Computed tomography of the chest showed signs of small and large airway disease. Ultimately, she was diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA) treated with mepolizumab.

IMPACT/DISCUSSION: EGPA is a rare ANCA associated necrotizing vasculitis of the small and medium sized vessels. The disease has three predominant features: asthma, eosinophilia, transient pulmonary infiltration, and systemic vasculitis. The American College of Rheumatology created a point system to diagnose EGPA.¹ The criteria is applied to patients with small or medium vessel vasculitis when other diagnoses mimicking vasculitis have been excluded.

Only three other case reports describe Hep B associated with EGPA.^2-4 This case demonstrates that EGPA should be on the differential when a patient has chronic Hep B infection along with other more common vasculitides.

CONCLUSION: Hep B can be associated with EGPA.

American College of Rheumatology outlines the criteria to diagnose EGPA.

WHEN HOME IS NOT AN OPTION: THE INTEGRAL ROLE OF INTERDISCIPLINARY PALLIATIVE CARE THROUGHOUT THE PROGRESSION OF LIVER DISEASE

Makeda Dawkins³; Mara Lugassy^1,2; Adam Schoenfarber⁴; David C. Wolf^5,6

¹Department of Medicine, New York Medical College, Valhalla, NY; ²Palliative Care Medicine, Section Chief, Westchester Medical Center, Valhalla, NY; ³Internal Medicine, Westchester Medical Center, Valhalla, NY; ⁴Palliative Psychosocial Work, Westchester Medical Center, Valhalla, NY; ⁵Department of Gastroenterology, Director of Transplant Hepatology, Westchester Medical Center, Valhalla, NY; ⁶Division of Gastroenterology and Hepatobiliary Diseases, New York Medical College, Valhalla, NY. (Control ID #3868743)

CASE: A 56-year-old man with six prior admissions for decompensated cirrhosis presented with abdominal pain and confusion. Examination showed jaundice, hepatic encephalopathy (HE), and ascites. Labs noted pancytopenia, coagulopathy, acute kidney injury, transaminitis, and hyperbilirubinemia. Lactulose and rifaximin were given for HE, Vitamin K, fresh frozen plasma, and cryoprecipitate for coagulopathy, and midodrine/octreotide/albumin for hepatorenal syndrome (HRS). CT abdomen confirmed cirrhosis and ascites, with paracentesis yielding 6L of ascitic fluid negative for spontaneous bacterial peritonitis. Hemodialysis was initiated as his HRS progressed. Due to his lack of citizenship, he was not eligible for liver transplantation.

He struggled with his disease reality, often refusing care, but endorsing pain and dyspnea. Interventions accumulated, namely transfusions for uncontrolled bleeding and paracenteses for refractory ascites. His status became dire following a spontaneous cerebellar hemorrhage, as he was not a candidate for neurosurgical intervention. Palliative care was initially consulted for psychosocial support and goals of care before a trial of dialysis. Their role continuously evolved, becoming key to complex decision-making and end-of-life care. After multiple family meetings, he ultimately pursued comfort-focused care. He passed comfortably after hemodialysis cessation. This case demonstrates the need for early interdisciplinary palliative care in patients with cirrhosis, from the initial diagnosis to transplant or end-of-life.

IMPACT/DISCUSSION: Cirrhosis is end-stage irreversible hepatic fibrosis, often accompanied by multiorgan complications with disease progression. As the eighth leading cause of death, the only curative treatment is transplantation. Ineligible patients suffer from a terminal disease, with recurrent hospitalizations diminishing their quality of life. As the prevalence of cirrhosis rises, hospitalists should recognize disease indicators, specifically those increasing mortality. Common misconceptions regarding palliative care, namely sole appropriateness at the end-of-life, may delay integration; however, the role of palliation evolves as cirrhosis progresses, from addressing unmet symptoms to providing psychosocial support and hospice care. Early palliation benefits all patients within the spectrum of cirrhosis, irrespective of transplant candidacy, with the role of palliative care becoming integral as the disease unfolds.

CONCLUSION: Patients with decompensated cirrhosis may present with various disease manifestations, including jaundice, HE, ascites, and bleeding. Hypotension and ascites are negative prognosticators, with SBP marking higher mortality risks.

Patients with cirrhosis benefit from early palliative care integration for psychosocial support and symptom management. Although liver transplantation is curative, transplantation and palliative care should not be considered mutually exclusive.

Clinical Vignette - Clinical Informatics and Health Information Technology

THINKING A-HEAD: AN EMR FEATURE THAT PREVENTED AN UNNECESSARY BRAIN BIOPSY

Jared Silberlust

Internal Medicine, Weill Cornell Medicine, New York, NY. (Control ID #3874249)

CASE: A 46-year-old man presented to the emergency room with altered mental status after a seizure. No prior medical history was known, and the patient was initially unable to share any details. Vital signs were normal, and the exam was significant for confusion, reserved affect, orientation to self only, left upper extremity motor weakness, and normal cardiopulmonary, abdominal, mouth, and skin exams. CBC, BMP, glucose, LFTs, thyroid studies, troponins, and a toxicology screen were normal. A CT scan of the brain revealed multiple intraparenchymal lesions and a leftward midline shift due to mass effect, and a subsequent brain MRI showed greater than 20 intraparenchymal enhancing lesions with edema and leptomeningeal enhancement, suspicious for metastatic disease. Neurosurgery was consulted and recommended urgent craniectomy with brain biopsy. Prior to the procedure, the pharmacist queried the lesser-known medication dispense history tab of the EMR. She found that in months prior, the patient had filled prescriptions for antiretroviral medications, pyrimethamine, and sulfadiazine. The craniectomy was canceled, the infectious disease team was consulted, and the patient began medical management for toxoplasmic encephalitis and HIV—diagnoses that were confirmed by the outpatient prescriber listed in the dispense history tab. After weeks of medication, the patient's brain lesions decreased in size, his neurologic symptoms resolved entirely, and proper outpatient follow up was achieved.

IMPACT/DISCUSSION: In the age of the electronic medical record, it is paramount to patient safety that providers leverage digital data as corroboration to a patient’s verbal history. Medication reconciliation errors are common despite structured drug interviews, and many patients demonstrate significant recall bias when discussing medications. Furthermore, a patient's story can be inaccurate, difficult to understand, or unattainable. The EMR medication dispense history tab, when available, offers information generated by aligning data from clinicians, EMR vendors, pharmacy benefit managers, health plans, and long-term care organizations. Medication name, dose, dispense date, and prescriber name can be displayed. Limitations include the potential for errors in specific insurance claims, absence of over-the-counter prescriptions, and absence of prescriptions that are paid for by the patient. Pharmacy staff are often champions of utilizing digital medication data to ensure patient safety. Involving pharmacists in the medicine reconciliation process helps to optimize patient care and can reduce treatment errors like prescribing the wrong medication or performing an unnecesary craniectomy.

CONCLUSION:

Medication dispense history data can improve the accuracy of a medical history. Limitations include insurance claim errors and absence of prescriptions for which patients self-pay.

Pharmacy staff are invaluable members of medical teams and should be active participants in ensuring accurate medication reconciliations.

Clinical Vignette - DEI, Health Equity, and Social Determinants of Health

A BROKEN HEART THAT COULD NOT BE FIXED

Tinuola B. Ajayi¹; Ricardo Cruz^1,2; Sarah Kimball^1,2

¹General Internal Medicine, Boston Medical Center, Boston, MA; ²General Internal Medicine, Boston University School of Medicine, Boston, MA. (Control ID #3876170)

CASE: A 46-year-old male migrant from Guatemala presented to primary care with a one-year history of chest pain. Initial work-up included an EKG with mild ST elevation and T wave inversions in V5-6, troponin levels 3 times above normal and BNP of 315. A transthoracic echocardiogram revealed reduced ejection fraction at 30% but cardiac catheterization showed normal coronary anatomy. Chagas serology was positive and there was an increased absolute eosinophil count of 700. These findings suggested Chagas Cardiomyopathy. Serology and peripheral blood smear sent to the CDC confirmed Chagas disease. He was initiated on CDC approved treatment with Benznidazole for 60 days. Over the next few years, despite being on maximal guideline-directed medical therapy his disease progressed to end stage cardiomyopathy. He underwent cardiac transplant evaluation but was deemed ineligible due to concerns regarding his insurance status and poor social support. Through an embedded hospital program, he began the process to adjust his immigration status and obtain more comprehensive insurance but was not able to complete the application. He died from a cardiac arrest almost 10 years from his initial presentation to primary care.

IMPACT/DISCUSSION: Organs for transplant are a scarce medical resource. Though undocumented immigrants account for about 3 % of all deceased organ donations, they make up less than 0.5 % of recipients. There is no legislation in the US that prohibits undocumented immigrants from receiving transplants, but the lack of insurance coverage is a major barrier. Due to his undocumented status, this patient was only eligible for Mass Health Limited (a form of emergency Medicaid), which precluded access to acute transplant services. Through a program in the Immigrant and Refugee Health Center at Boston Medical Center, he began to explore options to adjust his immigration status and seek alternative pathways to obtain more robust insurance. The goal of the collaboration with 2 community partners (Rian Immigrant Center and Health Law Advocates) is to support patients whose immigration status creates barriers to accessing necessary health services. They supported him in preparing a Medical Deferred Action application which would have qualified him for MassHealth Family Assistance and allowed him to be listed for a heart transplant. Of note, this can be a lengthy process and it is important to emphasize that early screening and referral of undocumented immigrants who may be future transplant candidates to appropriate immigration and public benefits legal representation could help mitigate this issue. Unfortunately, the patient died before the process could be completed.

CONCLUSION: Cardiac transplantation is a life-saving service that undocumented migrants often cannot access, creating a health equity concern. For patients who would otherwise be eligible for a transplant, they should be given referrals to immigration and public benefits legal resources.

A CASE ILLUSTRATING THE IMPACT OF THE COVID-19 PANDEMIC ON TUBERCULOSIS CASES

Kushinga Bvute, Daniel Gutman

Internal Medicine, Florida Atlantic University, Boca Raton, FL. (Control ID #3877185)

CASE: A 52-year-old immigrant male presented with weakness, intermittent fevers, dyspnea with minimal exertion, and a 20-pound weight loss over the last month. He has a 40-year pack history but denied cough, sputum production, or hemoptysis. He was febrile, T. 102.4, frail-looking, with diffuse rales. Chest X-ray showed patchy interstitial and alveolar infiltrates in the periphery of both upper lung fields, while his CT Chest showed multiple small nodules throughout the lungs. Differentials at the time of admission included malignancy or HIV. We consulted the Pulmonologist to assist with tissue diagnosis. A retroperitoneal lymph node biopsy taken during bronchoscopy showed necrotizing granuloma and stained positive for acid-fast bacilli. He was diagnosed with disseminated TB. He tested positive for HIV, with a CD4 count of 66, and his HIV viral load was 711,000- meeting the criteria for Acquired Immunodeficiency Deficiency Syndrome (AIDS). The infectious disease team assisted with care, and he started TB treatment and Bactrim for prophylaxis against opportunistic infection.

IMPACT/DISCUSSION: According to the World Health Organisation, in 2020, approximately 9.9 million people had Tuberculosis (TB) globally. The COVID-19 pandemic reversed years of progress in reducing the TB disease burden as multitudes of individuals experienced reduced access to tuberculosis diagnosis during the pandemic. As a result of the pandemic, the WHO reports the first year-on-year increase (of 5.6%) since 2005 in deaths from TB.

In 2020, approximately, 1.3 million people worldwide died from TB among HIV-negative people, up from 1.2 million in 2019. With 214,000 TB deaths among HIV-positive people in 2020 (a 2.4% rise from 2019), the forecast for 2022 appears worse. According to the CDC, the rise in TB cases in the USA mirrors global trends. The global number of people treated for latent TB to prevent active TB dramatically decreased by 21% to 2.8 million during the pandemic in 2020. As a result, more individuals presented late with higher morbidity and mortality. Sadly, TB cases highlight health disparities: in the USA, affected individuals are predominately foreign-born, while globally, the disease affects those of low socio-economic status. This case reinforces the urgent need to increase awareness and advocate for actions to mitigate and reverse the negative impact of the COVID-19 pandemic on the morbidity and mortality of individuals with Tuberculosis.

CONCLUSION:

-The COVID-19 pandemic severely disrupted TB services, reversing decades of progress toward reducing the disease burden.

-There is an urgent need to prioritize restoring essential TB services for case detection and treatment to aim for at least 2019 levels.

A DIFFERENTIAL DIAGNOSIS OF COST-RELATED MEDICATION NONADHERENCE

Natalie Sohn

Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #3875614)

CASE: A 68-year-old Yemeni Arabic-speaking man with a history of type 2 diabetes, hyperlipidemia, coronary artery disease, and financial insecurity presented for a follow-up visit to his primary care physician after multiple recent hospital admissions. Two months prior, he was admitted for a non-ST elevation myocardial infarction and had a stent placed. A few weeks later, he was re-admitted for dyspnea and diagnosed with acute decompensated heart failure with a left ventricular ejection fraction of 20-25%. He was diuresed, initiated on goal-directed medical therapy, and discharged. His discharge medication regimen included clopidogrel, aspirin, rosuvastatin, valsartan, spironolactone, furosemide, metoprolol, dapagliflozin, insulin glargine, and metformin.

At his primary care visit, he reported subacute progressive dyspnea. Exam was notable for tachypnea, elevated jugular venous pressure, bibasilar crackles, and lower extremity pitting edema. Further investigation found that he had been non-adherent to all medications except aspirin for two weeks due to prohibitively high costs. He had previously tried to enroll in Medicare Part D but was unsuccessful due to language barriers. Thus, his out-of-pocket medication costs were approximately $700, nearly half of his monthly income from Social Security. After multiple follow-up visits and telephone calls requiring a coordinated team of resident physicians, social workers, and pharmacy technicians, the patient was switched to more affordable medications, given medication coupons, and successfully enrolled in Medicare Part D.

IMPACT/DISCUSSION: Nearly one in three older patients take less medication than prescribed to avoid costs. Risk factors for cost-related medication nonadherence (CRN) include those with low income, under- or un-insured status, high cost-sharing plans, elevated chronic disease burden, and low physician trust. Poor medication adherence increases rates of disease progression, costly ED visits, prolonged hospitalizations, and mortality. CRN is a driver of health inequity and a manifestation of systemic racism.

The differential diagnosis of CRN includes 1) poor drug selection (prescribed drug is not on the insurance plan’s formulary); 2) lack of coverage (patient is under- or un-insured); 3) high cost-sharing (patient has a high deductible, copay, or coinsurance); and 4) poverty (lack of financial resources makes even the cheapest medications unaffordable). Next steps in management – such as switching to a generic medication, referring to social work for insurance enrollment assistance, using pharmaceutical assistance programs, and switching to alternative cost-transparent pharmacies – depend on correctly diagnosing a patient’s specific type of CRN.

CONCLUSION: Cost-related medication nonadherence is a common phenomenon that disproportionately affects marginalized communities. The primary care physician’s management of CRN is dependent on correctly diagnosing its root cause(s) to identify appropriate interventions.

BEYOND SURVIVING TO THRIVING: ENGAGING COMMUNITY HEALTH WORKERS IN COMPLEX TRANSITIONS OF CARE

Rajvi Patel¹; Christopher Moriates²; Snehal Patel²; Brenda Garza³; Michael Pignone²

¹Internal Medicine, Dell Seton Medical Center at The University of Texas, Austin, TX; ²Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; ³Health and Equity Department, The University of Texas at Austin, Austin, TX. (Control ID #3868336)

CASE: A 33-year-old Spanish-speaking woman with an uncomplicated first pregnancy presented for induction of labor at 39 weeks. During her labor, she had a tonic-clonic seizure and cardiac arrest suspected secondary to an amniotic embolism. Following 17 minutes of cardiopulmonary resuscitation and emergent cesarean section, the patient survived and a healthy baby was delivered. However, she remained critically ill and suffered multiple severe complications over a 9-month hospitalization, including postpartum hemorrhage, septic shock, spontaneous liver laceration with abscess formation and mesenteric ischemia. She required multiple surgeries including below the knee, breast and digit amputations and skin grafts.

In addition to prolonged critical illness, she experienced extensive social needs due limited family and community support. Recognizing the challenges she faced, an interprofessional team of clinicians, physical and occupational therapists, nurses, social workers, and a bilingual, bicultural community health worker (CHW) came together to coordinate her care. This team ensured the safety of her child through initial placement in a foster home. Through tremendous efforts involving community organizations and immigration lawyers, the team was able to obtain a humanitarian visa for the patient’s mother from Cuba. The patient was connected to a network of support through community groups for recovering from trauma. After discharge, the CHW continued to aid in her recovery at a skilled nursing home by helping her get a limb prosthesis to regain functionality and move into a women’s shelter. She was finally reunited with her daughter over a year after giving birth.

Her story was shared during a special “Alive and Awesome” (A&A) conference presentation, as a component of our Department’s Morbidity and Mortality conference series. The A&A format is an opportunity to highlight innovative care that positively affects patient-centered outcomes. During this conference our patient, her family, and the primary CHW returned to share their experiences in recovery.

IMPACT/DISCUSSION: Recovery from serious illness and prolonged ICU care is challenging, particularly when complicated by social stressors. CHWs are a group of individuals who work alongside healthcare professionals and local organizations to navigate and advocate for patients. They often share the language and life experiences of the people they serve. For our patient, a dedicated CHW that provided continuity of care during hospitalization and following discharge was instrumental to her recovery.

Her extraordinary case left a major impact on our hospital team. The A&A conference provided an opportunity to heal together, learn about critical illness from the patient's perspective, and celebrate the role of CHWs in bridging the gap from hospitalization to post-discharge recovery.

CONCLUSION: A CHW can play a key role in addressing the complex interplay of medical and social factors that patients with critical illness face in recovery.

CHALLENGES IN TREATMENT AND FOLLOW-UP OF UNDOCUMENTED PERSONS Anand Tekriwal¹; dylan bergstedt³; Hannah Carr²; Kira A. Grush²; Benjamin Titus²; Nicole-Gabrielle Delino²; John Cunningham⁴

¹University of Colorado, Denver, CO; ²Internal Medicine, University of Colorado - Anschutz Medical Campus, Denver, CO; ³Intermountain Healthcare, Denver, CO; ⁴Internal Medicine, Denver Health, Denver, CO. (Control ID #3867892)

CASE: A non-English speaking 39/M presented to the ED afebrile, diaphoretic, tachypneic, with 2+ lower extremity pitting edema and a diastolic murmur at the left upper sternal border. Admission labs included a Cr

1.79 mg/dL, troponin > 100 pg/mL, BNP > 6000. Transthoracic echocardiogram revealed an ejection fraction of 20% and severe aortic insufficiency. In preparation for valvular surgery for aortic valve dominant rheumatic heart disease, Patient Z’s citizenship within the United States needed clarification. The patient appeared guarded during these interactions. Nonetheless, three weeks later he underwent a successful bioprosthetic aortic valve placement. In the months after his surgery, Patient Z frequently missed follow-up appointments placing him at risk of post-surgical complications.

IMPACT/DISCUSSION: Many studies have shown that undocumented persons with severe, life- threatening conditions undergo significant hardships to access care out of fear of their legal status. Degraded therapeutic alliances negatively impact clinicians themselves as well and in settings around the world, adding to the strain of short-staffing and global lack of resources. In the United States, change is possible through policy changes aimed at assisting these populations. Greater awareness of the challenges and biases undocumented patients face in accessing healthcare can aid both patients themselves and drive helpful policies.

CONCLUSION: Despite our institution having mechanisms in place to provide care for undocumented persons, we nonetheless lost contact with a patient who presented acutely decompensated, received weeks of inpatient treatment and significant administrative effort in coordinating off-site cardiothoracic surgery. While it is rewarding to ensure Patient Z received standard of care treatment and he has an excellent prognosis, it is disheartening that our therapeutic alliance could not overcome other obstacles in continued care.

It is possible improved continuity of care could be accomplished if clinicians were better educated on policies and/or misinformation that prevents immigrant populations from seeking care and improved mechanisms were in place for educating undocumented persons on how to navigate the system. Specifically, hospital teams must establish transparency in their motives for requesting financial and legal information and ensure advocacy for the correct treatment guides patient care discussions to prevent patient harm and fear of social or legal repercussions for seeking care. The latter education, if delivered from patient advocates already allied with marginalized communities, may be particularly powerful, although systemic mistrust of the American healthcare system is common. More concretely, expanded service hours and transportation availability for marginalized communities can help address systemic healthcare inequities, serving as initial steps in community power-building approaches.

FAMILY MATTERS: UNMASKING MULTIPLE MYELOMA THROUGH FAMILIAL ADVOCACY

Chinelo Onyilofor¹; Lucille M. Torres-Deas²

¹Internal Medicine, Columbia University, New York, NY; ²Internal Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY. (Control ID #3871891)

CASE: A 64-year-old woman with a PMH of Alzheimer’s dementia and depression presents to establish care after being lost to follow-up during the COVID pandemic. Her daughter accompanies her to the visit to provide context of her mother’s current symptoms. Since the pandemic began, her mother started experiencing progressive memory loss and worsening depression, leading to her not being able to care for herself. While assisting her mother, the patient’s daughter noticed a small bump on the right posterior aspect of her head that had grown over the past several months. The patient had a strong family history of cancer, 2 siblings passed away from unknown bone cancer <1 year after diagnosis; both parents had unknown cancer. Physical exam notable for 2x2cm non-tender mobile mass located in the posterior aspect of her head without evidence of fluctuance, induration, or drainage. To both characterize the underlying mass and evaluate the patient’s cognitive impairment, an MRI brain without contrast was obtained, showing an extra-axial transcalvarial 3.4 cm mass with broad dural attachment and several 2-3mm lytic lesions throughout the calvarium, later confirmed by subsequent CT. Additional labs notable for normal CBC, BMP, and SPEP/UPEP; however, she had an elevated serum Kappa free light chain ratio of 42.8. She underwent a right frontoparietal craniectomy of the largest exophytic lesion, which was positive for a plasmacytoma. Whole body diffusion weighted-MRI was done, which confirmed multiple myeloma based on numerous focal lesions with low apparent diffusion coefficients. She was referred to oncology and started on induction therapy with daratumumab + lenalidomide/bortezomib/dexamethasone. During treatment, patient experienced worsening depression, often fixating on family members who have passed away from cancer. Weekly check- ins with her therapist at the Dominican health center and support from her family and church helped with the severity of the symptoms. Several months later, the patient underwent high dose melphalan with autologous hematopoietic cell transplantation. Since transplant, patient has been recovering with frequent follow-up and familial support.

IMPACT/DISCUSSION: This case highlights how multiple myeloma can be diagnosed as an asymptomatic plasmacytoma in the absence of clinical symptoms or initial laboratory findings. In patients with mental health illnesses or memory impairment, family members’ involvement can not only heighten understanding of the severity of the patient’s condition, but also, help alleviate the patient’s emotional burden while undergoing workup of a difficult diagnosis.

CONCLUSION: Consider obtaining CT head without IV contrast in a patient with a scalp mass and strong family history of bone cancer even if there is no evidence of anemia, hypercalcemia, or kidney injury. Also, recognize the importance of cultural, spiritual, and family practices for timely diagnosis, management, and patient well-being.

HOME HOSPICE IN THE HOTEL-BASED EMERGENCY SHELTER SETTING.

Srirama Josyula, Russell D. Berg

General Internal Medicine, Harborview Medical Center, Seattle, WA. (Control ID #3875100)

CASE: The events presented here took place during the SARS-CoV-2 pandemic during which the local county government expanded single occupancy homeless shelter options, including hotel shelters, as an infection prevention measure. A 56-year-old woman arrived at a hotel shelter after discharge from an alcohol treatment program. The patient was engaged by shelter medical staff for intake where she was diagnosed with Parkinson’s disease and started on carbidopa/levodopa. Four months later, shelter staff performed a welfare check and found the patient unconscious in her room. She was transported to the emergency department and admitted to the inpatient medical service for decompensated cirrhosis with hepatic encephalopathy, protein- calorie malnutrition, and spontaneous bacterial peritonitis. Upon discharge back to hotel shelter, medical staff outreached the patient to discuss values and treatment preferences. The patient confirmed her desire to drink alcohol and understood this would hasten death due to cirrhosis, indicating her preferences as do not resuscitate, do not intubate, and comfort measures only. The patient was referred to an outreach Palliative care team and was enrolled in home hospice services through a community organization, all the while she was still living in the hotel shelter. Hospice provided her with a hospital bed and daily bath aid with weekly nurse visits. By this time, she was bedbound and dependent for all activities of daily living. She was taken outside daily by shelter staff in a wheelchair to socialize with her friends and continue the habits that brought her comfort including alcohol and cigarette use. Approximately two weeks after beginning hospice services, she was found deceased in her room with large volume hematemesis.

IMPACT/DISCUSSION: We lack resources to provide compassionate care to unhoused individuals nearing the end-of-life. Evidence has demonstrated feasibility and cost-savings associated with shelter-based palliative care interventions for homeless individuals, a population with high rates of chronic medical problems and complex end-of-life needs. However, practical implementation of dedicated shelter-based hospice has encountered numerous sociopolitical barriers. This case highlights an innovative approach to hospice care in a hotel shelter for an unhoused individual with both complex medical needs and stigmatizing end-of-life preferences surrounding substance use. Additionally, the end-of-life care provided by shelter staff and outreach Palliative care team was delivered by professionals dedicated to caring for those experiencing homelessness.

CONCLUSION: A multidisciplinary approach is required for early identification and provision of resources for homeless individuals in need of end-of-life services. Hotel shelters with private rooms provide an innovative setting in which benefits such as home hospice care may be delivered. Future advocacy and research should focus on access to end-of-life care for individuals experiencing homelessness.

LANGUAGE DISCORDANCE AND VISUAL IMPAIRMENT: A CASE OF DISCONNECTION AND TRAUMATIZATION ASSOCIATED WITH HOSPITALIZATION

Linda Yu, Peggy B. Leung

Internal Medicine, Weill Cornell Medicine, New York, NY. (Control ID #3876154)

CASE: Our patient is a 71-year-old, monolingual Taishanese (Toisanese) speaking woman who presented to the ED with 1 week of fevers, left eye pain and decreased visual acuity. She was found to have endogenous endophthalmitis in the setting of a metastatic hypervirulent Klebsiella infection. Her condition was stabilized with IV antibiotics, and she was discharged home on ciprofloxacin.

Two weeks later, she presented to an ID appointment endorsing pus draining from her left eye and severe back pain. She had not been taking her ciprofloxacin because she wished to give her body a break from all of her medications. Her children shared that their mother maintained a distrust of Western medicine and that she had a "horrible experience” during her hospitalization because of her inability to communicate with providers and the lack of accessible Taishanese interpreters. She declined re-admission at this time.

One week later, she re-presented with recurrent fevers and encephalopathy and was found to have toxic epidermal necrolysis (TEN) with bilateral ocular involvement, thought to be related to one of the many antibiotics she had received. Ophthalmology recommended emergent placement of amniotic membrane grafts. Prior to proceeding, they attempted to reach her daughter for consent but were unable to do so.

In the next few days, the patient’s mental status remained limited. In a moment of relative lucidity, she shared through a Taishanese interpreter the level of distress she felt during the emergent procedure and her experience of not knowing what was happening around her – not being able to see her surroundings or who was with her, and instead feeling herself being held down for a reason she couldn’t understand.

IMPACT/DISCUSSION: This vignette presents a harrowing complexity in layers: a woman who speaks a language without robust interpreter accessibility, who loses her ability to visually process her surroundings and experiences horrific disconnection and distress – all in the midst of navigating a medical system she distrusts. This narrative gives voice to one of many stories which underpin a growing body of research demonstrating that limited English proficiency (LEP) is associated with worsened health outcomes and an increased risk of adverse events.

As providers, we can and should certainly advocate for interpreter use for our patients of LEP. However, the lack of interpreter accessibility ultimately underscores a need for urgent, systemic solutions – both, to increase the availability of interpreters themselves, but also, to re-envision a medical system that prioritizes patient care at the bedside, particularly for our patients who feel the least empowered to speak.

CONCLUSION: The intersectionality of language discordance and visual impairment amplifies the potential alienation and traumatization associated with hospitalization for vulnerable populations. Urgent solutions are desperately needed to increase interpreter accessibility, particularly of lesser spoken languages.

LATE-STAGE DIAGNOSIS OF CARCINOID HEART DISEASE DUE TO ACCESS TO HEALTHCARE

Maria E. Fierro¹; Aditi Sharma¹; Keerthi Thallapureddy¹; Prince Otchere²

¹Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ²MD Anderson Cancer Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX. (Control ID #3876818)

CASE: A 35-year-old female with recently diagnosed Stage IV neuroendocrine carcinoid tumor presents to cardio-oncology clinic after a TTE revealed late-stage carcinoid heart disease (CHD). The patient had onset of multiple GI symptoms 12 years ago and onset of cardiac symptoms 7 years ago. Due to lack of medical insurance, she had been obtaining care in Mexico. During this time, she underwent cholecystectomy and treatment for infectious colitis with no resolution of her symptoms. Her symptoms worsened so she sought care in the US. CT imaging in a US Emergency room revealed abdominal and hepatic lesions. Further characterization of the lesions by MRI was recommended; however, MRI was delayed by 3 months because she was uninsured. When finally obtained, MRI revealed a 2.4 x 2.7 cm mesenteric mass and innumerable hepatic lesions. Liver biopsy revealed well differentiated neuroendocrine tumor. She established care with oncology and was started on octreotide. 7 months after her diagnosis of carcinoid tumor, her oncologist noted a new murmur on physical exam so TTE was ordered. Her TTE showed CHD with right heart failure (RHF), severe tricuspid regurgitation, and moderate tricuspid stenosis. She was then referred to cardio-oncology and was started on diuretic and beta blocker therapy. She was also referred to cardiothoracic surgery for tricuspid valve replacement, which was performed 5 weeks after her initial TTE.

IMPACT/DISCUSSION: CHD affects 20% of patients with carcinoid syndrome. Routine screening of patients with carcinoid syndrome for cardiac involvement is recommended to prevent increased morbidity and mortality. We present a case of a 35-year-old Hispanic woman in South Texas who had a late diagnosis of CHD due to lack of access to healthcare. Diagnosis of carcinoid syndrome is challenging, but this patient’s diagnosis was significantly delayed by her lack of medical insurance coverage. Unfortunately, shortly after discovery of her malignancy, she was found to have CHD that had already progressed to RHF with severe tricuspid valve disease that ultimately required valve replacement. Delayed diagnosis of CHD is associated with poorer prognosis and concurrent RHF worsens prognosis further. Thus, if this patient had better access to the healthcare system, her malignancy may have been identified in a timely manner and regular CHD screening could have prevented progression to RHF and need for tricuspid valve replacement.

CONCLUSION: Delayed diagnosis of carcinoid syndrome is associated with development of CHD and poorer prognosis. Timely diagnosis of carcinoid syndrome and routine screening for cardiac involvement after diagnosis can prevent progression to CHD and RHF. This young patient’s prognosis was worsened by a significant delay in her diagnosis and screening due to lack of access to US healthcare.

LOST IN TRANSLATION: A CASE OF ACUTE HEARING AND VISION LOSS LEADING TO LOSS OF FOLLOW-UP

Ronnye Rutledge, Manpreet S. Malik

Emory University School of Medicine, Atlanta, GA. (Control ID #3874608)

CASE: The patient was a 62-year-old man with a history of hypertension who presented to a community hospital with 3 weeks of progressive hearing loss and vision changes. Symptom onset was insidious, and he had been unable to continue his job as a truck driver. His exam was notable for left-sided sixth cranial nerve palsy as well as bilateral eighth cranial nerve deficits. MRI showed “diffuse left extraocular muscle edema” and “enhancement of the… bilateral cochlea.” Cerebrospinal fluid studies were negative. Team members handwrote messages and utilized visual scales to communicate with the patient. He communicated with his daughter by text message. Infiltrative and infectious processes were considered. The patient received intravenous steroids and antibiotics to treat both possibilities. His left eye abduction improved but his hearing loss persisted. He was discharged on oral steroids with a plan to follow up with a multidisciplinary team, but missed multiple appointments due to lack of transportation and new inability to drive. He was unable to reschedule visits as he could not communicate with schedulers. Upon reviewing his post-discharge course, a provider contacted the patient’s daughter to help secure medication refills and arrange for appointment requests to be sent via text to his phone.

IMPACT/DISCUSSION: This case highlights the need to identify necessary supports for patients with sensory disabilities both during their hospital stay and upon discharge. Hospitals are ill-equipped to meet the needs of patients with sensory disabilities, specifically those with hearing and/or vision impairment. According to the CDC, adults with hearing loss are more likely to report poor health outcomes. Similarly, adults with vision loss are more likely to experience housing/food insecurity and to be uninsured, making access to care even more challenging. Outpatient scheduling often relies on auditory stimuli (e.g., ringing phones, voicemail) or visual stimuli (typed discharge instructions or appointment reminders). Though the Americans with Disability Act requires that hospitals provide deaf/hard of hearing and blind/vision impaired patients with appropriate interpreter services and assistive devices, these services vary widely and can be denied if provision would “result in an undue burden.” Many hospitals rely on video remote interpretation, which is prone to technical delays. Talk-to-text technologies such as TTY or IP relay services can help hearing impaired patients make appointments but require hospital staff to be skilled in receiving these calls. Clinicians should be aware of these challenges and assess patients’ need for access to communication support.

CONCLUSION: This case highlights often overlooked barriers to care faced by patients with sensory disabilities. These lessons should guide providers to screen for vision and hearing impairment in their patients, and offer access to appropriate resources to patients who would benefit while admitted and later in the community setting.

SUBSTANCE USE MAKES A MOVE

Ritu Bansal

Department of Medicine, University of California San Francisco, San Francisco, CA. (Control ID #3874917)

CASE: 32-year-old man, with history of ulcerative colitis, not on any medications, was brough in by ambulance for sudden onset of dizziness, lightheadedness, muscle spasms and sweatiness. Family history was unremarkable. Social history was notable for occasional cocaine, alcohol, MDMA use. In the ED, he started experiencing involuntary movement of his limbs and trunk. They were initially provoked by blood draw. The only notable exam was repetitive involuntary, writhing movement of his limbs and trunk along with slow extended muscle spasms. Cranial nerves, muscle tone, sensation, strength, and coordination were preserved, Babinski absent. Blood test revealed low calcium level of 7.8mg/dl & albumin 3.8g/dl. Rest of the lab, including CMP, CBC, HIV, Syphilis serology, CPK, magnesium and phosphorus levels, were normal. Non- contrast CT and MRI brain with & without contrast were unremarkable. Initial diagnosis was Hypocalcemia induced muscle spasms. 2gm of IV calcium gluconate was administered & patient was admitted to the tele- floor for observation. Ionized calcium could not be obtained as patient declined lab redraw. He preferred resting in a dark, quite room and requested minimizing noises,repeat vitals and exams. Multidisciplinary discussion was started with bedside nurse, charge nurse, tele tech, dietary service and to maximize comfort an agreement was reached to support quiet time and avoid vitals unless necessary as they worsened his spasms. Following day repeat calcium and ionized calcium were normal but symptoms persisted. Neurology was consulted. Based on the pattern of his involuntary movement (dyskinesia) and delayed temporal onset (tardive) he was diagnosed with cocaine and/or MDMA induced Tardive dyskinesia and started on Valbenazine 80 mg. Hospital Day 3, symptoms improved, and he was discharged with an outpatient neurology and CDRP appointment but was lost to follow-up.

IMPACT/DISCUSSION: Substance use associated movement disorders are uncommonly encountered as they are self-limiting or some like Crack dance, Punding, Flakka dance are dismissed as mindless moves or dancing by someone who is “High.” In ED, often there is associated agitation prompting administration of neuroleptic medications, worsening these symptoms, creating a perpetual cycle of avoiding health care. Pathopysiologically there is failure to downregulate dopamine at the synapses in some individuals. Our patient was exposed to multiple substances, and main contributor is unclear. Initial presentation with hypocalcemia and limb-truncal dyskinesia with lack of pathognomonic orofaciolingual symptoms delayed diagnosis. A handful of cases of cocaine associated movement disorders exist but we did not find one reported on Tardive dyskinesia.

CONCLUSION: *Substance use can present with spectrum of movement disorders.

*It is essential to approach patients with substance use with respect and if they decide to forgo recommended medical intervention, consider multidisciplinary, patient centered modification of plan.

Clinical Vignette - Geriatrics and Palliative Care

A CASE OF DEMENTIA PATIENT WITH MALNUTRITION SECONDARY TO POSSIBLE INSTITUTIONAL NEGLECT

Sumire Isomura¹; Kaihei Masuda¹; Keita Hibako¹; Mariko Shimazu²; Megumi Sano¹; Tetsuya Hoshi¹

¹GIM, Teine Keijinkai Byoin, Sapporo, Hokkaido, Japan; ²Center for Education, Research, and Clinical Trials, Teine Keijinkai Byoin, Sapporo, Hokkaido, Japan. (Control ID #3867751)

CASE: A 78 year-old-female living at a nursing home presented to our hospital for spreading purpura and generalized edema. The facility staff reported that purpura had begun 1 week prior to admission. She had resided at a nursing home for 8 months due to severe Alzheimer’s disease. Examination showed anasarca, purpura located along the eyelids bilaterally, forehead, back, upper and lower extremities. Laboratory tests showed anemia, leukopenia, thrombocytopenia, elevated PT-INR, followed by vitamin deficiency (A, B1, B2, B6, B12, C, D, E, K, folate). The facility staff claimed that the patient had been eating normally even though the laboratory data showed the opposite. Her final diagnosis was malnutrition secondary to possible institutional neglect. We set a multidisciplinary team composed of doctors, nurses, and social worker to discuss our plan for the suspected neglect. We reported to the municipal government as required by the Japanese law. The municipal government inspected the facility and without confirmation of abuse, concluded that the patient may return there. We also told her family about the suspected abuse, however her only family was her sister who had been estranged and said she did not mind her returning to the original facility. We recommended a nutritional guidance to the facility staff and the patient went back to the original facility after the treatment. The hospital team is concerned that the patient’s malnutrition will relapse.

IMPACT/DISCUSSION: This case highlights an issue of elder abuse at nursing home. In response to the aging population, Japan has created a system to protect the elderly. Japanese law requires all suspected elder abuse cases be reported to the municipal government. They conduct a survey and confirm whether the abuse has really occurred. Despite such measures, there are still many concerns left about institutional abuse. As it was in this case, not all the reported cases are confirmed as abuse and it becomes more difficult when the patient has less ability to make decisions due to dementia.

Institutional abuse is not the only issue in Japan because the whole world is aging. According to the World Population Prospects, the percentage of older adults over 60 years is 12.3% of the global population in 2015 and will reach to 21.3% in 2050. With a growing geriatric population, more people are expected to live in elderly care facilities. With their frailty, they tend to be more dependent on others for care and under greater risk for abuse compared to older adults in community settings.

Efforts should be made not only in the community but also by hospital staff to protect the elderly from possible abuse.

CONCLUSION: Recognizing the possibility of elder abuse in the hospital is a first big step to protect patients from such cases. When elder abuse is suspected, the general internist should send a multidisciplinary team including nurses and social workers to gather information and create an intervention plan.

A CASE REPORT ON EARLY PALLIATIVE CARE IN METASTATIC SMALL CELL LUNG CANCER IMPROVING QUALITY OF END OF CARE.

Md Rockyb Hasan¹; Tahsin Tabassum²; Thien Vo¹

¹Internal Medicine, Texas Tech University System, Lubbock, TX; ²School of Community Health and Policy, Morgan State University, Baltimore, MD. (Control ID #3858007)

CASE: A 50-Year-Old male was diagnosed with metastatic small cell lung cancer (SCLC) to the brain and adrenal gland and presented with shortness of breath. He received his first session of chemotherapy before the presentation. A multidisciplinary team including cardiology, oncology, cardiothoracic surgery, and palliative care was consulted for better patient care. The patient developed pericardial effusion with cardiac tamponade and underwent the pericardial window. Subsequently, he was found with atrial fibrillation and rapid ventricular response. He received electrical cardioversion, amiodarone, and a heparin drip. A chest tube was performed for pleural effusion. Cardiac tamponade and pleural effusion resulted from metastasis of lung cancer. The goal of care and prognosis has been discussed with the family and they agreed upon palliative or comfort measures. The patient died shortly after the initiation of comfort measures.

IMPACT/DISCUSSION: Lung cancer is the second most diagnosed cancer and 14% of the with small cell lung cancer in the United States. For regional small-cell lung cancer (SCLC), the 5-year survival rate is 16% whereas for distant metastasis the 5-year survival rate is 3%. The standard treatment plan is recommended to all lung cancer patients irrespective of stages. However, symptomatic lung metastases to the brain, adrenal glands, and pericardium or compressing or invading the spinal cord or nerve roots often have a substantial symptom burden. Medical and various intervention does not prolong life instead results in aggressive care at the end of life. Early palliative care significantly improves patient understanding of prognosis over time, which may impact decision-making about care near the end of life. Evidence has suggested that compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life. Palliative care should be considered an integral part of comprehensive metastatic lung cancer care, with potentially meaningful patient benefits.

CONCLUSION: Metastatic small-cell lung cancer (SCLC) often results in extensive symptom burden due to the involvement of multiple organs and may require aggressive care at the end of life. Integration of early palliative Care as a part of comprehensive management for these Patients may improve the quality of end-of- care in hospitalized patients.

CANNABIS FOR TREATING SEVERE AGITATION IN A PATIENT WITH ALZHEIMER'S DISEASE

Ryan Buck¹; Rebecca A. Abraham²

¹Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; ²Nursing, Northern Illinois University, DeKalb, IL. (Control ID #3877170)

CASE: Patient is an 80 year old woman with dementia from Alzheimer’s disease with progressive decline. She would sleep for large portions of the day, and struggle with anxiety. Family noted worsening agitation including yelling, becoming physically aggressive, and throwing objects. Attempts at distraction and redirection did not work. Medications included donepezil, alprazolam, and mirtazapine - none of which helped.

Family sought care from a cannabis nurse, and after education decided to start a regimen of 1:1 delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), cannabidiolic acid (CBDa), and cannabigerol (CBG). After starting this, the family reported that she was sleeping through the night. There was no worsening confusion or “high." Only side effect noted was dry eyes. Most importantly to them - they reported no further episodes of agitation/aggression, and that her anxiety was “90% better,” with a much improved quality of life for both the patient and caregivers.

IMPACT/DISCUSSION: Alzheimer's disease (AD) is a common neurodegenerative disease, afflicting 6 million adults in the US. Neuropsychiatric symptoms (NPS) are common, with agitation affecting more than 40% - leading to patient distress, worsening cognitive function, caregiver burden, poor quality of life, and increased institutionalization and cost. Treatment may include antidepressants, anxiolytics, antipsychotics and sedative hypnotics. However, these are not FDA approved for treating agitation, have poor evidence for efficacy, and come with significant risks including falls, stroke, and death.

The endocannabinoid system (ECS) is an important physiologic system that is involved in regulating homeostasis and cell signaling. Endogenous cannabinoids Anandamide and 2-AG interact with CB1 and CB2 receptors throughout the body. CB1 receptors are found concentrated in the brain in areas associated with higher level functions such as executive decision making, memory, and emotional response. Phytocannabinoids such as THC and CBD interact with CB1 and CB2 receptors in a similar manner to the endogenous cannabinoids.

Cannabinoids may improve agitation through the regulation of neurotransmitters. Cannabinoids have also een shown to have neuroprotective effects - reducing oxidative stress, and decreasing the burden of beta amyloid plaques in AD. Cannabinoids can also help maintain normal sleep/wake cycles.

CONCLUSION: Cannabinoids have been shown to be safe and well tolerated, with few side effects in patients with AD. There is growing evidence that they are helpful in treating NPS such as agitation. We have presented one patient with severe agitation who found significant symptom relief after beginning a regimen of cannabinoids. Current literature is limited by studies that include low quality evidence or uncontrolled trials. Further research with controlled studies and larger samples is needed to evaluate the role for cannabinoids in this population with limited safe and effective treatments.

DEEP VENOUS THROMBOSIS WITH CITALOPRAM INDUCED SIADH IN A PATIENT WITH PARKINSON’S DISEASE

Afaf A. Albalawi

Internal medicine, Tabuk university, Tabuk, Select State, Saudi Arabia. (Control ID #3876364)

CASE: An 86-year-old woman with Parkinson’s disease, hypertension, diabetes mellitus, hyperlipidemia, and osteoporosis presented to the emergency department with altered mental status, decreased oral intake, generalized weakness, left lower leg swelling. At baseline, the patient is functionally and cognitively declined. Medications included gliclazide, metformin, valsartan, and atorvastatin, with no medications for Parkinson’s disease. No history of venous thromboembolism (VTE) was noted. Echocardiogram 5 months prior showed normal systolic function; ejection fraction, 55%–60%; and Grade 1 diastolic dysfunction. At presentation, the patient was disoriented and lethargic. Blood pressure: 104/51 mmHg; random blood glucose: 125 mg/dl; and sodium: 123 mg/dl. Other parameters were normal, including adrenal function, with no sign of malignancy or autoimmune disease. Brain computed tomography showed age-related changes. Doppler ultrasound revealed DVT in the left lower leg. Four weeks prior, the selective serotonin reuptake inhibitor (SSRI) citalopram was started for behavioral changes (agitation, hallucinations, repetitive vocalizations, and insomnia), resulting in restlessness and vocal changes (low-volume speech). Two days prior, citalopram was discontinued due to excessive fatigue. The patient was admitted and managed with hypertonic solution and intravenous heparin, with other medications held. After 2 days, sodium normalized. The patient was discharged on oral apixaban (2.5 mg, BID), and all home medications were resumed except gliclazide. At follow-up, plasma sodium remained normal.

IMPACT/DISCUSSION: Citalopram is effective for dementia-related agitation, but little evidence supports its use for dementia with Lewy bodies. Unlike SSRIs, cholinesterase inhibitors improve cognitive function with fewer side effects and without worsening motor symptoms. Hyponatremia and other SSRIs side effects increase VTE risk. In this case, hyponatremia and hypoactive delirium likely led to bed confinement, a hypercoagulable state, and DVT. Citalopram combined with Gliclazide could increase effects on sodium and risks of syndrome of inappropriate antidiuretic hormone secretion. SSRIs use can directly (platelet aggregation, venous stasis) or indirectly (obesity, sedation) cause DVT. This case highlights the need for frequent sodium monitoring and prophylactic anticoagulation when considering SSRIs initiation in patients with functional decline. Additional clinical studies remain necessary to elucidate the mechanisms linking SSRIs use and VTE.

CONCLUSION: SSRIs should not be first-line treatments for behavioral symptoms in Parkinson’s disease with Lewy body dementia due to risks of hyponatremia.

SSRIs combined with sulfonylurea increase hyponatremia risk.

In older patients with functional decline, VTE prophylaxis should be initiated prior to SSRIs.

GERIATRIC DEPRESSION: FORGET ME NOT

Shaleen Thakur

Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3875911)

CASE: A 63-year-old male with T2DM, HTN, and multiple ischemic strokes in the last several years with resultant cognitive impairment, was seen in clinic accompanied by his daughter for follow up of recurrent major depressive disorder. Prior to his strokes he had no depression but starting shortly after his first stroke and preceding cognitive changes he had begun experiencing passive suicidality and amotivation which he reiterated again during this clinic visit. PHQ-9 remained unchanged at 21. Medications included escitalopram 10mg, ASA, statin, and sitagliptin 100mg. Examination was notable for a wheelchair-bound man with expressive aphasia with difficult to assess cognition, R hemiplegia, and flat affect with poor eye contact despite intact cranial nerves. He was recommended for repeat neurocognitive testing and psychotherapy but declined both.

IMPACT/DISCUSSION: Like with our patient, for older adults who experience cognitive impairments, it can be difficult to differentiate whether the cause is depression or dementia. Depression in older adults can cause pseudodementia, an apparent decline in intellectual function that is due to lack of motivation or energy, but mirrors the cognitive decline noted in dementia. There are some key differences to be considered when discerning depression and dementia. With depression, symptoms take weeks to months to manifest, whereas in dementia it is usually months to years. Mood in patients with depression is persistently dysthymic, unlike dementia which fluctuates. Patients with depression are usually concerned about memory changes despite the deficit being concentration, whereas dementia patients have true deficits in short term memory that they are not concerned about.

Major depressive disorder affects 3% of older adults, with significant depressive symptoms affecting up to 20% of older adults. It is particularly important for primary care physicians to screen, as of the 3%, around 75% initially present to their PCP. Geriatric depression can be refractory to medical therapy given its multifactorial nature, and it often necessitates a combined pharmacotherapy and psychotherapy approach. In patients who could have a mixed picture, particularly with elements of depression confounded by an underlying dementia diagnosis, it is important to emphasize the benefit of talking therapies. Additionally, studies have shown that older adults with depression benefit most from aggressive, persistent therapy, so their therapy should be continued for longer periods of time than compared with younger persons.

CONCLUSION: Changes in cognition can differentiate depression from dementia. Patients with depression will have difficulties with concentration, whereas patients with dementia will have difficulties with short term memory.

Geriatric depression often necessitates longer courses of therapy, is refractory to medical therapy, and usually responds best to socialization.

IMMUNOSENESCENCE IN THE ELDERLY: A CASE REPORT OF ATYPICAL SEPSIS

Gavin Jones. College of Medicine, Penn State College of Medicine, Hershey, PA. (Control ID #3834809)

CASE: A 90-year-old woman with a history of dementia, nephrolithiasis, and diverticulitis presented to the ED for evaluation of left lower abdominal pain of unknown duration after being found confused and tremulous in her home earlier that day. On initial evaluation, she was ill-appearing but afebrile and hemodynamically stable with an SPO2 of 88%, which required starting 2L of O2 to maintain SpO2 >92%. Glasgow coma scale was 13 with reduced scores in eye-opening and verbal responses. Physical exam was significant for dry oral mucosa, diminished pulses, soft non-distended abdomen with voluntary guarding, and mild left-sided CVA tenderness. Laboratory studies revealed a creatinine of 1.84mg/dL, lactate of 2.3mmol/L, leukocytosis of 18.8K/uL, thrombocytopenia of 127K/uL, T bili of 0.7mg/dL, and urinalysis positive for leukocyte esterase. Abdominal CT obtained in the ED revealed a left-sided calculus in the ureteropelvic junction, perinephric fat stranding, and hydronephrosis with gas pockets suggestive of emphysematous pyelitis. She underwent nephrostomy tube placement and empiric treatment was started with vancomycin, cefepime, and IV fluids while awaiting urine and blood cultures, which were later found to be positive for E. coli. With this discovery, antibiotics were narrowed to ceftriaxone and the patient was discharged 9 days later once clinically stable.

IMPACT/DISCUSSION: The presentation of life-threatening infections in nonagenarian patients may differ significantly from their younger counterparts. Instead of fever, which is absent in as many as 25% of elderly patients with bacterial infections, acute changes in mental status may be the first indicator of sepsis. If afebrile, a history of rigors is often the most accurate predictor of bacteremia in patients aged >80 years. In contrast, septic patients < 60 years of age, typically presented with fever, chills, hypotension, and tachycardia. The principal cause of the atypical presentation of sepsis in elderly patients is immunosenescence, a process whereby the steady accumulation of lifelong somatic mutations contributes to a progressive decline in the capacity of hematopoietic progenitor cells to produce mature immune cells and inflammatory mediators, impairing the immune response in septic patients. While nonagenarians with age-related immunosenescence may show signs of end-organ damage (E.g., lactate >2mmol/L, Cr elevation >0.3mg/dL) with clear evidence of infection and have a SOFA score >2 to suggest septicemia (as in this case), their unique presentation may result in scoring too low to meet SIRS criteria or be considered high risk on qSOFA, which may lead to falsely reassuring the unwary practitioner and underestimating in-hospital mortality.

CONCLUSION: Immunosenescence related to the lifelong accumulation of somatic mutations can lead to an atypical presentation of sepsis in nonagenarians. These patients may meet SOFA criteria while scoring too low on SIRS and qSOFA screenings to appropriately appraise illness severity.

INCIDENTAL DIAGNOSIS OF PATENT FORAMEN OVALE IN AN OCTOGENARIAN WITH PARADOXICAL EMBOLIC EVENT

Utsav Aiya, Avijit Deb, Rakin Rashid, Rajesh Thirumaran, Krishna Desai

Internal Medicine, Mercy Fitzgerald Hospital, Darby, PA. (Control ID #3876865)

CASE: An 85-year-old female with hypertension, hyperlipidemia, bilateral knee replacement complicated by left lower extremity deep vein thrombosis and pulmonary embolism for which she was started on apixaban 5mg BID presented to the emergency department for lower abdominal pain with radiation to left flank. Workup included a contrast-enhanced CT scan showed evidence of a left renal infarct, new when compared to MRI 5 months prior. Transthoracic echocardiogram revealed moderate concentric left ventricular hypertophy, mild left atrial dilation and mild tricuspid regurgitation. Transesophageal echocardiogram showed no thrombus in the left atrial appendage but did reveal a patent foramen ovale (PFO) 0.5 cm in diameter. A contrast bubble study was performed with sonicated saline and showed >20 bubbles from right to left across said PFO. After discussions regarding the risk-to-benefit of PFO closure, a shared decision was made to forgoe closure and switch antigoacutlation to dabigatran 150 mg BID given concern for apixaban failure. She was discharged with notable symptomatic imprvmement and continues to be adequately managed in the outpatient setting on optimal medical therapy.

IMPACT/DISCUSSION: PFO is regarded as a disease of the young and is often overlooked as the mechanism of thromboembolic events as patients get older. Lack of data in older patients has hindered the development of clinical guidelines for PFO closure. Older patients are deemed to be of higher risk for stroke based on vascular risk factors alone. Older patients may also have additional risk factors that predispose to paradoxical embolism, such as acquired hypercoagulable states and immobility leading to venous thromboembolism. Younger patients with traditionally fewer vascular risk factors have a higher probability of a true cryptogenic stroke, and a longer lifetime risk of recurrent stroke. This fact, in combination with the data from the three main randomized controlled trials – RESPECT-LT, CLOSE and REDUCE and the several meta-analyses that followed – has shifted societal guidelines towards recommending PFO closure in younger patients with cryptogenic stroke. Trial data in older patients, however, remains limited and additional studies are needed to assess the benefits of PFO closure for people over the age of 60 years.

CONCLUSION: This case is an example of successfully managing an elderly patient with therapeutic anticoagulation in lieu of PFO closure as studies are bereft of significant benefit of such intervention in this age range.

MICRO-INDUCTION WITH BUPRENORPHINE/NALOXONE IN AN ELDERLY WOMAN ON CHRONIC OPIOIDS

Helen C. West¹; Shana Ratner²; Sydney Power¹

¹Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; ²Division of General Internal Medicine, UNC Chapel Hill, Chapel Hill, NC. (Control ID #3873755)

CASE: An 80 woman with depression, frailty, and anxiety on chronic low dose benzodiazepines has been prescribed oxycodone for chronic back pain for 12 years. She experienced side effects of constipation, falls and nocturnal hypoxemia confirmed by a sleep study. Her prior attempts to deprescribe her opiates and benzodiazepines were unsuccessful due to worsening pain, anxiety, and insomnia with minimal dose reductions. She was referred to the opioid use disorder clinic in her primary care office to try a novel approach with micro dosing of buprenorphine.

At the time of this referral, she was taking 10 mg of oxycodone 5 times per day. She started on a micro dose induction of buprenorphine/naloxone while continuing her same daily dose of oxycodone. The induction protocol was individualized to reflect her frail status and sensitivity to prior dose changes. She discontinued her oxycodone all at once on day 11 without experiencing withdrawal. She reported less constipation, improved sleep, less pain, and less time spent taking and thinking about opioids. She has remained on 12 mg of buprenorphine/naloxone in divided doses for the past 3.5 months and is pleased with the improvement in her quality of life and the reduction in her risk.

IMPACT/DISCUSSION: The prevalence of pain in the elderly population is 25-50% which carries a significant negative impact on functional status and level of disability. An elderly population that already has reduced physical reserve is more susceptible to the significant harmful effects of opioids. Despite this, opiate prescribing is highest in those over 65, making up 26.8% of opioids prescribed in the US. A harm reduction approach to deprescribing opioids is crucial for healthy aging.

Buprenorphine is considered safe and appropriate for deprescribing chronic opioids and for use in palliative care. The partial mu-receptor agonism results in a ceiling effect that reduces the risk of negative opioid effects such as respiratory suppression, sedation, and constipation. While buprenorphine also has a ceiling effect for potency of pain relief, it can be difficult to discern withdrawal symptoms from underlying chronic pain. Our patient had worsening back pain, anxiety, insomnia, and irritability when her opioids were tapered in the past. Once on even low doses of buprenorphine she reported resolution of these symptoms. This is in keeping with the literature showing that doses as low as 1-2 mg of buprenorphine daily are enough to block the physical symptoms of withdrawal.

CONCLUSION: While the use of buprenorphine to transition from other chronic opioids is not novel, there is little in the literature on the use of micro dosing of buprenorphine in the outpatient setting in elderly patients. Minimizing the effects of withdrawal which can worsen delirium and risk of negative outcomes in frail elders makes further study of buprenorphine micro dosing protocols a priority in terms of safe deprescribing.

ON AGAIN/OFF AGAIN: WHEN TUBE FEED DECISIONS DISTRACT FROM THE BIG PICTURE, HOW CAN SHARED DECISION-MAKING ADVANCE CARE IN TERMINAL DEMENTIA?

Kimberly Chow¹; John A. Leech¹; Neelesh Nadkarni^2,3

¹Internal Medicine, UPMC, Pittsburgh, PA;²Geriatrics, UPMC, Pittsburgh, PA; ³Neurology, UPMC, Pittsburgh, PA. (Control ID #3871869)

CASE: A 90-year-old with prior stroke and advanced dementia presented from his nursing facility with encephalopathy and acute hypoxic respiratory failure due to aspiration pneumonia. His prolonged hospital course included time in the ICU during which a nasogastric feeding tube (FT) for enteral nutrition was inserted. On the geriatric service, he was aphasic, bed-bound, incontinent of bowel and bladder, and continued to aspirate requiring antibiotics, supplemental oxygen, and aggressive pulmonary hygiene. Evaluation by speech pathology demonstrated near-absent swallow function and agitation with handfeeding. Given his declining clinical status and now-terminal dementia, our team did not believe he would return to his prior baseline. Complicating this, his family felt strongly about the enteral feeding schedule, despite futility in pursuing the FT in lieu of addressing his poor prognosis. Family advocated for high-volume bolus daytime feeds and withholding nighttime feeds. This contrasted with the continuous TF recommended by speech pathology and nutrition. However, long-term TF was not within the patient’s goals and is not recommended in advanced dementia. We decided to use evidence-based medicine with rapport-building to address this complex patient/family dynamic.

IMPACT/DISCUSSION: We performed a literature review. Handfeeding and enteral nutrition have similar outcomes in mortality, aspiration pneumonia, and comfort. Enteral nutrition is associated with greater agitation, restraint use, and healthcare utilization. Geriatric guidelines do not favor enteral nutrition via FT in advanced dementia, but critical care guidelines recommend continuous over intermittent feeds due to small reductions in aspiration pneumonia and diarrhea. A few small randomized controlled trials and meta-analyses comparing intermittent versus continuous enteral nutrition demonstrated contradictory results regarding aspiration risk. Supine position increases nosocomial pneumonia risk.

Ultimately, we used guidelines and available evidence in our shared decision-making. We landed on cyclic feeds, or continuous rate during the day and no feeds when supine at night. As expected, this decision did not significantly change the patient’s course. The patient continued to aspirate. The nasogastric tube was removed after four weeks, and the family eventually elected to turn to comfort measures. However, working with the family toward our common goal of decreasing aspiration risk eased the way for future discussions regarding the patient’s overall goals and long-term trajectory.

CONCLUSION: -The ideal enteral nutrition strategy has yet to be elucidated in large randomized controlled trials. Enteral nutrition is not recommended in terminal dementia.

-When decision-makers focus on one small detail of care rather than the overall trajectory, working with them to make small yet difficult decisions with the available evidence can help build rapport and aid in future discussions regarding long-term disposition.

PRIMARY SQUAMOUS CELL CARCINOMA OF THE PAROTID GLAND: A RARE OCCURRENCE

Virginia Velez Quinones¹; Catherine Ostos Perez¹; Kristina D. Menchaca¹; Shaun Isaac²

¹Internal Medicine, University of Miami School of Medicine, Miami, FL; ²Hospital medicine, JFK Medical Center Foundation, Atlantis, FL. (Control ID #3867849)

CASE: A 77-year-old female presented with progressive dyspnea and oropharyngeal dysphagia. Physical exam notable for a painless, immobile, cystic-like mass on the right submandibular region and normal skin exam. Laboratory studies showed a corrected calcium of 13.2. On day 1 of admission, the patient suffered an acute right facial droop. MRI brain showed a tiny punctuate area of acute restricted diffusion and T2 prolongation of transaxial FLAIR imaging involving the right cerebellar hemisphere compatible with subacute infarction. Carotid Doppler US showed a 50-69% stenosis of right and left internal carotid arteries. Neurology was consulted and started on appropriate management, but it was determined the facial droop to be result of the parotid mass. CT chest showed bilateral pleural fluid collections and multiple nodular opacifications to the lung bases. US of the neck showed a 3.5 cm heterogenous, hypoechoic, poorly marginated mass containing calcifications at the right submandibular region. CT abdomen and pelvis showed no acute abnormality. ENT and Hematology/Oncology were consulted. Patient underwent parotidectomy and pathology report diagnosed squamous cell carcinoma of the right parotid gland. It was determined Stage IVA Primary Parotid Squamous Cell Carcinoma (SCC) due to spread to a large right supraclavicular lymph node. Further lab tests of PTH, calcium and phosphate confirmed hypercalcemia of malignancy. Oncologist determined the patient had advanced disease and recommended radiotherapy, but the patient opted for comfort measures and hospice care.

IMPACT/DISCUSSION: The parotid gland is a unusual site of metastasis and a remarkably rare site for primary malignancy. Reported cases of metastasis to the parotid gland usually occurs as a direct extension from tumors in the external ear or skin. Primary SCC of the parotid gland is an aggressive entity, more common in old age between the 7th and 8th decade of life. In patients with metastatic disease the tumor associated morality is estimated to be more than 50%. Common sites of metastasis for primary parotid cancer are lungs, bone, liver and brain. Due to parotid location, a tumor can lead to Bells palsy (facial droop). This case of primary parotid gland squamous cell carcinoma presented with chief complaint of progressive dyspnea and oropharyngeal dysphagia with associated hypercalcemia of malignancy and complicated by Bells palsy. In the setting of high mortality, aggressiveness of metastasis, and associated complications, this case highlights the need for earlier detection strategies for parotid malignancy.

CONCLUSION: Primary squamous cell carcinoma of the parotid gland is an aggressive malignancy that can have nonspecific varying presentations. Symptoms can be related to metastatic disease such as: dyspnea, bone pain or focal neurological deficits. Although rare, it is associated high mortality rate, hence, further research for earlier detection strategies are warranted with this malignancy.

SPEAKING SPANISH WITHOUT WORDS: THE POWER OF INTERDISCIPLINARY WORK TO ADDRESS INTERSECTIONALITY

Caroline Cubbison^1,2; Carine Davila^1,2

¹Medicine, Massachusetts General Hospital, Boston, MA; ²Palliative Care & Geriatric Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #3877006)

CASE: Mr. M is a 39-year-old Spanish speaking immigrant with an undifferentiated developmental disability (DD) and mutism who was hospitalized for cardiogenic shock from ischemic heart disease. The primary team offered placement of a left ventricular assist device (LVAD) as a bridge to potential heart transplant, but prior conversations left the medical team with the impression that the patient wished to forego the LVAD. Given the communication challenges and in coordination with LVAD evaluation, palliative care was consulted. Two native Spanish-speaking palliative care clinicians and a cardiac care unit-based social worker met with the patient and family and invested hours learning his communication preferences (including vocalizations and gestures) and establishing a consistent method of communicating with him. These interactions were trust- building, and following several individual and multidisciplinary meetings with the patient and family, it was discovered that the patient did wish to proceed with an LVAD. He underwent LVAD placement uneventfully and has had a favorable clinical outcome thus far, attending all follow up visits with his LVAD team.

IMPACT/DISCUSSION: Black and Latinx patients with developmental disabilities (DD) are diagnosed later in life, experience less shared-decision making, and have poorer health outcomes including increased hospitalizations, unmet health needs, and a shorter life expectancy when compared to their White counterparts (Gallegos Acad Pediatr 2021; Perez Jolles J Prim Care Community Health 2020; Prokup Ann Fam Med 2017; Wightman J Pediatr 2021; Landes Prev Med 2022). Training surrounding DD remains limited in adult graduate medical education, including palliative care.

The intersection of developmental disabilities including mutism with Hispanic/Latinx ethnicity and limited English proficiency can create challenging communication scenarios with seriously ill patients, particularly in a high-stakes decision such as urgent LVAD placement. These multiple facets of the patient's identity impacted his communication, placing him at risk for suboptimal care and leading to clinician distress for many care team members. This presentation will review the challenges experienced by our team, including (1) equity concerns around significant time investment in this patient's case resulting in less time available for other patients and (2) understanding the patient's inconsistency as true ambivalence versus thoughtful consideration. We will highlight strategies employed to overcome communication barriers, including (1) the use of multidisciplinary teams and (2) the consistent presence of the same invested clinicians.

CONCLUSION: Culturally competent and invested clinicians, particularly when they partner with interprofessional team members, can help bridge intersectional gaps and provide respectful care for patients with individual needs, as they did for this patient with DD and limited English proficiency facing the decision of whether to proceed with an LVAD.

THINKING TWICE ABOUT BENZODIAZEPINES: TREATMENT OF PROGRESSIVE DEMENTIA IN A HOSPITALIZED PATIENT

Mallika Lal¹; Brian McGarry¹; Arinea Salas¹; Kathleen Drago²; Rebecca A. Harrison³

¹Internal Medicine, Oregon Health & Science University, Portland, OR; ²General Internal Medicine & Geriatrics, Oregon Health & Science University, Portland, OR; ³Division of Hospital Medicine, Orgeon Health and Science University, Portland, OR. (Control ID #3876850)

CASE: A 68-year-old woman presented for three months of progressive decline in mental status. Past medical history was notable for coronary artery disease with recent stent placement, hypothyroidism, major depressive disorder recently started on mirtazapine. Further history revealed visual and auditory hallucinations, paranoid delusions, intermittent inability to recognize family, abnormal behaviors including speaking quietly to herself, and decreased oral intake leading to significant weight loss. Initial exam was notable for labile mood, suspicious and withdrawn affect, inattention, limited speech with increased latency, and decreased participation in exam with no focal neurological deficits, suggestive of hypoactive delirium. Labs on admission were notable for BUN 38mg/dl, Cr 1.12 mg/dl (baseline 0.9), LDH 265 U/L, alb 4.1 g/dl, Hgb 14.9 g/dl, platelets 134 K/cu mm. Homocysteine was elevated at 12.3 umol/L, B12 1565 pg/ml, vit D 25-hydroxy 59 ng/mL. TSH and ammonia levels were normal. Serum RPR and HIV were negative. Urinalysis and culture were negative for infection. A lumbar puncture showed negative workup for infectious, autoimmune, malignant causes, and paraneoplastic encephalitis. EEG showed diffuse slowing without seizures. MRI brain showed white matter changes, likely chronic ischemia. Our working diagnosis was hypoactive delirium and encephalopathy of unclear cause. She received an empiric 5-day course of IV methylprednisolone for autoimmune encephalitis recommended by neurology without improvement. During the lumbar puncture, she was given 0.5mg of IV lorazepam with marked improvement in symptoms. The differential diagnosis for lorazepam responsive delirium includes terminal agitation, alcohol withdrawal or catatonia. She was found to have echopraxia, mitmachen, mutism, staring, and withdrawn affect after stopping the lorazepam. This trial off of lorazepam and recurrence of symptoms was strongly suggestive of catatonia. She was restarted on scheduled IV lorazepam with improvement in symptoms. She transitioned to oral lorazepam and discharged home with support services to follow up with PCP and Geriatrics. At last follow-up, she had partially responded to lorazepam but experienced persistent paranoid hallucinations. The underlying cause of her catatonia is thought to be depression and Lewy Body dementia.

IMPACT/DISCUSSION: Catatonia is a disorder involving changes in movement and speech. The main causes include psychiatric and neurologic diseases including dementia, metabolic abnormalities, and medications. Recognition is important as the mainstay treatment is lorazepam which works by binding GABA receptors and is generally harmful in the elderly. Overlap with depression, dementia, and delirium make it important to recognize early and avoid harmful effects such as immobility and malnutrition.

CONCLUSION: Catatonia can overlap with depression, delirium, and dementia. Early recognition is important, as the main treatment is lorazepam which is generally harmful in the elderly.

TRAVELING LIGHT – WEIGHT MANAGEMENT IN A GERIATRIC PATIENT

Jennifer Meyfeldt

Internal Medicine, Creighton University, Omaha, NE. (Control ID #3867811)

CASE: A 75-year-old woman with a past medical history of hypertension, hyperlipidemia, and primary osteoarthritis of both knees presented to her primary care physician (PCP) to discuss her inability to travel. While the patient had been taking yearly trips to Europe in the past, she now felt unable to tolerate the long- haul flight due to her body habitus and limited mobility. Her weight was 214 lbs and body mass index (BMI) was 40.43 kg/m² consistent with class 3 obesity. Her diet consisted of rice, potatoes, vegetables, fruits, and various meat and dairy products. She reported snacking frequently after dinner. Activity was limited due to chronic knee pain. She was counseled about nutritional basics, behavioral interventions for weight loss, and swimming to increase activity.

Four months later, the patient's weight was 181.0 lbs and BMI was 34.2 kg/m². She reported gradual changes towards a high-protein (90-120 g/day), low carbohydrate (100-200 g/day) diet. She was swimming three times weekly and was walking longer distances, however, with an increase in left-sided knee pain. Due to her improved BMI and functional status, she was able to undergo left total knee arthroplasty.

Nine months after her first visit, her weight was 149.4 lbs and BMI was 28.3 kg/m². She spent her long- desired vacation in Europe. In addition, she reported having more energy, feeling happier, and blood pressure was controlled on 50% of her prior antihypertensive doses.

IMPACT/DISCUSSION: 41.5% of adults in the United States aged 60 and over between 2017-2020 were obese. Body composition changes with aging such as the redistribution of fat mass in the visceral component. These changes can result in sarcopenia (loss of skeletal mass and function), which in turn leads to adverse outcomes such as frailty, disability and loss of independence. However, available data also suggests that BMI < 25 and > 35 kg/m² is associated with higher mortality in the elderly, which has been termed the Obesity Paradox. Based on current recommendations for 0.5–1 kg/week or 8–10% of initial body weight after 6 months, this patient’s weight loss of 65 lbs or 30% within 9 months is considered rapid, raising concern for loss of muscle mass. However, based on her increasing levels of mobility and functional abilities, no formal diagnostic testing for sarcopenia was completed. Furthermore, she maintained the recommended protein intake of 1.0-1.2 g/kg body weight daily and increased her physical activity, both of which have been identified as effective strategies to combat loss of muscle mass and function.

CONCLUSION: This case outlines the positive effects of diagnosing and addressing obesity in a geriatric patient, including improved functional status, mobility, quality of life, and control of chronic medical conditions. The weight loss intervention was delivered in a primary care setting, which emphasizes the importance of formal obesity medicine training of PCPs including special considerations in geriatric patients.

UNDIAGNOSED GIANT CELL ARTERITIS CONTRIBUTING TO SUBACUTE NEUROCOGNITIVE DECLINE AND BEHAVIOR AND PERSONALITY CHANGES IN AN ELDERLY VETERAN

Fei Daly¹; Emily Waner^2,1

¹School of Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ²Medicine, Denver VA Hospital, Denver, CO. (Control ID #3871908)

CASE: A 91-year-old male presented with subacute neurocognitive decline, behavior and personality changes, fatigue, weight loss, anorexia, hypersomnia and increased balance instability. He had significant social and functional decline over a 4-month period where he transitioned from independent living to assisted. He was withdrawn and history was challenging. Initial concern was for dementia, pseudodementia and/or depression, mirtazapine was started. Review of systems were positive for new urinary incontinence and bilateral jaw pain, but no headaches, visual changes, or jaw claudication. Physical exam revealed evidence of malnutrition and TMJ tenderness. Complete infectious workup was negative. Normal pressure hydrocephalus was entertained, but head CT showed normal ventricles. Additionally, he had chronic lacunar infarcts but no signs of acute stroke, bleed, or masses. There was concern for malignancy but no solid tumors or lymphadenopathy were seen on chest, abdomen, and pelvis CT. Labs were notable for a leukocytosis (16,000), normocytic anemia (Hg 10, ferritin 1296), thrombocytosis (857,000), and elevated inflammatory markers (ESR 94, CRP 272) with a normal comprehensive metabolic panel. Due to his non-specific systemic symptoms, elevated inflammatory markers, plus jaw pain a temporal artery biopsy was pursued. Pathology was consistent with giant cell arteritis (GCA). He was started on steroids and tocilizumab, with improved functional status, cognition, and weight stabilization.

IMPACT/DISCUSSION: Given the non-specific concerns, the differential was broad. The parts consistent with GCA were weight loss, anorexia, fatigue and elevated ESR and CRP. However, GCA is uncommon and some classical symptoms (headaches, jaw claudication and vision changes) were missing, which placed it lower on our differential.

From this case, I learned the importance of identifying vulnerable patients in need of more advocacy and support, being mindful of providing high quality care to all patients and being aware of the dangers of anchoring to one diagnosis. Our patient was vulnerable as an elderly man with impaired cognition and function and unable to self-advocate. Additionally, symptoms may exist in patients who are unable to express them. The responsibility falls to the medical team to ensure diagnoses do not get missed and high-quality care is still delivered.

The initial diagnosis was depression with additional decline in cognition and function from either vascular dementia or normal aging. However, this did not completely explain his presentation with lab evidence of an inflammatory response. The team remained open to other causes, making the key diagnosis of GCA.

CONCLUSION: Consider GCA in patients older than 50 with elevated ESR and CRP of unknown etiology.

Pay close attention to systemic findings (weight loss, fatigue, anorexia) in vulnerable adults who might otherwise be unable to communicate their symptoms.

Changes in cognition and function may be more than normal aging or psychiatric.

Clinical Vignette - Healthcare Delivery and Redesign

AN INTERESTING CASE OF MULTIPLE CONGENITAL BILIARY DEFECTS LEADING TO PANCREATICODUODENECTOMY

Kushagra Kumar, Peter Tortora

Medical Student, Penn State College of Medicine, Hershey, PA. (Control ID #3848283)

CASE: A 23-year-old female presents to a New England hospital with concerns of severe abdominal pain. Two weeks prior, she was diagnosed with pancreatitis secondary to alcohol use, a pancreatic duct stone, and an incidentally discovered choledochal cyst during endoscopic retrograde cholangiopancreatography. Upon arrival to the ED, she appeared in mild distress with nausea without vomiting and severe abdominal pain with radiation to the back. Physical exam showed normal vital signs, mild epigastric tenderness, and hypoactive bowel sounds. Her labs were significant for a mild leukocytosis, AST of 502 u/L, lipase of 380 u/L, and amylase 197 u/L. A CT scan showed evidence of acute pancreatitis, multiple biliary filling defects, pneumobilia, and a fluid collection thought to be a pancreatic pseudocyst. After aggressive fluid resuscitation, an ERCP was performed.

Findings were significant for a type 1 choledochal cyst and a new diagnosis of incomplete pancreas divisum indicating two distinct congenital biliary abnormalities. These conditions predisposed her to risk of recurrent pancreatitis, choledochal stones, and cholangiocarcinoma. Surgical oncology determined a pancreaticoduodenectomy would likely be a definitive treatment, and she underwent a planned laparoscopic converted to open pancreatoduodenectomy without intra-operative complications.

IMPACT/DISCUSSION: Choledochal cysts and pancreatic divisum are both rare conditions, and are exceedingly rare concomitantly, with less than a dozen well-documented cases in the literature to our knowledge. The most common clinical presentation of choledochal cyst is recurrent upper abdominal pain, intermittent jaundice, and palpable right upper quadrant abdominal mass. In contrast, the patient in this paper presented with acute pancreatitis. Moreover, there is contention regarding the proper method of diagnosing these concomitant anomalies. The gold standard is ERCP, yet MRCP has been shown to have a higher sensitivity and is noninvasive while 40% of patients with high-risk characteristics, such as female gender and prior pancreatitis, develop post-ERCP pancreatitis. Additionally, there does not appear to be a consensus on surgical treatment, as patients in the literature underwent Roux-en-Y hepaticojejunostomy, Roux-en-Y hepaticduodenostomy, choledochectomy, papillectomy with hepatico-jejunostomy, and ERCP with biliary sphincterotomy. To our knowledge, the patient presented is the only patient with a choledochal cyst and concomitant pancreatic divisum to have undergone pancreaticoduodenectomy.

CONCLUSION: 1. Pancreatic divisum and choledochal cyst are both rare biliary defects that may present with symptoms mimicking pancreatitis

2. MRCP is a viable, noninvasive diagnostic alternative to ERCP that has a higher sensitivity and eliminates risk of post-ERCP pancreatitis

3. Several surgical management options exist for the treatment of choledochal cyst with concurrent pancreatic divisum

MERCURY-INDUCED MEMBRANOUS NEPHROPATHY IN A YOUNG FEMALE

Debbie Marie R. Fermin, Tamara Goldberg, Karim El Hachem

Internal Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY. (Control ID #3875018)

CASE: A 41-year-old female with no PMH presented to her PCP with a 4-month history of bilateral leg swelling and fatigue. She endorsed frothy urine but denied fever, chest pain, shortness of breath, orthopnea or abdominal pain. She recently immigrated from Senegal and her only medication was a topical steroid cream. Physical exam was notable for 1+ bilateral pitting lower extremity edema but also for lichenified plaques on the dorsum of her hands, shoulders and feet. Her laboratory workup revealed nephrotic syndrome with hypoalbuminemia (2.2 mg/dL), hyperlipidemia (LDL of 630 mg/dL) and urine albumin to creatine ratio of 10.6 gm/gm creatinine with a normal eGFR. Upon further questioning, the patient reported chronic use of a cosmetic skin lightening cream from Senegal. The patient was referred to Nephrology for further work up which included negative infectious and autoimmune serologies.

Given prolonged exposure to a skin lightening product, blood and urine mercury levels were sent and were elevated (blood mercury 20.3 [0-14.9 ug/L]), (urine mercury/Cr 139 [<5 ug/L]). Kidney biopsy revealed secondary membranous nephropathy. She was advised to discontinue her lightening cream, started on Lasix and Atorvastatin, and received chelation treatment with succimer. Following chelation, her nephrotic syndrome resolved and her mercury levels normalized.

IMPACT/DISCUSSION: This case highlights the importance of mercury exposure as a potential cause of nephrotic syndrome. While mercury toxicity is rare, one method of potential exposure is through transdermal absorption from lightening creams (1). Mercury has a strong affinity for renal tissue deposition making the kidneys particularly susceptible to injury. (2) The most common underlying pathology is membranous nephropathy, followed by minimal change disease (2). The diagnosis of chronic mercury-induced nephropathy should be suspected in patients with nephrotic syndrome, exposure to mercury containing products, and elevated 24-hour urine mercury (2). Therefore, including a history of transdermal cosmetic product use, particularly from outside the U.S., is essential to help inform the diagnosis (3). The overall prognosis of membranous nephropathy secondary to mercury toxicity is generally good (2) following immediate cessation of exposure and chelation treatment (4).

CONCLUSION: ● Mercury-associated renal damage commonly presents as nephrotic syndrome with membranous nephropathy and minimal change disease as major pathological features.

● Consider transdermal mercury-toxicity as a cause of nephrotic syndrome, particularly in patients without obvious cause who may be using unregulated products containing mercury.

● Membranous nephropathy secondary to repeated exposure to mercury has an overall good prognosis.

Chelation is the mainstay treatment.

Clinical Vignette - Medical Education and Scholarship

ANTIPHOSPHOLIPID SYNDROME PRESENTING AS ACUTE MYOCARDIAL INFARCTION

Helpees Guirguis²; Ronald Oudiz¹

¹Division of Cardiology, Harbor-UCLA Medical Center, Torrance, CA; ²Internal Medicine, Harbor-UCLA Medical Center, Torrance, CA. (Control ID #3874937)

CASE: A 24-year-old male with no past medical history presented from a community hospital with left- sided, non-exertional chest pressure radiating to his left shoulder associated with nausea and diaphoresis. He was found to have ST segment elevations in the anterolateral and inferior ECG leads and diagnosed with ST elevation myocardial infarction and transferred to an academic institution for diagnostic angiography and further care. Past medical history was only significant for marijuana use but no other illicit drug use. Family history was also negative for myocardial infarction or sudden cardiac death.

An emergent coronary angiography where 100% occlusion of the mid left anterior descending coronary artery (LAD) with a large thrombus burden was found. Balloon angioplasty of the LAD was performed in addition to aspiration thrombectomy, which resulted in restoration of blood flow to the LAD, however residual intracoronary thrombus remained. All other coronary arteries were of normal caliber. Work-up and risk stratification for atherosclerosis was initiated included a lipid panel and hemoglobin A1C which were relatively unremarkable. A transthoracic echocardiogram with bubble study showed a normal ejection fraction, with no regional wall abnormalities, no valve disease or patent foramen ovale was seen on Doppler imaging. In addition, the cardioembolic work-up included Doppler ultrasound of all extremities which did not reveal any abnormalities. A hypercoagulable work-up ensued. This included testing for lupus anticoagulant antibody, erythropoietin level, antiphospholipid antibody panel, factor V mutation analysis, homocysteine level, protein C&S activity, and prothrombin 20210G>A . The patient’s antiphospholipid panel including B2 glycoprotein IgM antibody, Cardiolipin IgA, IgG, IgM, Lupus anticoagulant antibody and antiphospholipid IgG antibody were all positive, exceeding the normal range. Patient was discharged on aspirin, rivaroxaban, and metoprolol.

IMPACT/DISCUSSION: This case demonstrates specific clinical features of APS manifesting as a MI including a young age at presentation, coronary artery atherosclerosis as a less commonly etiology, and presence of antiphospholipid antibodies. These features are different from the typical presentation of MI and may prompt further evaluation including hypercoagulable work-up.

The significance of this case highlights the term, myocardial infarction with nonobstructive coronary arteries, which accounts for 10% of acute coronary syndromes. This entity predisposes to typical outcomes and complications of MI including congestive heart failure, arrhythmias, recurrent coronary thrombosis, and death.

CONCLUSION: Venous thrombosis is the most common thrombotic manifestation of APS however, it is rarely diagnosed in relation to MI as the first manifestation of the disease, and therefore it’s underrecognized, highlighting the importance of identifying patients in whom APS manifests in the form of arterial thrombosis.

BETTER LATE THAN NEVER: DELAYED DIAGNOSIS OF PANCYTOPENIA.

Nuzhat Batool¹; Iffat Batool²; Hafsa Majeed¹; Julie Kanevsky¹; Emilie Chan¹

¹Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY; ²Medicine, University of Gujrat Nawaz Sharif Medical College, Gujrat, Pakistan. (Control ID #3874063)

CASE: A 58-year-old woman presented with one week of intermittent positional substernal chest pain associated with fever. She also reported chronic fatigue and a 45-pound weight loss over one year. Her past medical history was significant for hypothyroidism and pancytopenia of unknown etiology requiring intermittent blood transfusions over the previous two years. Her workup included a bone marrow biopsy performed at most recent admission to an outside hospital that showed normocellular trilineage marrow. The exam was notable for a fever of 101 and positional substernal chest pain. Lab results were significant for white blood cells 2,970 /mcL, hemoglobin 7.2 g/dL, and platelets 1,070 /mcL. HIV test and hepatitis serologies were negative. Iron and vitamin B12 levels were normal. Blood smear was unremarkable. She received extensive imaging studies, which were notable for mild splenomegaly and small pericardial and pleural effusions. A lower extremity doppler revealed deep vein thrombosis. Autoimmune serologies revealed antinuclear antibodies titer 1:640 with a homogenous pattern, positive anti-dsDNA antibodies (>1000U/mL), smith (2.4 AI) and histone (9.3 units) antibodies, and positive anti-cardiolipin IgG (35 MPL) and IgM (21 MPL). Further workup revealed a urine protein/creatinine ratio of 2.2 with no urinary cells or casts. The patient’s chest pain was attributed to pericarditis. The patient fulfilled 2019 European Alliance of Associations for Rheumatology/ American College of Rheumatology classification criteria for Systemic Lupus Erythematosus (SLE) based on positive ANA, serositis, proteinuria, leukopenia, thrombocytopenia, and the presence of dsDNA, low C3, and anti-cardiolipin antibodies. She was initiated on glucocorticoids, hydroxychloroquine, and mycophenolate mofetil with improvement in all parameters within days. She is currently following in rheumatology clinic and enjoying remission.

IMPACT/DISCUSSION: When establishing an etiology of pancytopenia, clinicians generally consider three major groups of disorders: bone marrow infiltration, bone marrow failure, and destruction or sequestration of cells. In SLE, pancytopenia can be due to any of these groups or a combination. Pancytopenia in SLE is less common than isolated cytopenias. It usually warrants further investigation with bone marrow biopsy to rule out hemophagocytic lymphohistiocytosis, macrophage activation syndrome, septic or drug-induced myelotoxicity, and hematological malignancies. The diagnosis of SLE in this patient was delayed for over two years as clinicians did not consider autoimmune disease in their differential for persistent unexplained pancytopenia. The absence of classic skin, joint and neuropsychiatric manifestations of SLE likely contributed to the delay.

CONCLUSION: This case emphasizes the importance of keeping SLE in the differentials for pancytopenia.

DON'T BE RASH

Alec Rezigh¹; Austin Rezigh²

¹General Internal Medicine, Baylor College of Medicine, Houston, TX; ²Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX. (Control ID #3852080)

CASE: A 55 year-old man with Human Immunodeficiency Virus (HIV) presented to the emergency room with acute onset diarrhea, anorexia, fevers, and rash. The diarrhea was non-bloody and began 5 days prior. Concurrent nausea limited oral intake; he had no dysphagia or odynophagia. Subjective fevers and chills followed. He then developed erythematous spots over his chest, abdomen, and extremities. He had no abdominal pain, dyspnea, chest pain, sick contacts, vomiting, or headache. He was sexually active with multiple men with inconsistent condom use. He was adherent to his anti-retroviral therapy (ART). He did not use alcohol, tobacco, or illicit substances. He worked at a shelter caring for dogs and cats; some had fleas.

Vital signs were notable for a temperature of 100.2 F (37.8 C), tachycardia to 120 beats per minute, and a blood pressure of 95/64 mmHg. Physical exam revealed regular tachycardia without murmurs and scattered erythematous macules across the trunk and extremities.

Laboratory studies showed hyponatremia, acute kidney injury, aminotransferase elevation, and mild thrombocytopenia. CD4 count was 126; HIV viral load was undetectable. Two days into his hospital course, fever and encephalopathy developed. Blood cultures, stool studies, and lumbar puncture were unrevealing. Computed tomography (CT) of the abdomen revealed hepatosplenomegaly.

With his exposure history, rash, laboratory data, and organomegaly, doxycycline was initiated with concern for murine typhus with resolution of his symptoms. Initial IgM and IgG antibody testing for typhus was negative. Repeat testing two weeks later returned positive, confirming the diagnosis.

IMPACT/DISCUSSION: Murine typhus is a rickettsial illness. Inoculation occurs via infective flea feces in a bite wound, typically via rats, dogs, or cats. The disease is usually mild with an incubation period of 1-2 weeks. The onset of illness is abrupt, with non-specific symptoms followed by fever, rash, and headache. Rarely severe disease is seen. Laboratory, exam, and imaging findings are usually non-specific and include hyponatremia, aminotransferase elevation, thrombocytopenia, hepatosplenomegaly, and rash. The diagnosis is made clinically with confirmation via serology. Caution must be taken as detectable antibody response occurs 5-7 days post-infection (and often longer in immunocompromised hosts) and can lead to initial false- negative results. Repeat testing in 2 weeks is recommended with a fourfold titer increase confirming the diagnosis. Treatment is with doxycycline.

CONCLUSION: - Consider murine typhus in a patient with rash, hyponatremia, aminotransferase elevation, thrombocytopenia, hepatosplenomegaly, and flea exposure

- Initial antibody testing early in a rickettsial disease course can produce false negative results; retest in two weeks to confirm

I’M WELL, BUT I’M NOT: A CASE REPORT OF RECURRENT CALCINOSIS CUTIS IN A PATIENT WITH WELL-CONTROLLED JUVENILE DERMATOMYOSITIS

Stephen A. Akinfenwa, Jessica W. Mary, Areeka Memon, Felicia Tanu, Clara Weinstock

Internal Medicine, University of Connecticut School of Medicine, Farmington, CT. (Control ID #3875233)

CASE: 24-year-old female with a history of juvenile dermatomyositis (JDM), well maintained on hydroxychloroquine, presented with a complaint of left-sided neck swelling that she first noticed a few days after a dental procedure. On exam, a small, painful, and fixed node was palpated just inferior to the left jawline, suspected to be a reactive node to the overlying dusky red skin rash associated with her dermatomyositis. She was provided supportive care for a suspected diagnosis of cervical lymphadenopathy. She returned a year later with a complaint that the same neck swelling steadily continued to grow and was becoming painful. On exam, there was a 20 mm subcutaneous lobular area with calcification overlying the left mandible and extending inferior to the body of the mandible. A small cutaneous/subcutaneous calcified abnormality was noted just inferior to this in the neck. Overlying erythema spread from the mid-mandible, over the calcific mass, to just posterior and inferior to the ear. She was reported to have had multiple excisions of calcified nodes in her left neck over the two years before this presentation. The mass was biopsied, and the pathology was consistent with dystrophic calcinosis cutis. She was started on topical and intralesional sodium thiosulfate, which provided some relief from the pain, but the calcified lesion was not improving. After one year of unsuccessful treatment with topical and intralesional medications, she was subsequently referred for surgical excision of the calcinosis

IMPACT/DISCUSSION: Calcinosis cutis is rare disease often associated with autoimmune connective tissue diseases like dermatomyositis. Although calcinosis cutis is not uncommon in JDM, it is rare and unusual for recurrent calcification on a non-traumatic area of the body, as in our patient on the neck. The underlying mechanism for calcinosis is not fully understood; it is often excruciating and prone to superimposed infections. The treatment is often complex. There is insufficient data available to determine the most effective treatment. However, responses to a wide variety of therapies have been reported in the literature. Some pharmacologic treatment options include drugs such as topical sodium thiosulfate,

colchicine, and diltiazem. Another treatment option is the surgical removal of the calcinosis. Although reports of poor wound healing and sinus tract formation increase the risk for surgical removal, evidence suggests that it is the most effective in some patients

CONCLUSION: Our patient presented with recurrent calcinosis cutis on the face and neck, highlighting this rarity. The most recommended treatment is with topical or intralesional medications. She did not improve with the conventional treatment and required multiple surgeries to excise the lesions, resulting in notable morbidity. As more cases of difficult to treat atypical locations of calcinosis come to light, earlier surgical intervention for a localized lesion may be considered to reduce progression and morbidity

MONKEYPOX MIMICRY: A CASE OF SECONDARY SYPHILIS PRESENTING AS MONKEYPOX

Ahmed K. Saleh¹; Jennifer L. Girard¹; Ammar Hasnie¹; Meghan Black²

¹Internal Medicine, The University of Alabama at Birmingham College of Arts and Sciences, Birmingham, AL; ²General Internal Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL. (Control ID

#3867911)

CASE: A 56-year-old man with a history significant for HIV presented to clinic with a complaint of a new pruritic rash on his chest. He first noticed the rash five days prior and since had progressed to his thigh . He received his monkeypox vaccine three days prior to the visit. He denied any developing genital, anal, or oral lesions or constitutional symptoms including fevers, chills, or malaise. He was compliant with his anti- retroviral medication and his last CD4 count was 900. He last had protected sexual intercourse 6 months ago, but did recently have an HIV positive friend visit from Mexico.

On exam, temperature was 97.9 F, blood pressure 115/61, and heart rate 117. Skin exam was revealing for multiple, purple, maculopapular lesions, a few with slight umbilication and crusting, on the left inner thigh and chest. No lymphadenopathy was appreciable.

Labs were notable for a mild leukocytosis with a negative monkeypox PCR and reactive RPR with titer 1:128 and FTA-ABS. He was treated with penicillin with resolution of his symptoms at follow up.

IMPACT/DISCUSSION: With the recent monkeypox outbreak and the prevalence in MSM populations, an important clinical consideration is the similarity in presentation between secondary syphilis and acute monkeypox infection. This case provides an example of this unique diagnostic challenge.

Secondary syphilis is a difficult diagnosis due to its variable presentation and decreasing prevalence. The most common manifestation of secondary syphilis is a cutaneous eruption that may be macular, papular or pustular. Syphilitic rashes are typically non-painful and non-pruritic with predilection for the palms, soles, and hairline of the forehead. Other systemic features can occur but are not considered hallmark.

In contrast, monkeypox infections usually present with a prodrome of fever, chills, headache, lethargy, and muscle aches prior to onset of the rash. The monkeypox rash typically presents on the face, hands, legs, and feet. It usually undergoes stages of evolution from macules, papules, and vesicles and may be painful and pruritic. Lesions typically crust and scab leaving areas of erythema and skin hyperpigmentation.

In our case, this man presented with an atypical syphilis rash that was concerning for early monkeypox given a questionable recent exposure and pruritic maculopapular rash. While monkeypox is increasing in prevalence, this case highlights the importance for internists to continue to consider atypical presentations of more common conditions like syphilis.

CONCLUSION: Both secondary syphilis and monkeypox present with variable cutaneous manifestations. Key differences include:

- Monkeypox commonly presents with pain and pruritis, unlike secondary syphilis.

- Monkeypox rash frequently presents after an infectious prodrome while secondary syphilis has a more indolent presentation.

- Secondary syphilis can have a variable presentation like that of monkeypox. It is important to consider also testing for syphilis if testing for monkeypox.

PEMBROLIZUMAB INDUCED HYPOTHYROIDISM IN PATIENT WITH METASTATIC UTERINE SEROUS CARCINOMA MANIFESTING AS MYXEDEMA CRISIS

Lavleen Kaur, Ravleen Kaur, Lekha Yadukumar, Muhammad Hassan Shakir, Aayushi Sood, Omar Z. Syed, Nirali Patel

Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA. (Control ID #3876817)

CASE: 64 year old women diagnosed with high grade endometrial carcinoma underwent hysterectomy with bilateral salpingo-oophorectomy with bilateral pelvic and paraaortic lymph node dissection. Post operatively the histological diagnosis was high grade uterine serous carcinoma. Subsequently the patient was found to have pulmonary metastasis after CT scan revealed a new 8x9 mm lobulated nodule in the right lower lobe, 4 mm nodule in left upper lobe and was treated with 7 doses of pembrolizumab so far. She presented to the emergency department with acute failure to thrive and hypotension along with fatigue and constipation that began two months before presentation. Lab work was consistent with myxedema crisis with elevated TSH > 90, low T3 and T4 , hyponatremia, elevated creatinine and sinus bradycardia with non-specific ST-T wave changes on the EKG. Patient was admitted to ICU and was treated with IV levothyroxine, IV hydrocortisone and fluids. Patient’s hemodynamic status and lab indices improved with treatment and she was transitioned to oral levothyroxine. Eventually the patient was diagnosed with TPO antibody negative hypothyroidism. Pembrolizumab was re-commenced once her thyroid stabilized and latest CT scan revealed a decrease in the size of pulmonary nodules.

IMPACT/DISCUSSION: The advent of immune checkpoint inhibitors (ICIs) has significantly improved the prognosis of patients with advanced malignancies. Pembrolizumab blocks the programmed cell death 1 pathway to help prevent cancer cells from hiding and helps the immune system to detect and fight cancer cells. Given their mechanism of action, immune-related adverse events (irAE) have been associated with their use, of which endocrinopathies like hypothyroidism, hyperthyroidism are common in patients treated with pembrolizumab. Most chemotherapeutic agents cause thyroid dysfunction in 20%–50% of patients. The exact mechanism by which pembrolizumab triggers hypothyroidism is exactly unknown but is most likely immune mediated. Hypothyroidism may also result because of the interaction of thyroid hormone with G protein- coupled membrane receptors and the mitogen activated protein kinase pathways and via actions on many levels of the hypothalamic-pituitary-thyroid axis. Due to the complexity in the cancer patients, hypothyroidism is often overlooked and can lead to serious complications. Therefore close monitoring of patients receiving these medications is required which may allow early recognition and treatment of thyroid disease, allowing continued treatment of the underlying cancer, as well as improving the quality of life of the patient.

CONCLUSION: Various immune-related adverse events have been associated with the use of immune checkpoint inhibitors (ICIs) including pembrolizumab. Underdiagnosis can have important consequences for the management of both hypothyroidism and the malignancy, therefore physicians should counsel patients about the potential irAEs and educate them about the various symptoms.

POST-MISCARRIAGE NEUROMYELITIS OPTICA SPECTRUM DISORDER: TRIGGER OR CO- INCIDENCE?

Muhammad A. Khan, Jose A. Mansen Arrieta, Grace Kajita

Internal Medicine, Montefiore Wakefield Campus, Bronx, NY. (Control ID #3874919)

CASE: A 36 year-old African-American woman with miscarriage one week prior presented with bilateral lower extremity paralysis associated with urinary retention, constipation, and fever. She was febrile to 100.9 F with normal vitals. Physical exam was significant for zero motor strength and diminished reflexes, and pinprick sensation in bilateral lower extremities. She had mild leukocytosis 12.1 k/uL (4.8 - 10.8 k/uL), microcytic anemia with Hb of 9.6 g/dl (12.2 - 15.3 g/dL), elevated ESR and CRP, negative antiphospholipid screen, and positive thyroid peroxidase and thyroglobulin antibodies (TPO Ab and TG Ab, respectively). MRI spine revealed long segment thoracic spinal cord signal abnormality from T4 through conus, consistent with transverse myelitis. Cerebrospinal fluid study was significant for Aquaporin 4 (AQP4) confirming the diagnosis of Neuromyelitis Optica Spectrum Disorder (NMOSD). The patient received Solu-Medrol 250 mg IV Q 6 hrs for five days, Eculizumab infusions, and physical therapy. Her bilateral lower extremity strength improved to 5/5 with 2+ reflexes. She is now able to walk with a cane.

IMPACT/DISCUSSION: NMOSD is a rare autoimmune disorder with various genetic and environmental risk factors with several contributing molecular mechanisms. It is predominant among middle-aged women and individuals with seropositive AQP4 antibodies. Ethnically, the incidence and prevalence are highest among Africans. Similar to our patient, NMOSD patients are more likely to have positive TPO Ab and TG Ab. Brain and cervical cord lesions are more common in NMOSD patients with anti-thyroid antibodies abnormalities, whereas our patient had a long segment thoracic spinal cord signal abnormality from T4 to the conus. Patients with NMOSD are at risk for miscarriages, mostly in the preceding three years, or after disease onset. For our patient, her miscarriage may have represented an early complication of NMOSD. Pregnancies have also been associated with increased NMOSD disease activity, which, for our patient, may explain timing of onset of symptoms. More studies are needed to determine temporal relationship of miscarriages with onset of disease.

CONCLUSION: Positive TPO Ab and TG Ab have a strong positive correlation with NMOSD. NMOSD can present with isolated transverse myelitis without optic neuritis. More studies are needed to determine temporal relationship with pregnancies/miscarriages.

Clinical Vignette - Medical Ethics and Humanities

A CASE OF END STAGE ALCOHOL RELATED LIVER DISEASE: COMMUNICATION STRATEGY FOR NAVIGATING CLINICAL UNCERTAINTY AND EXAMINING THE 6-MONTH RULE IN LIVER TRANSPLANTATION

Hannah M. Borowsky^1,2; Abigail Schiff^1,2; David Rubins^1,2

¹Department of Medicine, Brigham and Women's Hospital, Boston, MA; ²Harvard Medical School, Boston, MA. (Control ID #3875899)

CASE: RW was a 44-year-old man with mild transaminitis and daily alcohol use who was incidentally noted to have a cirrhotic appearing liver and ascites while undergoing elective cholecystectomy. His post-operative course was complicated by bowel perforation and decompensation of his newly diagnosed cirrhosis including hepatic encephalopathy and hepatorenal syndrome.

The liver transplant (LT) board deemed RW to not be a candidate for LT in part due to recent alcohol use. As his clinical status deteriorated, multiple conversations were held with RW and his family about prognosis and therapeutic options, including seeking re-evaluation for LT elsewhere, continuing supportive care at a hospital close to home, or initiating hospice. Ultimately, RW died surrounded by family several weeks after transferring to a local hospital.

IMPACT/DISCUSSION: Discussions about prognosis for patients with end stage ALD can be particularly challenging given uncertainty surrounding the possibility of LT and risk of rapid decline. At most U.S. LT centers, a recent history of alcohol use precludes LT until cessation is maintained for at least 6 months (the “6-month rule”), a time period many patients cannot survive.

To aid RW’s decision making, we employed the “best case/worst case scenario” communication framework to share prognostic information and promote decision-making aligned with patient goals. The medical team shared a best-case scenario (i.e. successfully undergoing a highly invasive transplant surgery with a long road to recovery) and a worst-case one (i.e. dying in the hospital far from family). Additionally, sharing the “most likely scenario” helped the team convey their worries without depriving RW of hope.

Historically, LT boards have used the “6-month rule” in their evaluation, making cases like RW’s difficult. ALD is the most common indication for LT, and survival rates are remarkably high (84% at 1-year), similar or superior to rates for those who receive LT for other reasons. Additionally, studies show that a 6-month cessation period does not predict risk for relapse or survival.

Restrictive practices around LT for ALD are informed by societal stigma, not scientific evidence. Alcohol use disorder is a chronic relapsing disease with effective medical and psychosocial treatments that can be given concurrently with LT. Denying life-saving LT to this population conflicts with ethical obligations to promote beneficence and equity. Widespread LT board policy change and research to advance medical and psychosocial treatments available to patients with ALD are needed.

CONCLUSION: For patients facing challenging treatment decisions, sharing the best case, worst case, and most likely scenarios can help navigate uncertainty and promote goal-aligned decision making.

LT can be a life-saving intervention for patients with ALD. There is evidence that patients who undergo LT without 6-months of alcohol cessation have equivalent outcomes and relapse rates compared to patients for whom the 6-month rule is applied.

GOING THE EXTRA MILE

Anand Habib, Brad Sharpe. Medicine

University of California San Francisco, San Francisco, CA. (Control ID #3877232)

CASE: A healthy 40-year-old limited-English proficient foreign national presented with a rapidly growing painful neck mass. While at sea as a merchant marine, he noted three weeks of dysphagia, one week of dysphonia, and 10kg of weight loss. Labs revealed a low TSH of 0.02mIU/L and normal free T4 of 6mcg/dL. Computed tomography showed a 10.8x6.3cm mass encasing his right carotid artery and necrotic lymph nodes. A broad differential was considered. Fine needle aspirate revealed stage 4b, BRAF+ anaplastic thyroid carcinoma (ATC).

Given his BRAF+ tumor, he urgently began a new oral therapy of dabrafenib/trametinib. Within days, his neck movement, dysphagia, and pain improved. Within a week, the mass had shrunk to 6.8x3.7cm. Given his lack of U.S. visa and rising hospital costs, his employer and their travel insurer asked about his repatriation. His multidisciplinary inpatient team ardently advocated for him to remain in the U.S. as he likely could not access the effective oral therapy in his home country. After four more days of extensive care coordination, he was discharged with a guard to a local hotel on ‘medical parole.’ He had successful surgical resection three months later and seven weeks of adjuvant chemoradiation. Six months are hospitalization, he returned home with a year’s supply of dabrafenib/trametinib.

IMPACT/DISCUSSION: We approach the diagnosis of neck masses based on temporality. Acute neck masses are usually due to infections (e.g., CMV, EBV, HIV, TB, Bartonella, Toxoplasma, upper-respiratory or odontogenic illnesses). Subacute masses are commonly neoplastic (squamous cell, lymphoma, parotid tumor) or from non-infectious systemic illness (e.g., amyloidosis, sarcoidosis, Sjogren’s). Chronic masses are generally thyroid pathologies, benign tumors (e.g., carotid body), or cysts (e.g., branchial cleft, thyroglossal duct). Despite the subacute onset, this patient’s rapidly progressive neck mass was a BRAF+ ATC.

ATC is a rare (2%), aggressive thyroid cancer with usual median survival of five months. 10-50% of ATC are BRAF+. RAF/MEK inhibition with dabrafenib/trametinib has improved median survival to 15 months. This patient responded within days of starting therapy.

New cancer therapies both offer hope and are exorbitant. One month of dabrafenib/trametinib is $26,500. Physicians have a complex fiduciary duty to their patients and to the healthcare system. Weighing these priorities is challenging. Utilitarianism would criticize this patient’s outcome given the costs and tradeoffs. While healthcare resources are limited, rationing based on ability to pay reifies health inequities. Dogged advocacy despite medicolegal and financial barriers led to this vulnerable patient's otherwise unlikely excellent outcome.

CONCLUSION: ATC is a cannot-miss, rare diagnosis for generalist clinicians. Distributive justice enjoins us to approach ethical quagmires of balancing individuals’ health with steep financial costs via a preferential option for the most socially vulnerable patients.

Clinical Vignette - Mental/Behavioral Health and Substance Use Disorders

A TALE OF TWO EPIDEMICS: COMORBID ALCOHOL USE DISORDER AND OPIOID USE DISORDER

Carter Baughman¹; Julia Lindenberg²

¹Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #3871962)

CASE: A 49-year-old female with a history of depression, gastric bypass surgery, alcohol use disorder (AUD), and opioid use disorder (OUD) well-controlled on buprenorphine-naloxone presents to her primary care physician after admission for alcohol withdrawal and ketoacidosis. She states that her AUD has been difficult to control for the past year after the passing of a family member. Since hospital discharge, she has continued to use alcohol daily and is interested in treatment. Due to contraindication of starting naltrexone with buprenorphine-naloxone, she was prescribed acamprosate. Despite close follow-up, she did not start the acamprosate. She is subsequently admitted for alcohol-associated pancreatitis.

IMPACT/DISCUSSION: AUD and OUD affect over 34 million US adults annually. Despite this prevalence and USPSTF screening guidelines, AUD and OUD are significantly underdiagnosed and undertreated in primary care. In 2019, only 7.3% of US adults with AUD received any treatment and 28% of people with OUD received treatment. Patients with comorbid AUD and OUD on opioid therapy are particularly challenging to treat, because the most effective pharmacotherapy, naltrexone, is contraindicated.

Naltrexone, acamprosate, and disulfiram are FDA-approved medications for AUD and should be considered in all patients with moderate-severe AUD. Naltrexone decreases cravings, the risk of relapse, and binge drinking. Acamprosate reduces the risk of relapse but not binge drinking, thus is more effective in abstinent patients, and is dosed TID. Disulfiram causes unpleasant side effects when mixed with ethanol and has shown sustained abstinence in meta-analyses but not blinded trials. Naltrexone is therefore preferred due to its efficacy, once daily dosing, and ability to be started while the patient is using alcohol. Topiramate, baclofen, and gabapentin are used off-label for AUD. Topiramate modestly improves abstinence and binge drinking, and baclofen increases time to relapse and abstinence. Gabapentin increases rates of abstinence on a dose dependent scale. These agents should be considered in patients with contraindications to naltrexone.

While naltrexone is contraindicated for patients with AUD and OUD on opioid therapy, naltrexone otherwise is a first line agent for both AUD and OUD. Methadone and buprenorphine are often used for OUD alone and may be inappropriate for urgent OUD treatment due to an initiation barrier to naltrexone. However, in patients successfully initiated with extended-release naltrexone, it is equally as safe and effective as buprenorphine-naloxone for OUD. Thus, internists should have heightened awareness for a potentially critical window to initiate naltrexone for patients with comorbid AUD and OUD.

CONCLUSION: Internists should be cognizant of the underdiagnosis and undertreatment of AUD and OUD and work to screen for and treat these chronic conditions. Patients and clinicians would benefit from further study of best practices for managing patients with comorbid AUD and OUD.

DELAYED COGNITIVE IMPAIRMENT POST-ACUTE HYPOXIC ENCEPHALOPATHY

Triet Le²; Duc Le¹; Mark Fredrickson¹; Bei Zhang¹; John Norbury¹

¹School of Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; ²School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX. (Control ID #3877219)

CASE: A 75-year-old man had 6-day of ICU stay for acute hypoxic respiratory failure following cardiac arrest, during which he also had a short episode of seizure-like activity. In PCU, wife reported that he had an episode of altered mental status overnight. After 6 days of Seroquel regimen, he remained intermittently confused prior to getting transferred to an inpatient rehabilitation facility (IRF) with a diagnosis of hypoxic encephalopathy. At the IRF, patient's Saint Louis University Mental Status (SLUMS) score was 12/30 which indicated cognitive impairment. On Day 5, Amantadine 100mg BID and Donepezil 10mg QHS were started as wife reported that patient started waking up and getting out of bed at night. Patient’s cognition gradually improved. On Day 8, wife reported that patient “finally returned to his normal self”. Amantadine and Donepezil were continued through 23 days of his IRF stay. By discharge, the patient's SLUM score improved to 27/30.

IMPACT/DISCUSSION: Amantadine is well-documented to effectively accelerating the recovery process of patients with traumatic brain injury. The purported mechanism of amantadine is facilitating presynaptic release and blocking reuptake of dopamine and antagonizing N-Methyl-D-aspartate (NMDA) receptors, thus exerting neuroprotective and stimulative benefits. Donepezil, an acetylcholinesterase inhibitor, is known to improve the cognitive performance in patients with mild cognitive impairment. For our patient, Quetiapine, a commonly used antipsychotic agent carrying antihistaminic, α1-adringergic, and antidopaminergic properties, didn’t help with confusion and cognitive impairment following hypoxia and electrophysiologic disturbances. The patient improved rapidly after starting on Amantadine and Donepezil. From a neurorehabilitation perspective, we would hope the case raise clinicians’ attention to potential benefits (e.g., accelerated recovery) of using selected neuropharmacological agents in hypoxic and metabolic brain injuries.

CONCLUSION: Patients with significant cognitive impairment following hypoxic encephalopathy may benefit from treatment with Amantadine and Donepezil. Further controlled studies are needed.

EXPECT THE UNEXPECTED - A RARE CASE OF MYROIDES ODORATIMIMUS BACTEREMIA IN A PATIENT WITH INJECTION DRUG USE

Benjamin L. Jones¹; Leslie Suen^2,3; Daniel Minter⁴

¹University of California San Francisco School of Medicine, San Francisco, CA; ²Division of General Internal Medicine, University of California San Francisco, San Francisco, CA; ³Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA; ⁴Division of Infectious Diseases, University of California San Francisco, San Francisco, CA. (Control ID #3861116)

CASE: A 36-year-old unhoused, cisgender man with heart failure due to chronic methamphetamine use was brought to the emergency room with altered mental status after being found down. He was afebrile and normotensive but was in respiratory failure, and his exam was notable for facial and lower extremity edema. He had a white blood cell count of 20.0 k/uL and severe respiratory and metabolic acidosis. The patient was admitted to the ICU for heart failure exacerbation and mixed cardiogenic and septic shock, and was started on empiric ceftriaxone. Two of 2 blood cultures drawn on admission grew Myroides odoratimimus with susceptibility testing later revealing elevated MICs to ceftriaxone (32 mcg/mL) and cefepime (8 mcg/mL). Antibiotics were escalated to meropenem, then transitioned to levofloxacin following clinical improvement to complete a 10-day course. Blood cultures were negative at discharge.

The patient disclosed that he often injected methamphetamine using environmental water and saliva, and our addiction consult service found he was not ready to reduce injection drug use (IDU). He was later provided with syringes, sterile water, and other safer injection supplies through a collaboration between our hospital and a community organization.

IMPACT/DISCUSSION: As our patient presented from the community, we expected him to be at low risk for multidrug-resistant (MDR) pathogens. To our surprise, his bacteremia was due to Myroides species, which rarely infect humans but tend to exhibit complex drug resistance. Myroides species are gram negative, non- fermenting bacteria that live in water and soil. Approximately 60 cases of Myroides infections have been reported, including bacteremia, cellulitis, and endocarditis. Our patient reported IDU with non-sterile water, which we suspected was the likely source of his infection. This is the first reported case of Myroides bacteremia due to IDU to our knowledge.

Infectious complications are increasingly common in patients hospitalized with IDU, and include HIV, hepatitis C, and bacterial infections. As infections rise, cases involving rare and potentially difficult to treat pathogens like Myroides species are also likely to increase.

Avoiding IDU is the best way to prevent infections, but not all patients are ready to stop injecting for many reasons, including social and structural challenges. Harm reduction is a set of strategies known to reduce infectious complications of IDU and promote wellness for people who use or inject drugs (PWID). These include education on safer drug use and distribution of sterile supplies for use in substance preparation and injection. Our patient was not prepared to reduce his use, highlighting the importance of harm reduction in this case.

CONCLUSION: Clinicians should be aware that PWID may be at increased risk of infections caused by rare and potentially MDR pathogens like Myroides species. Access to harm reduction supplies is a crucial tool in the prevention of IDU’s infectious complications, common and rare alike.

PROVIDER AND PATIENT AWARENESS OF SYNTHETIC OPIOID CONTAMINATION IN RECREATIONAL DRUGS CAN SAVE LIVES

Katherine E. Mooney, Linda Baier Manwell, David A. Feldstein

Department of Medicine, Division of General Internal Medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #3869442)

CASE: A 63yo male with hyperlipidemia, depression, and history of polysubstance use presented for depression follow-up. He reported hopelessness, sadness, and insomnia, which increased after the unexpected death of a brother two years ago. He was previously prescribed escitalopram for depression but only used it briefly. He had quit all recreational drugs but started using cocaine again since his brother’s death. He denied IV drug use and reported one alcohol drink per day and occasional cigar use. He lives with two siblings; most family members have substance use disorders and relationships are volatile. His vitals, exam, and TSH were normal. PHQ-9 and GAD-7 scores were 14 and 9, respectively. He agreed to re-start escitalopram and scheduled in-clinic psychotherapy while awaiting drug treatment. Our region has had multiple hospitalizations from cocaine contaminated with fentanyl, so we offered urine drug screening. It was positive for both substances. We provided naloxone, fentanyl test strips, and instructions on their use.

IMPACT/DISCUSSION: Opioid overdoses and deaths continue to increase in the U.S. despite a 50% decrease in opioid prescribing over the last decade. The epidemic is driven by synthetic opioids like fentanyl. In the 12-months ending in January 2022, 107,000 people died from overdoses and two-thirds were due to synthetic opioids. Synthetic opioids are increasingly found in cocaine, methamphetamines, and heroin, and many people are unaware of exposure to potentially lethal substances. Cocaine overdose deaths rose from 5,419 in 2014 to 19,447 in 2020 largely due to the presence of synthetic opioids. Knowledge of local drug contamination with synthetic opioids can help determine a patient’s risk of exposure. If this is unknown, toxicology panels can identify exposure. Providers can help decrease mortality for patients who are at risk of accidental exposure and overdose by prescribing naloxone and instructing on its use. Fentanyl test strips, which detect fentanyl and its analogs, can also decrease the risk by alerting patients to the presence of synthetic opioids in recreational drugs. Emerging research suggests changes in drug use behaviors, such as reducing the amount used or having naloxone nearby, when patients are made aware that a drug contains fentanyl. Fentanyl test strips are legal in about half of the states and available without a prescription. They are free at some pharmacies, syringe service providers, and opioid treatment programs. This case made me aware of the risk of accidental opioid overdose for patients using non-opioid drugs. I will discuss preventive methods with my patients who use substances known to have possible opioid contamination.

CONCLUSION: Patients with non-opioid substance use disorder may be at risk of opioid overdose and death. In the clinical setting, providers can lower risk by testing patients for synthetic opioids, prescribing naloxone and, where legal, recommending fentanyl test strips.

THE CATATONIC DILEMMA: A DIFFICULT AND COSTLY DIAGNOSIS

Monica H. Klaybor, Brad A. Keith

Internal Medicine, Medical University of South Carolina, Charleston, SC. (Control ID #3876182)

CASE: A 36-year old female with schizoaffective disorder presented mute and unable to follow commands. Prior to hospitalization, her mother reported the patient became withdrawn and aggressive. After 3 months at her regional hospital with diagnostic work-up unrevealing and no improvement in presumed catatonia, she was transferred to our institution for higher level of care. Initial physical exam showed tachycardia, tachypnea, and afebrile. The patient was lying in bed; diaphoretic. Bilateral lower extremity plantar flexion was present along with diffuse rigidity. Deep tendon reflexes demonstrated diffuse hyperreflexia. Abnormal labs were CK 958 U/L and WBC 11 k/cumm. Other infectious, autoimmune, and metabolic labs including CSF studies were unremarkable. Imaging showed no abnormalities. EEG showed no seizure activity. Neurology and Psychiatry provided competing diagnoses of encephalitis and malignant catatonia. Treatment for malignant catatonia with high doses of lorazepam was initiated with little improvement. Electroconvulsive therapy (ECT) was started and improvements in mentation and rigidity slowly began after ECT session #21. She began responding to commands and answering questions appropriately. She completed 36 inpatient ECT treatments with significant resolution of catatonia. Her hospital course was complicated by nosocomial COVID-19 infection, neck abscess, segmental PE, gastrostomy tube placement, and 6 urinary tract infects associated with Foley catheter use. She was ultimately discharged after 187 days at our institution to a rehabilitation facility with continued Lorazepam treatment and 8 more outpatient ECT sessions.

IMPACT/DISCUSSION: Catatonia is a syndrome that co-occurs with several psychiatric and medical conditions, and has been deemed ‘the catatonic dilemma’ due to the heterogeneous presentation and frequent misdiagnoses. The patient presented with mutism, profound rigidity, autonomic instability, and delirium. Encephalopathy was difficult to rule out due to her presentation. She was not a candidate for an inpatient psychiatric ward or outpatient management due to her inability to perform activities of daily living. Symptomatic improvements with ECT sessions were gradual over time. The national US average cost for a hospitalization is $11,700 per night and $2,500 per ECT session. In this case, insurance reimbursed our hospital $898,828 for the 6-month length of stay at our institution. When patients with malignant catatonia are stable, moving care to a skilled nursing care facility with outpatient ECT could potentially reduce the financial burden to patients and hospital systems.

CONCLUSION: Malignant catatonia typically presents with mutism, profound rigidity, autonomic instability, delirium, and fever in a patient with psychiatric disorders. Early recognition and treatment with ECT if refractory to benzodiazepines is critical for patient improvement. The diagnostic work-up and treatment of malignant catatonia can result in a costly, prolonged hospital course.

THE QUIET CULPRIT: A CASE OF SILENT SYNDROME

Abigail Clark¹; David S. Thylur²

¹Internal Medicine and Psychaitry, Emory University Woodruff Health Sciences Center, Atlanta, GA; ²Emory University, Atlanta, GA. (Control ID #3867801)

CASE: A sixty-four-year-old man presented to an emergency department with a three-week history of constipation and symptoms concerning for a manic episode. He had a diagnosis of bipolar disorder type I treated with lithium and clozapine for many years. On exam, he was hyperactive and hallucinating. His abdomen was distended; he had a coarse tremor and unsteady gait. Lithium level was 1.3 mmol/L (normal 0.6-1.2 mmol/L) . Clozapine level was 396 ng/mL (normal: 350-900 ng/mL). An abdominal radiograph revealed multiple loops of distended small bowel consistent with ileus. The patient was admitted to a medicine service with a diagnosis of clozapine-induced ileus complicated by an acute manic episode with psychotic features. His clozapine and lithium were discontinued. After five days, the patient’s ileus and neurologic symptoms improved. His lithium and clozapine levels were undetectable. His mania, however, worsened. Consult psychiatrists on his care team recommended restarting lithium. After receiving one dose of lithium 900 mg, the patient had a seizure. He was also disoriented, with a coarse tremor and gait instability. Lithium level was 0.7 mmol/L. Other diagnostic testing was normal. Lithium was discontinued due to concern for lithium neurotoxicity. Within a few days, his disorientation resolved, but he still had a tremor and gait instability. Ultimately, he was transferred to a psychiatric hospital and three months later exhibited persistent tremor and gait instability. His presentation was consistent with SILENT syndrome.

IMPACT/DISCUSSION: Bipolar disorder affects up to four percent of adults in the United States and is a condition the General Internist will likely encounter. Lithium is a first-line treatment for bipolar disorder. Given its narrow therapeutic index, lithium toxicity is a common problem. The syndrome of irreversible lithium-effectuated neurotoxicity (SILENT) is defined as neurologic dysfunction—most often cerebellar and brainstem dysfunction—in the absence of prior neurologic illness, that persists for at least two months after discontinuing of lithium. SILENT syndrome is rare and most often occurs after lithium toxicity at therapeutic or supratherapeutic lithium levels. Lithium distributes slowly into the brain as compared to the blood, meaning serum lithium levels often do not correlate with brain lithium concentration. In our patient, for example, his neurologic symptoms were a more valuable indicator of neurotoxicity than serum measurements. SILENT syndrome may occur after any type of lithium toxicity including acute, chronic or acute-on-chronic toxicity, but most often occurs following chronic toxicity; its symptoms may remain present indefinitely.

CONCLUSION: This case demonstrates the potential for serious neurologic sequelae to arise from chronic lithium use and for neurotoxicity to occur at therapeutic lithium levels. Careful attention should be given to new neurologic findings in patients taking lithium long-term in order to prevent SILENT syndrome.

WALKING ALONGSIDE ALCOHOL USE IN THE OUTPATIENT SETTING

Patricia N. Tyson, Andrew J. Klein

Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #3876873)

CASE: Ms T is a 31-year-old mother of four who presented to the ED 27 times for acute on chronic pancreatitis flares after consumption of alcohol prior to being connected to outpatient continuity clinic. In addition to frequent ED visits, in the year prior to outpatient care, she had multiple prolonged hospitalizations after which she was discharged with a G-J tube for tube feeds.

Each time she was hospitalized, she minimized her alcohol consumption and the way alcohol has impacted her life. With each encounter, concerns that alcohol was negatively impacting her health were reiterated.

Four months after joining continuity clinic, she stopped drinking alcohol. While she continued to have multiple ED visits for abdominal and chest pain management, they became less frequent. She has become able to endure the chronic pain without frequent presentations to healthcare settings for opioid pain medications. She was now devastated by the state of her body. She has advanced hepatic fibrosis, chronic abdominal pain with nausea, poor PO intake and is debilitated from multiple long hospitalizations. She engaged with physical and behavioral health, chronic pain and GI specialists to improve her care.

Since joining continuity clinic, over the last 9 months, she has been to the ED 7 times for pain management, suggesting the positive impact a primary care team can have on a pathway to sobriety in patients with alcohol and opioid co-use and chronic pain.

IMPACT/DISCUSSION: Ms. T showed the impact continuity clinic can have on the intersection of alcohol, opioid co-use and chronic abdominal pain. Alcohol and opioid co-use has been associated with chronic pain. This has been shown to particularly impact those who have low distress tolerance or the ability to cope with negative emotions (Zegel et al 2021). This co-use with chronic pain decreases the likelihood of treatment for either substance use disorder (Witkeiwitz 2018)

Brief Alcohol Interventions have long been determined to have positive outcomes for patients with alcohol use disorder. It involves a 5-25 minute intervention that is designed focus on the negative health outcomes of alcohol use and motivate recovery (O’Donnell 2014). It has shown overall reduction in alcohol use (Kaner et al 2018).

While the majority of PCPs feel as though they can legitimately address AUD in the clinic (88%), many barriers including lack of time (63%), training (57%) and poor task-related self-esteem (53%) prevent them from addressing alcohol use in the clinic (Wilson et al, 2011). Ms. T’s ongoing recovery shows the importance of engaging this intersection in the outpatient setting despite the barriers.

CONCLUSION: Chronic pain along with low distress tolerance increase the likelihood of alcohol and opioid co-use.

Brief Alcohol Interventions are short interventions that are ideal for primary care and have been shown to decrease total alcohol use.

Primary care offices have found many barriers to implementing these interventions despite the benefits for patients.

Clinical Vignette - Quality Improvement and Patient Safety

ACQUIRED THROMBOTIC THROMBOCYTOPENIC PURPURA IN HIV POSITIVE INDIVIDUALS.

Aisha Sultana Shaik¹; Bushra Jilani¹; Shubham Agrawal¹; Neel S. Patel¹; Sabah Iqbal¹; Nithya Ramesh¹; Sohiel Deshpande¹; Rakin Rashid³; Rajesh Thirumaran²

¹Internal Medicine, Mercy Fitzgerald Hospital, Darby, PA; ²Hematology and Oncology, Mercy Fitzgerald Hospital, Darby, PA; ³Internal Medicine, Trinity Health, Lansdowne, PA. (Control ID #3875379)

CASE: A 28-year-old female with no significant past medical history presented to our hospital with complaints of dizziness and a fall associated with a brief loss of consciousness. She was tachycardic on arrival, and labs showed hemoglobin-10.2, platelet-17,000, LDH-247, D-dimer-2.03, creatinine-0.53, INR-1.2, PT-13.6, and PTT-32.4. With a plasmic score of 5, the patient was diagnosed with TTP and admitted for further evaluation of thrombocytopenia. A blood smear revealed acanthocytes, schistocytes, and elliptocytes. She was started on methylprednisolone IV and lab studies were sent, including haptoglobin, LDH, and ADAMTS-13 antibody. She underwent emergent plasmapheresis. It was discovered that she had congenital HIV infection and was on and off antiretroviral therapy after obtaining her old medical records. A repeat HIV screen was positive, with a viral load of 75,600 copies/mL and a CD4 count- 8. She was reinitiated on HAART. She had a 96% ADAMTS-13 activity score. With a diagnosis of acquired TTP due to HIV, the patient was discharged home on prednisone taper as her platelets improved.

IMPACT/DISCUSSION: VWF is a glycoprotein secreted by the endothelium, binds to platelet receptor glycoproteins and acts as a ligand to mediate platelet adhesion and aggregation. ADAMTS-13 converts endothelial VWF to plasma multimers; when ADAMTS-13 is deficient, large polymers of VWF combine with platelets to form aggregates in normal circulation. TTP is diagnosed clinically with supporting laboratory tests. Patients have anemia, thrombocytopenia, elevated LDH, low haptoglobin and almost all cases are associated with schistocytes on the peripheral smear.TTP is rare with an annual incidence of 2.99 per 1,000,000 population in the USA, has high mortality. Early diagnosis and treatment are critical for preventing morbidity and mortality. Plasma exchange is the standard treatment for TTP. HIV is associated with 15-40-fold increased risk of TTP. Unexplained thrombocytopenia in a patient with no significant previous medical history should prompt HIV testing. TTP is more common in patients with advanced disease, low CD4 count and other comorbidities such as cryptococcal meningitis. Published case reports show that levels of ADAMTS13 in HIV-infected patients with TTP are relatively preserved. HIV-related TTP was expected to decline with the widespread availability of HAART. However, HIV continues to be a significant cause of secondary TTP.

CONCLUSION: Thrombotic thrombocytopenic purpura (TTP) is a microangiopathic condition that can lead to multiorgan failure. TTP is distinguished by five key characteristics: thrombocytopenia, microangiopathic hemolytic anemia, renal abnormalities, fever, and neurological problems. Not all patients exhibit all of the cardinal characteristics. About 5% of TTP patients have congenital ADAMTS-13 deficiency; the remaining 90% could have ADAMTS-13 deficiency due to autoantibody formation and conditions such as SLE, pregnancy, organ transplantation, HIV, and drug exposure.

A RARE CASE OF GEMCITABINE INDUCED ATRIAL FIBRILLATION

Bryant P. Javier⁴; Richi Kashyap¹; Farhan Khalid³; Sara Malik¹; Jan Westerman²

¹Internal Medicine, North Alabama Medical Center, Florence, AL; ²Critical Care, North Alabama Medical Center, Florence, AL; ³Monmouth Medical Center, Long Branch, NJ; ⁴Parkview Health System, Pueblo, CO. (Control ID #3875441)

CASE: A 73-year-old caucasian male was diagnosed with refractory diffuse large B-cell lymphoma. He was receiving chemotherapy with a combination of Rituxan, Gemzar, Cisplatin, and Dexamethasone. The last round of treatment was given around 5 days before admission. He presented with sudden onset of shortness of breath, and dizziness. He was initially hemodynamically stable but quickly decompensated with the development of tachycardia and hypotension. EKG showed an irregular rhythm suggestive of atrial fibrillation with an RVR of 130. The echocardiogram demonstrated moderately reduced left ventricular systolic function with an ejection fraction of 35 %, mild left atrial enlargement, mild right atrial enlargement. Additionally, the right ventricular systolic function was mildly reduced. The patient received IV diltiazem, amiodarone, and IV fluids. He required vasopressor support with norepinephrine. Subsequently, the patient deteriorated with recurrent ventricular fibrillation unresponsive to standard resuscitation and unfortunately expired. Hyperthyroidism and electrolyte imbalance potential precipitating factors of atrial fibrillation were ruled out. There was no prior history of any cardiac arrhythmia before this episode.

IMPACT/DISCUSSION: Cardiotoxicity associated with gemcitabine use, presenting as atrial fibrillation and cardiomyopathy, is a rare event, and only a few cases have been reported so far. Phase 1 and 2 trials with gemcitabine did not show a significant risk for cardiotoxicity; however, with its widespread clinical use over the last decade, a few cases of cardiotoxicity related to gemcitabine use have been reported. Acute toxicities include arrhythmias and myocardial ischemia or infarction. The evidence for prothrombotic and procoagulant effects of gemcitabine comes from several reports of the occurrence of vascular events (like thrombotic microangiopathies, strokes, visceral infractions, and vasculitides) in association with gemcitabine infusion. The cardiomyopathy seems to develop after a few months to years of treatments with gemcitabine. The exact mechanisms of myocardial damage and the total dose of gemcitabine required to induce myocardial toxicity are unknown.

CONCLUSION: There are few reported cases of atrial fibrillation developing as a consequence of the cardiotoxicity of gemcitabine infusion. The common grade 3 and 4 toxicity known of this drug is myelosuppression. Medical oncologists consider the potential for cardiac decompensation in at-risk populations as they consider chemotherapeutic regimens for the broad array of malignancies for which Gemcitabine has demonstrated otherwise favorable response rates.

ATYPICAL CASE OF VERTEBRAL OSTEOMYELITIS: MANAGEMENT IN RURAL HEALTHCARE SETTING

Udit Asija¹; Muhammad Hassan Shakir^2,1; Archana Sridhar¹; Chilsia Shafi¹; Jesvin Jeyapaulraj¹

¹Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA; ²Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA. (Control ID #3876848)

CASE: A 65-year-old male with a past medical history of chronic lower back pain presented with generalized weakness and non-midline non-localized migrating back pain between shoulder blades for 2 weeks. Recently prescribed cyclobenzaprine didn’t relieve symptoms. On physical examination, the patient was febrile (Tmax 102.5F), tachycardic, lethargic and had multiple scar marks on bilateral lower extremities from past bed bug bites. Examination of the back didn’t reveal any focal point of tenderness. Laboratory investigations revealed leukocytosis 31200 WBCs/microliter, ESR 44 mm/hr, and CRP 155.6 mg/L. Initial blood cultures were positive for MRSA and the patient was initiated on intravenous Vancomycin for bloodstream infection based on sensitivity results. Repeat blood cultures every 48 hours failed to become sterile despite treatment with appropriate antibiotics. To ascertain the cause of the persistent MRSA bacteremia, transthoracic and transesophageal echocardiograms were performed and were negative, ruling out infective endocarditis. A bone scan and a tagged WBC scan were performed which failed to provide a specific source of infection. However, Thoracolumbar spine MRI revealed a 3.9 cm epidural abscess to the left of T4-T5, T5-T6 vertebral osteomyelitis (VO), developing L2-L5 VO along with epidural abscess predominantly involving the L4 spinous process with extension into the pedicles and moderate central canal narrowing. Lower back pain, a common chronic symptom, prompted whole-body imaging rather than a focused MRI spine to find the infectious source and led to excessive testing and radiation exposure. The patient was eventually referred to a tertiary care center for further evaluation by spinal surgery and was eventually discharged after surgical debridement on vancomycin for 6 weeks.

IMPACT/DISCUSSION: VO is a notoriously insidious pathology related to complicated MRSA bacteremia and its evaluation is guided by clinical suspicion, demographics, patient characteristics, presentation, and initial laboratory/imaging investigations. Over the past few decades, various diagnostic modalities, including nuclear imaging techniques, have emerged to help with the diagnosis. The adjunctive role of these to MRI becomes less important, especially in rural settings with a paucity of resources. Our case is intended to serve as a reminder of the high sensitivity and sensitivity of MRI in the diagnosis of VO, especially given the high cost, radiation exposure, lag in timely diagnosis, and high risk of false negatives with radiographs, bone scans, and nuclear imaging techniques.

CONCLUSION: -Choosing MRI over nuclear imaging techniques as the initial diagnostic modality of choice can thus save valuable time, and resources and potentially reduce significant morbidity and mortality.

-Given the vague clinical presentation and inconsistent natural history of the disease, we also stress the need for the development of a scoring system to determine the pretest probability of VO in such patients.

DELAYED ARTIFACTUAL HYPOGLYCEMIA FOLLOWING SEPTIC SHOCK IN A PATIENT WITH SCLERODERMA

Alex Guzner¹; Emil Heinze²; Lakshmi Sadasivam²

¹Internal Medicine, University of California Los Angeles, Los Angeles, CA; ²Medicine, David Geffen School of Medicine at UCLA, Sylmar, CA. (Control ID #3874764)

CASE: An 89 year old man with a history of systemic sclerosis complicated by interstitial lung disease and Raynaud’s phenomenon presented to our hospital with septic shock due to aspiration pneumonia and urosepsis. He was started on oxygen via high flow nasal cannula, antibiotics and vasopressors, and was admitted to the intensive care unit. His shock and respiratory status improved, and he was weaned off vasopressors. On hospital day 7, fingerstick blood glucose values were noted to be 60 mg/dl or less in all fingers, without symptoms of hypoglycemia. Despite lack of symptoms, he was started on 10% dextrose intravenously, yet his fingerstick glucose values continued to be less than 60 mg/dl. Simultaneous measurement of glucose levels from plasma and earlobe demonstrated values over 100 mg/dl. At this point, his intravenous dextrose drip was stopped and glucose checks were only performed via earlobe sticks, with glucose readings always above 90 mg/dl.

IMPACT/DISCUSSION: Although artifactual hypoglycemia in Raynaud’s phenomenon has previously been reported, the unique timeline of symptom development in this case raises a new pathophysiologic mechanism through which this condition may be triggered to develop. Currently, this process is hypothesized to be due to peripheral vasoconstriction leading to decreased availability of glucose in capillary beds of extremities. Glucose level via earlobe prick has been demonstrated to correlate better with plasma glucose level due to the presence of less connective tissue here. In this case it was noted that artifactual hypoglycemia emerged only after several days of fingersticks, after the patient had recovered from septic shock, and after he had been weaned off vasopressors.

In patients with Raynaud’s phenomenon, extremity trauma can cause vasoconstriction via central and local mechanisms that elevate the levels of vasoconstrictors such as endothelin-1 (ET-1) and loss of the vasodilators prostacyclin and nitric oxide. It is also known that during sepsis, nitric oxide and ET-1 are produced in excess with nitric oxide predominating early and ET-1 later. The patient described above was receiving multiple fingerstick glucose checks which can be equated to microtrauma. In this setting, late in the course of sepsis, as the vasodilatory component of sepsis begins to improve, in conjunction with repeated microtrauma, peripheral vasoconstriction has multiple triggers to predominate, leading to decreased perfusion to the fingertips and unmasking of artifactual hypoglycemia.

CONCLUSION: In conclusion, in patients with Raynaud’s phenomenon with low blood glucose on fingerstick glucose check, in the absence of symptoms of hypoglycemia, an earlobe glucose check or venous check should be performed before administering intravenous dextrose. In addition, close attention must be paid to extremity perfusion when these patients develop sepsis due to alterations in the already delicate balance between vasoconstrictors and vasodilators in this population.

DRUG-INDUCED HYPOGLYCEMIA: A CASE OF RARE BUT LIFE-THREATENING HYPOGLYCEMIA WITH A COMBINED USE OF GLIPIZIDE AND LEVOFLOXACIN.

Muntazir Ali Sayed^1,2; Syeda B. Mustafa²; Javaria Mushtaq²; Muhammad Rehan²; Syed Hussain²; Hafiza M. Sadiq²

¹Internal Medicine, RCSM Government Medical College Kolhapur India, Jersey City, NJ; ²R- Endocrinology, Hamilton, NJ. (Control ID #3875458)

CASE: A 72-year-old female with a past medical history of type 2 diabetes mellitus, chronic kidney disease, post-total thyroidectomy, cirrhosis, and chronic obstructive pulmonary disease was prescribed oral Levofloxacin (500mg daily) for symptoms of chronic urinary tract infection. Patient was on Glipizide (5mg) and Metformin (1000mg) for her diabetes. The last dose of Glipizide was taken 7 hours before the first dose of Levofloxacin. Patient developed seizures a few hours after the dose of Levofloxacin and her serum glucose level was found to be 24 mg/dL. Considering these alarming findings, patient was immediately admitted to the hospital. Patient received multiple doses of intravenous administration of 50% dextrose and dextrose- containing fluids (10% dextrose infusion). Patient’s Levofloxacin was discontinued the next day and patient continued receiving intravenous infusion of D10. Patient’s serum insulin levels showed unsuppressed values (83 microIU/mL) along with elevated levels of C peptide (5279 pmol/L, upper normal limit < 1400 pmol/L), which suggested hyperinsulinemic hypoglycemia. Patient was intravenously administered 50μg Octreotide around 29-30 hours after presentation in order to suppress her hyperinsulinemia. Patient’s serum glucose levels returned to her baseline within 2-3 hours after the administration of octreotide.

IMPACT/DISCUSSION: This case emphasizes the importance of reviewing drug-drug interactions when managing severe hypoglycemia cases. The interaction between sulfonylureas and fluoroquinolones can be complicated by hypoglycemia, which can be severe. It is critical to be vigilant with drug to drug interactions as they can lead to significant morbidity and add a high cost to the healthcare system. Fluoroquinolones potentiate the sulfonylurea’s effects on glucose by inhibiting ATP K+ channels in pancreatic B-cells; this leads to overstimulation of pancreatic islet cells. This further leads to inappropriately uninhibited levels of insulin. All of these factors, result in hypoglycemia.

Even though Levofloxacin is frequently used, there is very poor awareness about its potential hypoglycemia effects. It should be noted that fluoroquinolones in themselves are not initiators; however, they solely enhance insulin secretion. Potential treatment is administration of octreotide in addition to administering dextrose infusion.

CONCLUSION: Hypoglycemia associated with fluoroquinolones is an uncommon but severe and life- threatening and potentially reversible condition, which often responds only to discontinuation of quinolones. However, octreotide can be used to quickly reverse hypoglycemia in such cases and can be used as an effective tool for this purpose. It is important that all potential drug-drug interactions be reviewed to provide safe and quality medical care to patients.

PROFOUND HYPOMAGNESEMIA IN A PATIENT TREATED WITH LONG-TERM PROTON PUMP INHIBITOR

Chinnawat Arayangkool¹; Joseph Lee²; Kuo-Chiang Lian³

¹Internal Medicine, University of Hawai'i System, Honolulu, HI; ²Internal Medicine, University of Hawai'i at Manoa John A Burns School of Medicine, Honolulu, HI; ³Hospitalist Program, The Queen's Medical Center, Honolulu, HI. (Control ID #3876754)

CASE: A 83-year-old man with gastritis treated with omeprazole and recent acute lacunar stroke presented to the hospital with intractable nausea and vomiting. One week prior to admission, he was admitted with intractable nausea, vomiting, and aphasia. MRI brain revealed an acute to subacute lacunar infarction in the left corona radiata. During hospitalization, his nausea and vomiting was refractory to antiemetic treatment but resolved by the time of discharge. Additionally, he had no residual neurological deficits on discharge. Shortly after discharge, he had recurrence of intractable nausea and vomiting which did not improve with oral antiemetic medication. He had no fever, chills, abdominal pain, changes in stool pattern, or neurologic symptoms.

On presentation, his vitals were normal. Physical exam was unremarkable including a normal abdominal exam and neurological exam. Laboratory testing showed profound hypomagnesemia with serum magnesium less than 0.2 mg/dL. Other electrolytes were unremarkable except for hypokalemia and hypocalcemia. CT abdomen/pelvis with contrast showed gastric wall thickening and cholelithiasis without evidence of cholecystitis. Subsequent esophagogastroduodenoscopy failed to identify a gastrointestinal cause for vomiting. Repeat MRI brain did not reveal a central cause of vomiting.

The patient was treated with multiple doses of IV magnesium sulfate and oral magnesium oxide with prompt improvement of symptoms. However, his serum magnesium level remained persistently low. Urine magnesium indicated increased renal excretion, however this was tested in the setting of ongoing magnesium replacement. After reviewing his medications further, omeprazole was discontinued and replaced with famotidine with subsequent stabilization of magnesium level.

IMPACT/DISCUSSION: The presentation of hypomagnesemia can vary widely but may include nausea, vomiting, arrhythmias, muscle cramping, and paresthesias. Hypomagnesemia is a rare side effect of chronic proton pump inhibitor (PPI) usage. The risk of hypomagnesemia increases with the duration of treatment. It is thought that increased pH within the small bowel leads to decreased affinity of magnesium binding to active magnesium transport channels, such as transient receptor potential melastatin (TRPM) cation channels. Variant alleles of the TRPM6/TRPM7 genes are associated with malabsorption which might be further aggravated by the use of a PPI. Thus only those with genetic predisposition are severely affected, which contributes to the rarity of this adverse effect. This case highlights the importance of careful medication review in patients presenting with symptomatic hypomagnesemia, with consideration of long-term PPI therapy as a rare potential cause.

CONCLUSION: Nausea and vomiting can be the early signs of hypomagnesemia Long-term PPI usage can increase the risk of severe hypomagnesemia, especially when used concurrently with other magnesium lower medications PPIs should be prescribed only when there is a clear indication

STEMI SECONDARY TO INTRAMUSCULAR EPINEPHRINE: A CASE REPORT AND LITERATURE REVIEW

Kyrillos Faragalla¹; Tony Haddad²; Sarah Parent²

¹Internal Medicine, University of Saskatchewan, Saskatoon, SK, Canada; ²Cardiology, University of Saskatchewan, Saskatoon, SK, Canada. (Control ID #3877086)

CASE: A 58-year-old male with uncontrolled diabetes, hypertension, two first degree relatives with coronary artery disease, and smoking history, has been experiencing recurrent episodes of hives and throat tightness with no obvious triggers, for which he used an epinephrine auto-injector. On initial presentation to local clinic, he had one such episode but developed sudden onset chest pain directly after epinephrine use. Electrocardiogram (ECG) showed anterior ST elevations and inferior ST depressions. As thrombolysis was unavailable, he was started on dual antiplatelets, heparin, nitroglycerin, and analgesics and sent to our hospital. On arrival, he was chest pain-free but had persistent ST elevations on ECG and Troponin T was 2608 ng/L (<14 ng/L). He had hives and wheals on exam. Coronary angiography showed 90% LAD stenosis with evidence of thrombus, treated with a drug-eluting stent, and 70% RCA stenosis. Echocardiogram showed an ejection fraction of 35% and anteroseptal akinesia. He was discharged four days later on appropriate medical therapy including antihistamine. Unfortunately, he was not compliant with the latter, and two months later he developed new hives, dyspnea, and a transient syncopal episode. He elected not to use his epinephrine but it was still given by paramedics. Thirty minutes later he developed chest pain and ECG at local hospital showed an anterior STEMI with Troponin I 0.257 μg/L (<0.033 μg/L). He was thrombolysed then sent to our centre where repeat angiogram showed in-stent thrombosis of his LAD stent, treated with an overlapping stent. He was diagnosed with chronic urticaria and discharged on high-dose antihistamine in addition to his cardiac medications. On one-month follow-up he remained asymptomatic without hives.

IMPACT/DISCUSSION: To our knowledge, this is the first case with recurrent thrombus-induced myocardial infarction secondary to exogenous epinephrine. We conducted a literature review of cases meeting criteria for acute coronary syndrome (ACS) following adminstration of epinephrine. Among the 102 cases found, 60 cases were diagnosed as takotsubo cardiomyopathy, 33 cases had likely coronary vasospasm, seven cases had coronary thrombosis on angiogram, and two were unspecified. Unlike patient demographics, cardiovascular risk factors, dose and route of epinephrine, symptom onset, troponin level, or ECG changes, echocardiogram was the only non-invasive test to help differentiate the mechanism of ACS, sometimes obviating the need for angiogram. Additionally, among reviewed cases, all patients with pre-existing stents had in-stent thrombosis on angiogram.

CONCLUSION: While epinephrine-related ACS often represents stress-induced cardiomyopathy, epinpehrine can also cause true myocardial infarction due to intracoronary thrombus. Patients with prior coronary stents may be at higher risk of in-stent thrombosis with epinephrine use. It is therefore critical to differentiate true anaphylaxis from similar benign conditions prior to admintering epinephrine.

Clinical Vignette - Women’s Health, Sex, and Gender-Informed Medicine

#2 PENCIL (THIN) POOP AND PELVIC PAIN: NAVIGATING A GI-GYN DIFFERENTIAL FOR STOOL CHANGES

Grace L. Lisius, Rebecca Green

Department of Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #3876639)

CASE: A 41-year-old mother presented to clinic with chronic progressive constipation, new thin caliber stools, and subacute vaginal bleeding. Several months ago, she had worsening constipation despite no lifestyle changes, necessitating twice daily Miralax. She had bloating and nausea, but no bloody stools. Over the past month, she had new constant, heavy vaginal bleeding and lower pelvic pain. She had difficulty passing stools, now pencil-thin, and right lower quadrant pain like “an apple stuck”. No weight loss. History notable for two C-sections and no family history of gastrointestinal or gynecologic cancer. She was up to date on cervical cancer screening. Her vitals were normal. She had right lower quadrant tenderness without masses. Pelvic exam had uterine tenderness without cervical motion tenderness. Labs showed normal hemoglobin. Her CT abdomen and pelvis showed no masses or lymphadenopathy, and asymmetric thickening of the uterine fundus and body consistent with adenomyosis. Her colonoscopy was normal. With presumptive diagnosis of adenomyosis, she initiated a hormonal IUD with gradual resolution of her vaginal bleeding, abdominal pain, and stool changes.

IMPACT/DISCUSSION: Adenomyosis remains a challenging diagnosis with varied clinical presentations including gastrointestinal, gynecologic, and urinary symptoms. Diagnosing pre-menopausal adenomyosis is especially difficult due to representative bias of the historical post-menopausal illness script via hysterectomy pathology. The true uterine and extra-uterine symptom burden in pre-menopausal women is unclear, and additionally clouded by medical system diagnostic limitations and minimization of menstrual symptoms. Literature prevalence of adenomyosis ranges from 1% to 70%, reflecting a lack of pathologic and imaging criteria (pelvic MRI and transvaginal ultrasound). Gastrointestinal and urinary symptoms are noted anecdotally in the literature, but unfortunately no frequency estimate exists. In this patient with both gynecologic and gastrointestinal manifestations, balancing the don’t-miss etiologies of colon cancer and IBD, constructed a diagnostic dilemma which required splitting and separately evaluating the GI and GYN symptoms, then later reassessing as one process. Levonogesterol IUDs are the non-surgical standard treatment given uterine-specific action. The overlap frequency between pelvic inflammatory conditions such as adenomyosis with gastrointestinal and urinary symptoms is also not well understood and further studies are needed to inform management of these patients.

CONCLUSION: Adenomyosis remains crucial differentials in patients with gastrointestinal and gynecologic symptoms. Balancing the can’t-miss diagnoses of cancer and IBD with less defined diagnoses of adenomyosis constitutes a key step in diagnosis and directing management.

A CASE OF ARCAPA IN PREGNANCY

Natalie R. Bhalla, Adam Small. NYU Langone Health, New York, NY. (Control ID #3873071)

CASE: A 39 year-old G2P1 woman presented for evaluation of palpitations in pregnancy. The palpitation episodes last for approximately 5 minutes, no associated symptoms, with spontaneous resolution. The patient had been physically active her whole life and never had any exertional limitation or anginal symptoms. A tracing from her Apple Watch demonstrated supraventricular tachycardia. An echocardiogram was performed to evaluate for structural abnormalities. It demonstrated dilated epicardial vessels and a prominent color Doppler signal indicating flow into the proximal pulmonary artery. The flow pattern was diastolic-dominant, suggestive of either anomalous coronary artery origin from the pulmonary artery or a coronary-to-pulmonary artery fistula.

In effort to avoid radiation and contrast in pregnancy, a non-contrast cardiac MRI was performed. The MRI demonstrated a normal origin of the left coronary artery, and probable anomalous right coronary artery from the pulmonary artery. Given the limitations of cardiac MRI, the study was inadequate to confirm the diagnosis of anomalous right coronary artery from the pulmonary artery (ARCAPA).

Her SVT was managed medically. She had a low burden of arrhythmia on low-dose metoprolol and no arrhythmias during labor and delivery. She had an uneventful vaginal delivery with telemetry monitoring. After delivery, EKG-gated CT scan confirmed the diagnosis of ARCAPA.

IMPACT/DISCUSSION: For women with a history of heart disease who wish to become pregnant, there are numerous risk-stratification scores commonly used, such as CARPREG II and the mWHO classification. These scores can be used to estimate the risk of maternal cardiac events through pregnancy and the puerperium.

The mWHO classification focuses primarily on anatomy and complexity of cardiac disease; it stratifies patients into 4 categories, ranging from class I with no known increased in maternal morbidity or mortality, to class IV where pregnancy is contraindicated. The CARPREG II score assigns points to 10 risk factors, both clinical and anatomic.

Anomalous origin of a coronary artery from the pulmonary trunk is a rare congenital cardiac lesion.

Anomalous left coronary artery from the pulmonary artery (ALCAPA) and ARCAPA can create a left-to- right shunt from the left coronary to pulmonary artery, which might result in a ‘steal’ phenomenon. In this situation, blood flow will go away from the myocardium, which can lead to ischemia and infarction.

Since ALCAPA is considered a higher-risk lesion, repair is generally recommended when the diagnosis is made. Indications for repair in ARCAPA include symptoms, ventricular dysfunction, or evidence of coronary ischemia attributed to the anomaly.

CONCLUSION: ARCAPA and ALCAPA are rare congenital cardiac lesions, which can lead to a shunt phenomenon causing ischemia.

There are numerous maternal risk score calculators for pregnant persons with cardiac conditions.

Conservative management may be appropriate for a well-compensated patient with ARCAPA in pregnancy.

A CASE OF SYSTEMIC LUPUS ERYTHEMATOSUS PERICARDITIS IN THE POSTPARTUM PERIOD

Farid Farkouh

Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #3876753)

CASE: A 24-year-old G1P1 woman with a history significant for pre-eclampsia and recent normal vaginal delivery presented to the emergency room with chest pain and dyspnea. On week 36 of her pregnancy, the patient developed pre-eclampsia with hypertension and proteinuria. She was induced at week 37 and had an uncomplicated vaginal delivery. She did well for the next 2-3 days but then developed pain and stiffness in multiple symmetric joints (hands, shoulders, ankles). About two weeks after delivery, patient developed chest pain and dyspnea. Both were exertional and positional in nature. Symptoms were worse when laying down and with deep inspiration. Her Symptoms prompted her to present to the hospital. In the hospital, EKG showed regular sinus rhythm with no acute ST changes but was remarkable for low voltage. Point of care ultrasound of the heart was significant for large pericardial effusion, which was confirmed on formal echocardiogram. Lab workup was remarkable for an acute kidney injury, elevated CRP to 14.5, reactive ANA (1:5120), elevated Anti-DsDNA antibodies, low C3 and C4 levels, negative SSA/SSB, negative RF and CCP. Patient underwent pericardiocentesis due to the large size of the pericardial effusion and the possible effects on her vital signs. Kidney biopsy confirmed active class IV lupus nephritis. Patient was managed with a prolonged steroid taper, along with mycophenolate and hydroxychloroquine. She had significant improvement and was able to be weaned off the steroids. She is currently maintained on mycophenolate, hydroxychloroquine and belimumab.

IMPACT/DISCUSSION: The differential diagnosis for chest pain and dyspnea in the postpartum period is broad. It includes postpartum cardiomyopathy, Spontaneous Coronary Artery Dissection (SCAD), pulmonary embolism among others. It is generally accepted that pregnancy and the postpartum period are associated with a higher rate of SLE disease flares. Studies have shown that the effect of pregnancy on SLE flare rates can be modified by continuing hydroxychloroquine (HCQ) during and after pregnancy. The hazard ratio (HR) of flares in pregnancy compared with non-pregnant/non-postpartum periods is estimated to be 1.83 (95% CI 1.34 to 2.45) for patients with no HCQ use and 1.26 (95% CI 0.88 to 1.69) for patients with HCQ use.

CONCLUSION: This case highlights the broad differential for chest pain and dyspnea in the postpartum period. It also highlights the significantly increased risk of SLE disease flares in the late pregnancy and early postpartum period. For our patient, this was the first flare and chance to diagnose the disease. For patients with known SLE, continuing hydroxychloroquine during pregnancy has been shown to lower the risk of SLE disease flares.

A CAUTIONARY TALE OF THE LACK OF LARC

Rebecca Unterborn¹; Alexandra Fuher¹; Elizabeth Esselman¹; Jennifer Michener^2,1

¹Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ²General Internal Medicine, University of Colorado, Denver, CO. (Control ID #3873771)

CASE: A 19 year old patient with a history of anxiety, major depressive disorder presented to her primary care provider (PCP) requesting birth control to prevent pregnancy. She was started on a combined progestin and estrogen oral contraceptive pill (OCP). One month later she returned for headaches and was found to have elevated blood pressure likely secondary to her new OCPs. She was interested in intrauterine device (IUD) placement and discontinuing oral options due to side effects. However, the clinic was unable to place an IUD due to lack of clinical staff training and access to devices. A referral was placed to a gynecology clinic for IUD placement, but she did not make it to her scheduled appointment. She presented to four more PCP appointments, where she continued to express interest in IUD placement and she was re-referred to gynecology multiple times, but she faced challenges navigating additional appointments with new providers when she already had rapport and trust with her PCP. To date she still has no birth control and has not presented to a gynecology appointment.

IMPACT/DISCUSSION: This case highlights the importance of providing long acting reversible contraceptives (LARCs) in general internal medicine (GIM) clinics. LARCs are more than 99% effective at preventing unwanted pregnancy, a near perfect example of preventative medicine. Many Internal Medicine (IM) governing bodies and program directors agree that internists and trainees should be competent in contraception management, including IUDs and implants, however training in LARC placement is not standardized amongst IM residency programs. This curriculum is also often fraught with barriers to implementation, including lack of trained preceptors and unclear definitions of procedural proficiency. Additional barriers range from logistical (i.e workflow issues, obtaining necessary equipment, and credentialing) to stakeholders' belief that LARC implementation is out of the scope of GIM physicians. Patients also face barriers when pursuing LARC placement, as demonstrated with this case. It can be challenging for patients to navigate multiple appointments with different providers. Therefore, allowing PCPs to place LARCs, in a setting that is comfortable, trusting, and well known to the patient, can help improve access. GIM practitioners make up about 40% of the PCP pool, thus if they were to master LARC practices it would broaden LARC access, shorten time to LARC placement, and ultimately prevent unwanted pregnancies. Additionally, more LARC-competent GIM physicians can potentially free up time for our gynecology colleagues to perform more specialty-focused procedures and consultations.

CONCLUSION: LARC placement is a simple, effective procedure that reduces the incidence of unwanted pregnancy, yet this procedure is not consistently taught during internal medicine residency training. Standardized resident training in LARC placement would significantly reduce both patient and clinician barriers to accessing LARC.

AN UNUSUAL PRESENTATION OF SQUAMOUS CELL CARCINOMA OF UNKNOWN PRIMARY

Harpreet Gosal¹; Kanwardeep Singh^1,2

¹Internal Medicine, Hamilton Medical Center, Dalton, GA; ²Augusta University Medical College of Georgia, Augusta, GA. (Control ID #3876515)

CASE: A 66-year-old female with past medical history only significant for elective bilateral mastectomy in the 1980s due to known family history of breast cancer, presented with new onset right groin pain. She reported a history of recent car travel from Colorado to Georgia one week prior to presentation. Pertinent finds on physical examination included limited passive and active movement of right hip and right groin tenderness. Right lower extremity ultrasound done suspected a 1.7 cm evolving hematoma in the right groin. Subsequently, patient returned a week later to the clinic with worsening pain, now presenting with significant asymmetric swelling of the right thigh extending down to the knee. A second ultrasound performed indicated markedly enlarged lymph nodes in the right inguinal region of 3.4 cm, compressing the right femoral vein. The patient denied any history of recent infection. Social history was only positive for former tobacco use of 30 years, and sexual history was unremarkable. She completed a short antibiotic course without improvement. She was sent for an ultrasound-guided biopsy with results returning positive for metastatic p16 poorly differentiated squamous cell carcinoma (SCC). Patient was seen by oncology for further evaluation. PET scan revealed bulky lymphadenopathy in the chest and abdomen, extending into the pelvis, along with abnormal uptake representative of malignancy. Despite extensive diagnostics, the primary site was not identifiable. The cancer was found to have a PD-L1 positivity of 41-60% and patient was started on palliative treatment with carboplatin, paclitaxel and pembrolizumab.

IMPACT/DISCUSSION: SCC comprises approximately 5% of carcinomas of unknown primary (CUP), with CUP of the inguinal region accounting for 1-3% of all CUPs. The median age of diagnosis is 60 and has an overall poor prognosis with an average survival of 7 to 11 months. The primary lesion is identifiable in less than 30% of cases. SCC CUP involving the cervical lymph nodes have been well documented, whereas involvement of the inguinal lymph nodes are rarely encountered. They are thought to arise primarily from an anogenital malignancy, and careful gynecological examination is required in females. Determining a primary site can be potentially curative even after spread to regional lymph nodes. However, no primary tumor was identified in our patient despite extensive diagnostics and examinations.

CONCLUSION: Our patient was initially assessed for right groin pain in the setting of suspected evolving hematoma. Given the repeat ultrasound finding of markedly enlarged lymph nodes, she was further worked up for unilateral inguinal lymphadenopathy. The most common presentation occurs secondary to an infectious process, however malignancy cannot be excluded. This case demonstrates the challenges of recognizing a rare presentation of metastatic disease, assessing the need for repeat imaging with worsening symptoms and understanding the presentation of CUP.

A PREGNANT PATIENT WITH VARIEGATE PORPHYRIA: ASSESSMENT AND MANAGEMENT STRATEGIES TO ENSURE SAFE ANTENATAL, DELIVERY, AND POSTPARTUM CARE

Stephanie Braunthal¹; Lindsey Mahoney¹; Melissa S. Kilsey²; Kenneth K. Chen¹; Elisa McEachern¹; Srilakshmi Mitta¹

¹Obstetric Medicine, Brown University, Providence, RI; ²Pharmacy, Women and Infants Hospital of Rhode Island, Providence, RI. (Control ID #3873514)

CASE: A 40 year-old G4P2012 at 36 weeks gestation with a history of variegate porphyria presented to the combined obstetric internal medicine-hematology clinic for labor and delivery planning. She was diagnosed after recurrent abdominal pain and cramping while she was on oral contraceptives as an adolescent. Her mother, maternal aunt, and maternal grandmother all have porphyria variegate. She has not flared since discontinuing hormonal contraception, including during previous pregnancies. This pregnancy was complicated by gestational diabetes and gestational thrombocytopenia. To prepare for delivery, a multidisciplinary meeting led by obstetric internists, which included maternal-fetal medicine, anesthesiology, hematology, and pharmacy was conducted. Particular attention was paid to clinical symptoms that overlap with those in pregnancy and postpartum, as well as medications that must be avoided for anesthesia, pain control, and preeclampsia. A joint care plan was proactively placed in the chart, and panhematin, the agent used in acute attacks, was obtained in advance. The patient presented in labor at 39 weeks gestation and delivered without complication by spontaneous vaginal delivery. She did not have any visceral attacks during delivery or postpartum, but did have mild cutaneous symptoms that resolved after one day and did not require acute intervention. Given previous flares with hormonal contraception, the patient is planning for tubal ligation.

IMPACT/DISCUSSION: Variegate porphyria is an autosomal dominant inherited acute porphyria that causes porphyrins to build up in the skin and nervous system as a result of a pathogenic mutation of protoporphyrinogen oxidase, the seventh enzyme in the heme synthesis pathway. Age of onset is typically after puberty. Symptoms include cutaneous blistering of sun-exposed areas and acute neurovisceral attacks. A wide variety of medications, tobacco, alcohol, stress, fasting, and hormones are triggers; progesterone is particularly porphyrinogenic. Many of the medications with stronger safety profiles in pregnancy and postpartum are contraindicated. Diagnostic tests include urine porphobilinogen, urine, stool, and plasma porphyrins, as well as genetic testing. Avoidance of triggers is paramount to treatment, and resources such as the American Porphyria Foundation have easily accessible online clinical decision making tools. Glucose loading, which diminishes excretion of heme precursors, and panhematin, which limits the rate of heme biosynthesis, can be used during exacerbation.

CONCLUSION:

- Variegate porphyria must be considered in young adults who present with recurrent blistering, non-specific neurologic symptoms, or abdominal pain.

- General internists should be aware of acute porphyria triggers and incorporate them into their clinical decision making.

- Steroid hormones may trigger variegate porphyria flares, however our case is evidence that pregnancies can be carried out safely with the appropriate multidisciplinary planning.

BILATERAL ARM PAIN AS AN UNUSUAL PRESENTATION FOR ACUTE CORONARY SYNDROME

Kengo Z. Soghoyan, Jesse E. Doyle, Rajashree Thirumeni, Robert Ficalora, David Curtis, Robert Quade

Internal Medicine, Indiana University School of Medicine, Indianapolis, IN. (Control ID #3875433)

CASE:

A 74-year-old female with a notable history of coronary artery disease status post percutaneous coronary intervention of the left anterior descending (LAD) coronary artery in 2010. She had a normal dobutamine stress test in July 2021 and a normal treadmill stress test in September 2021. The patient presented to our cardiology clinic due to chest discomfort with particularly bothersome bilateral upper extremity pain. The cardiologist was concerned with her atypical presentation and asked that she report to the Emergency Department. Initial ECG was without ST-segment elevation or T-wave changes. Serial high-sensitivity troponins resulted 0, 0, 0.01, 0.01 (reference range 0.0 to 0.04 nanogram/milliliter). With her current presentation, two normal stress tests within the past six months, and ongoing symptoms, the cardiology team recommended the patient undergo left heart catheterization. Remarkably, the study revealed proximal-LAD 80% stenosis, mid-LAD 95% stenosis, first diagonal 95% stenosis, and first obtuse marginal 70% stenosis. Cardiothoracic surgery was consulted, and she successfully underwent triple-vessel coronary artery bypass grafting (CABG). Her postoperative course was uneventful, and she was discharged home when medically stable.

The patient returned to our Emergency Department within five days following a 3-hour history of bilateral upper extremity pain. She reported that this pain is like what she experienced before her CABG. Repeat left heart catheterization revealed a patent saphenous vein graft to first obtuse marginal and the left internal mammary artery to LAD in sequence with the diagonal is widely patent; however, there was a near 90% occlusion of the marginal branch distal to the insertion site of the graft. By approaching the native vessel, she successfully received a stent to the obtuse marginal with TIMI grade III flow afterward. Following the stent placement, her symptoms resolved.

IMPACT/DISCUSSION: With her unusual presentation and subsequent remarkable findings on cardiac catheterization, this case highlights the evolving methodology of ACS diagnostics. Females and those with comorbidities such as diabetes mellitus often present with atypical anginal equivalents. Clinical gestalt is not enough to rule in ACS. Unusual cases such as this warrant thorough investigation.

Literature review with PubMed using MeSH terms "bilateral arm pain" and "acute coronary syndrome" did not yield any report of bilateral arm pain as a presenting symptom of NSTEMI. On review of gender and ethnicity-based symptomatology related to ACS, no clear indicator was identified that correlates white women's presentation with NSTEMI.

CONCLUSION: Women can present with atypical symptoms in acute coronary syndrome (ACS). However, with the adoption of high-sensitivity troponins, the diagnostic incidence of ACS has climbed in all demographics. Though extensive diagnostic algorithms have been developed for ACS, unusual cases still provide a challenge.

CONTRACEPTION COUNSELING IN CUSHING’S DISEASE

Emily Rider-Longmaid

General Internal Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #3877322)

CASE: A 28-year-old woman with history of recurrent Cushing’s disease presented to outpatient primary care clinic for contraception counseling. She was diagnosed with pathology-confirmed Cushing's disease in 2018, and underwent a total of three transsphenoidal surgeries without remission of disease. She continues to have evidence of a pituitary ACTH-secreting tumor on labs and imaging, and awaits gamma knife radiation. She currently takes hydrocortisone, levothyroxine, and desmopressin. She is sexually active with one male partner and does not desire pregnancy. Her last menses was in summer 2020 and she believes she cannot get pregnant. She does not use or practice any contraception. Her most recent labs showed normal cortisol, normal FSH and LH, and low estradiol, consistent with secondary ovarian insufficiency due to hypogonadotropic hypogonadism. However, given her ongoing treatment of Cushing’s disease and normal cortisol level, she may start ovulating again.She does not desire pregnancy and her medications carry teratogenic risks. Hormonal contraception is contraindicated: estradiol interferes with the cortisol assay, causing falsely elevated results. Progesterone increases risk of venous thromboembolism (VTE) in patients with Cushing’s disease as the disease elevates the risk of VTE even after cure. Copper IUD and progesterone IUD were discussed with the patient, and she plans for copper IUD at her next visit.

IMPACT/DISCUSSION: The importance of birth control counseling and prescription is often overlooked in patients with amenorrhea. Underlying hypogonadotropic hypogonadism is further considered by both physicians and patients to be sufficient in preventing unwanted pregnancies. As the etiology of said hypogonadotropic hypogonadism is treated, contraception becomes an important and necessary focus of care. In Cushing’s disease with secondary ovarian insufficiency, monitoring estradiol instead of FSH and LH will help determine when the patient will start ovulating again. This case discusses the significance of choosing appropriate contraception given medical co-morbidities; both estrogen and progesterone are contraindicated in patients with Cushing’s disease. Understanding the effect of estrogen on cortisol assays and recognizing Cushing’s disease as a hypercoagulable state, even after treatment, are key in counseling these patients. Finally, this case is a reminder for the primary care physician to consider the teratogenicity of patient medications in patients who may become pregnant, and to convey these risks to their patients.

CONCLUSION: This case illustrates an example of secondary ovarian insufficiency in the context of hypogonadotropic hypogonadism, with associated lab results.

This case shows that despite Cushing's disease, patients undergoing treatment should be counseled on and receive birth control.

This case explains the contraindications of the most common types of birth control in Cushing’s disease and the need to explore non-hormonal options.

DEEP VENOUS THROMBOSIS AND PULMONARY EMBOLISM IN A PATIENT ON AN OCP AND PROCOAGULANT

Alekses Clifton, Richmond S. Doxey

Internal Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #3873980)

CASE: A 30-year-old female with no significant past medical history presented to her primary care physician after noticing increased bruising over the previous week. She denied any vaginal bleeding, hematochezia, melena, epistaxis, or abdominal pain. Her only medication was a combined estrogen-progesterone oral contraception pill that she had been taking for approximately one year. Her CBC at that appointment showed platelets less than 6. The patient went to the ED where repeat lab work showed similar thrombocytopenia.

She denied any tobacco use, endorsed social drinking and occasional marijuana use.

She was admitted for immune thrombocytopenia and treated with IV steroids for four days. Viral, autoimmune, and hemolysis work up was unremarkable. Platelets recovered from <6 to 140 at discharge. She was readmitted two weeks later after repeat labs showed platelet count of 9. She again responded to steroids and was treated with a prolonged taper. A month after her initial presentation she was started on Promacta (eltrombopag). Six months later she completed rituximab infusions and was able to stop Promacta due to rituximab response. Approximately 10 days after stopping Promacta, she began having pain and swelling in her right upper arm. A venous thrombosis was found at that site as well as a subsegmental left lower lobe pulmonary embolus. Her Promacta had been discontinued two weeks prior, and her OCP was discontinued at the time of discovery of the clots. She was started on Xarelto to treat the DVT and PE. The patient received three months of anticoagulation. She is currently doing well off anticoagulation and platelet counts remain stable off Promacta. Her contraception method was switched to Nexplanon to remove systemic estrogen from her treatment. Of note she had no family history of bleeding or clotting disorders.

IMPACT/DISCUSSION: This case highlights the risk of thrombosis/embolism with not only combined hormone oral contraception but also procoagulant medications. These thrombotic complications can be observed at low or normal platelet counts. The risk for thromboembolism with eltrombopag is 3-6%; additionally, the combined hormonal contraception has been cited to cause nineteen cases of DVT/PE in 10,000 current users per year. Literature has shown that the increased risk of VTE related to combined hormonal contraception is highest in the first year. Our patient was taking two different medications that could have caused her thrombosis event. This case should remind prescribers to consider all contraceptive methods and consider switching to contraception with lower thromboembolic risk when prescribing other medications that could contribute to thromboembolic disease.

CONCLUSION: 1.The patient’s DVT and PE were likely provoked from OCP (1 year duration) and Promacta (6 month duration).

2.With a history of provoked thrombosis on OCP, estrogen-containing contraception methods are contraindicated, and alternative methods should be considered.

DOUBLE TROUBLE: A CASE OF SYPHILIS AND MONKEYPOX CO-INFECTION IN AN HIV- POSITIVE PATIENT

Sean Lee, Ipsita Hamid, Rebecca Wig, Abhinav Dhakal

Medicine, Banner University Medical Center Tucson, Tucson, AZ. (Control ID #3859928)

CASE: A 30-year old man with HIV non-compliant with ART and prior syphilis infection (post-treatment titer 1:1024) presented with 1-2 weeks of non-tender skin lesions which began on his torso and spread to the extremities. The lesions varied from pustules, to reddish nodules, to dark purple scabs that could be deroofed. The patient denied close contact with any person with similar lesions; he was also monogamous with a male partner and engaged in protected intercourse. On review of systems, the patient denied fever, dyspnea, chest or abdominal pain, headache, weakness, sensory changes, B-symptoms, dysuria, or arthralgia. Physical exam was unremarkable except for the aforementioned lesions and some non-tender anterior cervical lymphadenopathy.

Notable labs included WBC 15, ESR 47, CRP 102, negative gonorrhea/chlamydia urethra screen, negative HSV-1/2 antibody test, no growth on blood culture, CD4 count 765, HIV viral load 236000, and RPR titer 1:512. Lesion biopsy revealed a non-specific inflammatory infiltrate with lymphocytes and neutrophils. No organisms were identified on staining; however, PCR returned positive for monkeypox DNA. The two-fold decrease in RPR titer indicated either treatment failure or reinfection. Since no chancre was found and monkeypox lesions could mask concurrent secondary syphilis, we empirically treated for latent syphilis. The patient obtained 1 dose of IM penicillin before discharge but was lost to follow-up and did not receive the other 2 doses.

IMPACT/DISCUSSION: Before labs were obtained, monkeypox was high on our differential given the patient’s risk factors of untreated HIV infection and prior STI¹. Moreover, the lesions appeared consistent with monkeypox as described in literature – well-circumscribed nodules and pustules that eventually scab over and deroof^1,2. However since other STIs such as secondary syphilis, disseminated HSV, and gonococcemia can also present as pustular rashes, we included testing for these potential monkeypox mimics.

Our case demonstrates that STIs can co-present, and that in high-risk patients with lesions suspicious for monkeypox, other STIs with cutaneous manifestations should also be on the differential. Without a repeat RPR titer, we would have attributed the patient’s symptoms to solely monkeypox and missed an opportunity to treat his syphilis. Finally, our case emphasizes the importance of promptly alerting public health officials for contact tracing – especially among patients with a high likelihood of being lost to follow-up.

¹ Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox Virus Infection in Humans across 16 Countries - April-June 2022. N Engl J Med. 2022;387(8):679-691.

² cdc.gov/poxvirus/monkeypox

CONCLUSION: In patients presenting with suspicious skin lesions and risk factors such as untreated HIV, index of suspicion should be high for STI co-infection. Clinicians should have a low threshold to initiate broad screening for STIs with potentially overlapping cutaneous features such as monkeypox and syphilis.

GENDER AFFIRMING HORMONE THERAPY AND CARDIOVASCULAR RISK

Katie Bopp, Amy H. Farkas

General Internal Medicine, Medical College of Wiscponsin, Milwaukee, WI. (Control ID #3874426)

CASE: A 66 yo transgender woman on gender affirming hormone therapy (GAHT) of oral estradiol with PMHx CAD s/p NSTEMI, T2DM, and tobacco use presented to the emergency department from outpatient echocardiogram lab for atypical chest pain and concern for new wall motion abnormalities. Initial ACS work up including troponins and EKG was unremarkable, and subsequent myocardial perfusion imaging (MPI) showed no perfusion deficits. Following discharge, the patient underwent elective cardiac catheterization which showed evidence of mild intra-stent restenosis, however no other significant lesions. The patient’s cardiovascular risk factors were extensively reviewed, and the patient was counseled on risk reduction strategies including smoking cessation, improved blood sugar control, increased physical activity, and transition to transdermal estradiol patch.

IMPACT/DISCUSSION: Gender affirming hormone therapy consists of testosterone for transgender men and estrogen +/- anti-androgens for transgender women. This is an essential component of healthcare for transgender patients. Providers must understand the potential risks of GAHT and have dedicated risk/benefit conversations with each patient. The World Professional Association of Transgender Health (WPATH) has developed standards of care that serve as guidelines for providers. It is recommended to start GAHT in all eligible people, however, medical conditions that could be exacerbated by exogenous hormones should be addressed prior to starting treatment (i.e., polycythemia, hormone sensitive cancer, personal or family history of DVT or PE, etc). It has been shown that conjugated estrogens are associated with up to 20-fold higher risk of venous thromboembolism (VTE). Therefore, conjugated estrogens are not recommended and instead oral, transdermal, or intramuscular formulations of estradiol are used for GAHT.

Unfortunately, literature to date regarding the short and long-term risks of GAHT is scarce and inconsistent. Additionally, cardiovascular risk is confounded by variables such as mental health and substance use disorders and health inequities that exist within transgender populations. Understanding this, current literature suggests that transgender women on GAHT have an increased risk of myocardial infarction when compared to cisgender women, as well as an increased risk of ischemic stroke and VTE when compared to both cisgender women and cisgender men. Of note, studies comparing different estrogen formulations and the risk of VTE found that transdermal estradiol had no increased risk. As a result, the WPATH recommends prescribing transdermal estrogen for transgender women at higher risk of developing VTE based on a previous history of VTE or age > 45, such as the patient in this case.

CONCLUSION: Current evidence suggests increased risk of MI, ischemic stroke, and VTE in transgender women on GAHT. Transdermal estrogen should be prescribed for those with history of VTE or age > 45.

GLOBAL DIFFERENCES IN CERVICAL CANCER PREVENTION AND THE IMPACT OF COVID-19 DISRUPTIONS

Shambhavi Singh¹; Deborah Kwolek¹; Brooke Hartenstein²

¹Department of Medicine, Massachusetts General Hospital, Boston, MA; ²Medical Education, Florida State University College of Medicine, Tallahassee, FL. (Control ID #3874484)

CASE: A 23 year old G2P2 female presents to establish care after recent immigration from Venezuela. She denies any symptoms or past medical history. She has one sexual partner and a half pack-year smoking history.

Patient was given catch-up immunizations, including anti-HPV vaccine. Patient underwent her first pap smear with HPV reflex testing, which demonstrated atypical squamous cells, and possible high grade squamous intraepithelial lesions HSIL (ASC-H) and positive testing for HPV 16. Given high grade lesions with virulent HPV staining, patient also underwent colposcopy. Visual exam found aceto-white epithelium along the squamo-columnar junction, and pathology showed focal high-grade squamous intraepithelial lesion (CIN 2).

Patient was counseled about HPV, pre-cancerous cervical changes, and cervical cancer, with plan to follow up and repeat colposcopy in 6 months.

IMPACT/DISCUSSION: Vaccination against HPV was shown to be highly effective in preventing pre- malignant and malignant cervical lesions in 2006. Since then, ~80 countries have developed national HPV vaccination programs. This leaves ~115 countries and a major proportion of the world (including our patient’s country of origin) without a national HPV vaccine programs. Reasons for low vaccine adoption vary globally, although cost remains a significant barrier. Even in countries with robust HPV vaccination programs including the USA, recent disruptions due to the COVID-19 pandemic have set back vaccination efforts. Models estimate that 80% vaccination rates could eliminate high risk HPV, and even a 20% rate would significantly reduce pre-cancerous lesions. Current vaccination rates are around 2-5% globally, and therefore, primary prevention of HPV infection still remains a challenge.

In the USA, complete cervical cancer screening programs require multiple clinical visits, highly trained personnel, and specialized equipment. Comparing costs across methods shows that HPV PCR testing is the costliest step, followed by pap smears, while visual inspection is the cheapest. Major contributors to cost vary by country: in India, specialized equipment is the major issue, and in Kenya and Peru, travel to a healthcare site capable of performing testing was the largest barrier. Therefore, country-specific solutions using either visual inspection as the screening method or developing portable and/or self-collection options are necessary. This clinical case highlights the differences in global prevention and screening practices, and shows how practice breaks down in the face of extreme stress on both individuals (arduous immigration journeys) and healthcare systems (COVID-19 pandemic).

CONCLUSION: Primary prevention of cervical cancer remains an implementation challenge both locally and globally, requiring innovative diagnostic tools that can be used in low resource settings.

The COVID-19 pandemic has resulted in a recent drop in preventative care and new guidelines for catch-up strategies are necessary to make up for backlogs in care.

HPV DIAGNOSES: ALL ADVENTUROUS WOMEN DO

Claire Dugan¹; Jen Rusiecki²

¹General Internal Medicine, Bellevue Hospital Center, New York, NY; ²Internal Medicine , University of Chicago, Chicago, IL. (Control ID #3876632)

CASE: A 31 y/o woman with a history of MDD presented to clinic to discuss her pap smear/HPV results. She had a normal pap smear (NILM) but tested positive for HPV, with her genotype negative for 16, 18, 45 – the most high-risk variants. We determined that the patient should have a repeat HPV/pap in one year based on a 5 year CIN3+ risk of 4.8%. The patient was distraught when she received her results – she felt shame, was concerned about cancer, confused why her HPV vaccine from 2006 “did not work,” and felt unsure about how to discuss these results with her new heterosexual male partner. She experienced reassurance with education about the transient, common nature of HPV infection and the knowledge that higher risk strains are responsible for the majority of HPV-associated cancers. On further review, guidelines about partner disclosure from professional societies were lacking and unclear. There is no commercially available HPV test for men and condom use may or may not decrease the risk of transmission. Through shared decision making, our patient decided to disclose her HPV status to her partner. He (a 29 yoM without significant PMH) had not received an HPV vaccine and was planning to discuss getting one with his PCP. They did not change their sexual practices.

IMPACT/DISCUSSION: HPV diagnosis will become more common in future years, especially with recommendations from the American Cancer Society to phase out cytology testing and start primary hrHPV testing at a younger age (25). Only 53% of eligible individuals in the US are vaccinated against HPV and many received an earlier iteration of the Gardasil vaccine, which only protects against 4 virus strains.

In spite of HPV’s prevalence, providers receive little guidance on discussing HPV diagnosis and future cancer risk. Many labs genotype HPV, allowing for risk stratification, but providers may be less familiar with virus strains and their specific risks to patients. Our patient’s anxiety about her diagnosis was addressed through giving data about the likelihood of regression and lower risk of her specific strain of HPV.

There is a notable lack of recommendations on partner disclosure for HPV+ patients. Shared decision making and the risk of additional HPV-associated cancers motivated our patient to disclose her result to her partner, who may pursue vaccination as a result. There are conflicting recommendations on vaccinating individuals older than 26, but a partner’s exposure to HPV might push a patient to get a vaccine.

CONCLUSION: - Providers should expect many women to test positive for HPV in the coming years - Providers should approach discussions about HPV with empathy and concrete information about cancer risk, incorporating genotype into discussion

- Providers should expect patients to inquire about HPV partner disclosure. At present, formal guidelines are lacking. Shared-decision making should incorporate how HPV status might change sexual practices or vaccination status

INDUCING LACTATION IN A TRANSGENDER WOMAN WITHOUT GALACTAGOGUES: A CASE REPORT

Baila Elkin¹; Alisa Duran^3,4; Kevin Rauwerdink³; Elizabeth S. Goldsmith²

¹Internal Medicine, Cleveland Clinic, Cleveland, OH; ²Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN; ³Minneapolis VA Health Care System, Minneapolis, MN; ⁴University of Minnesota Twin Cities, Minneapolis, MN. (Control ID #3872717)

CASE: Our patient was a 36-year-old transgender woman, a United States military veteran receiving care through the Veterans Health Administration (VHA), who was planning on having a child with her partner and wanted to breastfeed. Her partner, a transgender man, carried and delivered the child and wished to return to testosterone use shortly after delivery. Her primary goals included sufficient milk production to allow bonding, even if not the sole source of infant nutrition. Our multidisciplinary team included a clinical pharmacist with gender-affirming hormone therapy expertise and a lactation specialist with gender-affirming therapy expertise. Our patient was status post orchiectomy with an initial testosterone level of 27 ng/dL, and on a dose of 4mg PO 17-beta estradiol. We began the patient’s lactation induction 98 days prior to her partner’s pregnancy and 377 days prior to her partner’s eventual due date. Our protocol involved 1) increased estrogen and progesterone to mimic physiologic levels during pregnancy; 2) physical nipple stimulation using a breast pump; and 3) reduced estrogen and progesterone shortly before delivery to mimic physiologic levels after birth. We opted against a galactagogue due to US Food and Drug Administration (FDA) recommendations against domperidone as well as patient concerns of side effects with other galactagogues. Our patient began seeing the first drops of milk 40-50 days after beginning nipple stimulation. After decreasing estradiol and progesterone doses, she saw an increase in milk production, to about 2mL per pumping session one week after decreased estradiol and progesterone . Interestingly, our patient’s estradiol levels remained under 200 pg/mL throughout the lactation induction process, even at higher levels of 17-beta estradiol dosing. This is in consonance with other published case-reports on lactation-induction in transwomen.

IMPACT/DISCUSSION: Lactation support in transgender women is increasingly recognized as clinically important yet has limited clinical precedent. While previous case reports describe successful lactation induction their protocols involve domperidone, a galactagogue unavailable for this purpose in the US and recommended against by the FDA. We present a case of successful lactation induction in a transgender woman using a protocol not involving galactagogues. Working with a multidisciplinary team including pharmacy and lactation specialists and using a protocol involving (1) initial increase of estradiol and progesterone, (2) nipple stimulation, and (3) eventual reduction of estradiol and progesterone, our patient was able to lactate without the use of galactagogues, allowing her to meet her goal of bonding with her baby.

CONCLUSION: This is the first reported case of successful lactation induction without galactagogues for a transgender woman to our knowledge, and provides an example protocol modeled on physiologic lactation stimuli that other clinicians may adapt with their own patients in similar circumstances.

MIGRATION OF A CONTRACEPTIVE SUB-DERMAL DEVICE INTO THE LUNG

Joud Enabi, Alejandro J. Herrera-Ramos, Rami Al-Ayyubi, Pablo Amador Mejia, Deepika Devalla

Internal Medicine, Texas Tech University Health Sciences Center, Permian Basin, Odessa, TX. (Control ID #3859622)

CASE: A 38-year-old woman with insignificant past medical/surgical history had an Implanon subdermal contraceptive implant inserted in her left upper limb for contraception after delivering her third baby in June/2022. During her annual visit, the implant was not palpable. An X-Ray of the left arm was performed, and it failed to detect the implant; thus, she underwent a chest X-ray, and a linear foreign body projected in the region of the left lower lobe was found. The findings were highly suspicious for an embolized implant. Computerized tomography (CT) of the chest reported a 4 cm long linear hyperdensity in the left lower lobe favoring to be a migrated implant in a subsegmental pulmonary artery branch. After consultations with interventional radiology, foreign body removal of the Implanon through an endovascular approach to the pulmonary artery using a right common femoral vein access was considered. General anesthesia was provided, and the patient was placed supine on the fluoroscopy table. An ultrasound examination of the right groin was performed to confirm patency of the right common femoral vein. The right common femoral vein was punctured using a sterile technique and local anesthesia with ultrasound guidance. Interventional radiology proceeded to retrieve the implant removal of the Implanon through an endovascular approach to the pulmonary artery using a right common femoral vein access. The patient was discharged without complications. Further contraception plan is to be discussed with the patient at the outpatient clinic of the obstetrics and gynecology department.

IMPACT/DISCUSSION: Significant migration of a subdermal contraceptive implant over 2 cm is rare and occurs primarily caudally from the insertion site[1]. The risk of other side effects is estimated to be roughly up to 1.1%[2]. In this case, it is estimated that the subdermal contraceptive implant was placed into the basilic vein during the insertion. As a result, the subdermal birth-control implant migrated through the upper limb veins and settled in a pulmonary artery branch in the left posterior basal segment. The implant should be palpable throughout the use and can be detected on X-ray and CT imaging. If unable to palpate the device, use imaging, including ultrasound, X-ray, and CT imaging, to localize the implant[3]. Our case supports the approach of such rare complications by minimally invasive interventional radiology approach rather than the surgical approach.

CONCLUSION: An Etonogestrel implant is a 4 cm rod-shaped subdermal contraceptive implant coated with barium sulfate that is usually inserted into the inner side of the non-dominant arm[4]. Subdermal implants can carry the possibility to migrate within a small range, usually less than 2 cm from the insertion sites, yet, significant migration over 2 cm is rare[5]. This paper discusses the case of a patient with a migrated subdermal Implanon contraceptive implant in the left pulmonary artery in a 38-year-old woman.

MPOX EXPOSURE IN PREGNANCY

Sarah H. Brown¹; Ilona T. Goldfarb^2,3; Erica S. Shenoy^4,5; Deborah Kwolek^1,3

¹Massachusetts General Hospital Department of Medicine, Boston, MA; ²Maternal Fetal Medicine, Massachusetts General Hospital, Boston, MA; ³Medicine, Harvard Medical School, Boston, MA; ⁴Infection Control Unit, Massachusetts General Hospital, Boston, MA; ⁵Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA. (Control ID #3875032)

CASE: In May 2022, a 43 year-old healthcare worker (HCW) was 20 weeks pregnant when she cared for a patient ultimately diagnosed with mpox several days into a hospital admission, the first recognized case of mpox in the United States. Because mpox was not suspected, the patient was initially on standard precautions. The HCW wore a medical mask as part of universal source control and did not have direct contact with the lesions. She changed the patient's linens wearing gloves and no gown. Based on public health guidelines at the time, the HCW was considered to have had an intermediate risk exposure. The HCW underwent risk-benefit counseling regarding post-exposure prophylaxis (PEP) with Modified Vaccinia Ankara (MVA) vaccine by a Maternal Fetal Medicine specialist.

IMPACT/DISCUSSION: Infections from viruses in the Orthopoxvirus genus during pregnancy can lead to severe maternal illness, vertical transmission, spontaneous abortion, and stillbirth.¹ It is important to risk- stratify pregnant individuals who have sustained exposures to mpox in order to offer timely PEP, as vaccination within four days of exposure can prevent infection and within 14 days can reduce the risk of severe disease.² Using a mpox exposure risk stratification tool based on public health guidelines and augmented with additional detail, the exposed HCW was deemed intermediate risk due to contact of clothes and intact skin with potentially contaminated linens. Individualized shared decision making on PEP was recommended.³ The replication-incompetent MVA vaccine is presumed to be safe for use during pregnancy and is recommended by the Centers for Disease Control to be offered to eligible pregnant people.⁴ No adverse fetal effects of the MVA vaccine were observed in rat and rabbit studies although there are no studies on human pregnancy.² Ultimately, the HCW decided to not pursue PEP, reported no symptoms during the 21- day monitoring period, and later gave birth to a healthy baby girl.

CONCLUSION: Mpox can cause congenital infections so risk-stratification of exposed pregnant people and consideration of MVA vaccine PEP is of particular importance.

References:

1. D’Antonio F, Pagani G, Buca D, Khalil A. Monkeypox infection in pregnancy: a systematic review and metaanalysis. Am J Obstet Gynecol MFM. 2023;5(1):100747.

2. Meaney-Delman DM, Galang RR, Petersen BW, Jamieson DJ. A Primer on Monkeypox Virus for

Obstetrician–Gynecologists. Obstet Gynecol. 2022;140(3):391-397.

3. Shenoy ES, Wright SB, Barbeau DN, et al. Contact Tracing and Exposure Investigation in Response to the First Case of Monkeypox Virus Infection in the United States During the 2022 Global Monkeypox Outbreak. Ann Intern Med. Published online November 8, 2022. doi:10.7326/M22-2721

4. Center for Disease Control. Clinical Considerations for Monkeypox in People Who are Pregnant or Breastfeeding. Updated October 14, 2022. Accessed December 15, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/pregnancy.html

NEUROSYPHILIS WITH TABES DORSALIS OR SEVERE ALCOHOL WITHDRAWAL?

Elijah D. LaSota, Amber Hardeman, Sarah Cossich

Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #3872256)

CASE: A 32-year-old male with alcohol use disorder presented with fatigue, nausea, lower extremity edema, paresthesia, sharp pains, and intermittent weakness in his legs worsening over the past weeks. He denied headaches, chest pain, fevers, diarrhea, urinary/bowel incontinence, syncope, or falls. Physical exam included general anxiety, tachycardia, distended abdomen, bilateral upper extremity tremor, and bilateral calf/shin tenderness to palpation. No decreased reflexes or sensation. He was afebrile, hypertensive, and saturating 100% on room air.

The patient had a CIWA of 12 and was admitted for alcohol withdrawal. He reported a daily intake >1 pint and his last drink 24 hours prior. Labs showed macrocytic anemia; normal WBC, TSH, UTOX, Trop, HIV, and hepatitis panel. DVT U/S and CT PE were negative. Despite fluids, benzo taper, vitamin supplementation, gabapentin, cyclobenzaprine, and opioid pain control, his BLE symptoms worsened, prohibiting ambulation and broadening the workup.

Neuro exam elicited dysmetria, abnormal stance, and ataxic gait. MRI brain showed moderate parenchymal loss, MRI spine demonstrated mild degenerative bone changes. Folate, B12, CK, ANA, and myositis, autoimmune, and ENA antibody panels were normal. Serum FTA-ABS and RPR were reactive to 1:1.

Further history revealed multiple sexual partners, several treated sexually transmitted infections, and no condom usage. Notably, patient stated he was treated for presumed syphilis ~14 years prior without positive testing. LP revealed a bland CSF profile; however, VDRL CSF was reactive at 1:64.

Neurosyphilis (NS) treatment was initiated and his symptoms and overall status rapidly improved.

IMPACT/DISCUSSION: Syphilis cases have been on the rise, reaching the highest incidence since 1992; though NS is infrequently reported. As this incidence increases, so too should our suspicion for severe cases. NS diagnosis requires reactive serology and CSF VDRL/FTA-ABS, neurological signs/symptoms, and elevated CSF cell count or protein; the latter of which was not present in this patient. Although the true relationship between serum RPR titer and infection status is debated, greater disturbances in laboratory values, especially CSF profiles, generally correlate with more severe symptoms. Rarely, advanced NS with tabes dorsalis has been reported to reach a “burn out” stage as in this case.

CONCLUSION: This case was significant for symptoms initially attributed to vitamin deficiency secondary to chronic alcoholism and withdrawal, later confirmed as NS per VDRL CSF and despite initially low suspicion for syphilis infection due to low serum RPR titers, bland CSF profile, and reported prior treatment. Lessons learned from this case include maintaining a low threshold for LP and CSF analysis in the presence of reactive RPR results and suspicious peripheral neuropathy symptoms, including VDRL CSF in addition to FTA-ABS CSF, especially in the setting of nationwide increased incidence of syphilis infections.

PLAN A MAKING MEDICATION ABORTION ACCESSIBLE TO PATIENTS IN THE GENERAL MEDICINE SETTING

Charity Sylvester²; Mindy Sobota¹

¹Division of General Internal Medicine, Brown, Providence, RI; ²Internal Medicine Residency Program, Brown University, Providence, RI. (Control ID #3875589)

CASE: A 42y cis-female patient with a history of hypertension presents to her general internist with a missed period, LMP 5w ago. Patient notes some diffuse lower abdominal cramping and vaginal bleeding 3d ago that saturated 1 pad and then stopped. Urine hCG confirmed pregnancy. We counseled her on her pregnancy options; she did not desire additional children at her age and requested an abortion, legal in our state. A pelvic ultrasound and serum quantitative hCG were ordered to rule out miscarriage or ectopic pregnancy and confirmed a 5w, 2d intrauterine gestational sac. After discussing the risks and benefits of abortion via medication versus referral for a procedure, she chose pills.. We assessed for contraindications to medication abortion including: severe anemia, bleeding disorders, anticoagulation use, or use of chronic steroids. Finding none, we counseled her on mifepristone/misoprostol and reviewed the medication guide on how to use the pills. We then ordered mifepristone 200 mcg po x 1 followed in 24-48h by misoprostol 200 mcg x 4 buccally or vaginally. The prescriptions were sent to a mail order pharmacy. We faxed a provider agreement to the manufacturer and pharmacy. The patient called the pharmacy to pay $75 for the pills and express shipping given Rhode Island state insurance does not cover abortion. On follow up phone call 1w later she reported passage of clots within 24h of taking the misoprostol. Repeat quantitative hCG decreased greater than 80%, confirming a successful abortion.

IMPACT/DISCUSSION: Presentations for a missed period are not uncommon in primary care and general internists should be prepared to counsel patients on pregnancy options including parenting, adoption, and abortion. For patients like ours who requested medication abortion in a state where it remains legal, access and affordability are still significant barriers to timely care, affecting poor people disproportionately. Medication abortion is safe, effective and can be prescribed by primary care clinicians (NASEM 2018). Studies indicate that patients prefer primary care for their abortion, and that internists are willing to prescribe abortion pills but lack training. Starting in 2021 our program included medication abortion training for all general medicine residents and the FDA updated prescribing to include mail order pharmacies, removing the requirement to store medications onsite. Providing medication abortion in primary care via mail order pharmacy provides patients with the autonomy to complete the process in the comfort of their home at a lower cost. An internist who can assess for contraindications and provide follow up may offer medication abortion in states where it is legal to do so.

CONCLUSION: Offering medication abortion in a primary care setting improves access to safe, effective and timely medical care.

E-prescribing medication abortion pills to a mail order pharmacy is an alternative to stocking the medications onsite, which can be a logistic hurdle.

POSITIVE HIV VIRAL LOAD: NOT SO STRAIGHTFORWARD

Son Quyen H. Dinh^1,2; Joshua Dubow¹

¹Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Fenway Health, Boston, MA. (Control ID #3876787)

CASE: A 34-year-old man with asthma and prior gonorrhea infection presented for HIV pre-exposure prophylaxis (PrEP) follow-up. For the past two years, he had been taking emtricitabine/tenofovir 200-300mg daily for PrEP. He reported only one missed dose in the last month. Since his last visit three months prior, he reported having oral, anal receptive, and anal insertive sex with six male partners without using condoms. At presentation, he was asymptomatic. In following CDC guidelines, routine labs were performed: gonorrhea and chlamydia screening (through urine, throat swab, and rectal swab), syphilis screening, fourth generation HIV antigen/antibody test, and HIV-1 RNA viral load. His labs resulted with a negative HIV antigen/antibody test but a detectable HIV viral load (<20 copies/mL). He was instructed to stop PrEP, to abstain from sexual activities or use condoms, and to repeat an HIV-1 RNA viral load testing after one week. On repeat testing, his HIV viral load was undetectable, indicating a likely false positive on original testing. He was instructed to resume PrEP.

IMPACT/DISCUSSION: PrEP use is increasing rapidly and has become a cornerstone of HIV prevention. Updated CDC guidelines published in 12/2021 recommended obtaining HIV-1 RNA quantitative viral load in addition to HIV antigen/antibody assays every three months for routine lab monitoring. The goal of this new recommendation is to enhance detection of early HIV infection during the window period of HIV antigen/antibody tests. However, since the implementation of this new protocol, cases with negative HIV antigen/antibody tests but detectable HIV viral load have been observed. Two possible explanations exist: a false positive test or early HIV infection with low RNA viral load due to suppression by PrEP. In these situations, providers are faced with the challenge of interpreting ambiguous results and relaying a possible HIV diagnosis to patients.

There are three possible management pathways for patients who have ambiguous HIV screening while repeat testing is pending. The first option is to continue PrEP medication, as the likelihood of PrEP failure is very low for an adherent patient. However, if the patient is infected with HIV, continuing PrEP can increase the risk of developing drug resistance, specifically for mutations M184V (emtricitabine) and, less prevalently, K65R (tenofovir). The second option is to add a third anti-retroviral drug as post-exposure prophylaxis for 28 days, which can be particularly useful in nonadherent patients. The third option is to discontinue PrEP for one to two weeks and stress the importance of abstinence or consistent condom use. This may allow for more accuracy as HIV RNA would rapidly increase while the patient is off antiretroviral therapy.

CONCLUSION: -Ambiguous HIV testing while on PrEP may indicate a false positive test versus early HIV infection partially suppressed by PrEP.

-A detailed history is important for risk stratification and determining the next step in management.

PRIMARY HYPERPARATHYROIDISM AS A CAUSE OF INTRACTABLE NAUSEA AND VOMITING IN PREGNANCY

Maureen Fausone

Internal Medicine, Vanderbilt University Medical Center, Nashville, TN. (Control ID #3869833)

CASE: A 26-year-old G2P1 woman presents at 9 weeks gestation with 4 weeks of nausea and vomiting. She cannot tolerate PO and has been treated at other EDs with fluids and antiemetics 5 times over the past 2 weeks. Pertinent positives include fatigue, epigastric pain, and history of a sexually transmitted infection. Pertinent negatives include cramping, vaginal bleeding and discharge, diarrhea, dysuria, and headache. She had mild nausea and vomiting in her first pregnancy and no other complications. She is adopted. She had surgery for Hirschsprung’s disease as an infant and has a history of anemia. Her only medications are pre- natal vitamins and ferrous sulfate. She is allergic to trimethoprim-sulfamethoxazole and doxycycline. She uses no substances. Exam is significant for mild epigastric tenderness. She has calcium 13.8, PTH 213, phosphorus 1.4, vitamin D 22, TSH .015, and elevated free T4. Outside records showed incidental elevated calcium three years ago at an ED visit. Thyroid ultrasound shows parathyroid nodule, hyper-vascular thyroid, and thyroid nodule. Continuous IV fluids keep her calcium between 11 and 12. Per MFM the upper limit of normal for calcium in pregnancy is 9.5 mg/dL. The patient was taken for parathyroidectomy. Her nausea resolved in 24 hours, and she was able to tolerate food. Calcium fell to 10.4 in 24 hours and 9.6 in 2 weeks. Endocrine recommended genetic testing for MEN syndrome.

IMPACT/DISCUSSION: Primary hyperparathyroidism (PHPT) is common in older women. This population can undergo monitoring if they are asymptomatic, not high risk for nephrolithiasis, without osteoporosis or history of fragility fractures, and do not have decreased renal function. Patients less than 50 years old should be referred for parathyroidectomy. Hypercalcemia in pregnancy carries significant maternal and fetal risks. In one case series involving 77 pregnancies, fetal loss occurred in 48% of pregnancies in which the mother had PHPT but did not undergo parathyroidectomy. The majority of fetal losses occurred in late first or early second trimester. Based on this data surgery should not be delayed until second trimester. More than 10% of patients with PHPT will have a mutation in one of eleven genes. Young patients, such as those under the age of 45, those with multi-gland disease, family history of hypercalcemia, or features concerning for an MEN syndrome should be referred for genetic screening. This patient likely had PHPT for multiple years that was exacerbated by nausea and vomiting of pregnancy and hyperthyroidism.

Norman J, Politz D, Politz L. Hyperparathyroidism during pregnancy and the effect of rising calcium on pregnancy loss: a call for earlier intervention. Clin Endocrinol (Oxf). 2009;71:104-109. doi:10.1111/j.1365-2265.2008.03495.x

CONCLUSION: Physiologic changes of pregnancy alter expected lab values which may not be noted in the EMR. Pregnant women with PHPT should be referred for surgery. Young people with PHPT should be referred for consideration of genetic testing.

STD HIDE-AND-SEEK

Chelsea R. Navarrette

Internal Medicine, University of Nebraska Medical Center, Omaha, NE. (Control ID #3872480)

CASE: A 22 year-old male presented for ER follow-up and an annual physical. PMH of asthma and ADHD. Medications include albuterol MDI as needed. Social history significant for binge-drinking behavior on weekends. On further inquiry, offers that he is sexually active with women only and consistently uses condoms. He is interested in STD testing “if it is free.” He participates in penile-vaginal and oral intercourse. No known STD exposures. No penile discharge, dysuria, or genital skin lesions. No sore throat or odynophagia noted. STD testing ordered, including HIV, treponemal pallidum antibody, and gonorrhea/chlamydia (G/C) DNA probes of urine and throat specimens. The oropharyngeal sample was collected by rubbing a sterile swab along the tonsillar pillars, posterior pharynx, and both tonsils. The G/C DNA probe of the urine was negative, but the throat swab returned positive for gonorrhea. The patient returned to clinic for an intramuscular dose of Ceftriaxone 500mg and expedited partner therapy was arranged.

IMPACT/DISCUSSION: Testing asymptomatic, at-risk patients for STDs is an integral part of reducing STD rates. Each year, 20 million STD’s are diagnosed in the US, resulting in $16 billion in healthcare expenditures. Left untreated, gonorrhea can lead to pelvic inflammatory disease, epididymitis, and arthritis- dermatitis syndromes due to disseminated infection. A thorough sexual history is an often-overlooked piece of a preventive visit due to potential provider/patient discomfort or time constraints. Using open-ended questions and the “Five P’s of Sexual History” can help increase provider comfort during these difficult conversations. Sexual history should include details on number of sexual partners as well as type of intercourse – penile-vaginal, penile-anal, oral intercourse, or intercourse between two female partners.

Testing each site of sexual contact is important for screening, as gonorrhea can cause symptomatic or asymptomatic pharyngitis. For men, instructing the patient to pee into the cup before finishing the void in the toilet can increase yield, as a first-catch specimen is more likely to test positive. In women, urine NAAT (nucleic acid amplification testing) is lower yield, and a vaginal self-swab can be more sensitive. Women can be coached to insert the swab like a tampon and rotate for 20 seconds. Similarly, anyone having anal intercourse should obtain an anal swab. This can be performed by the patient or provider by inserting a swab 2-3cm into the rectum. All patients who test positive for G/C should be re-tested at 3 months due to high risk of re-infection.

CONCLUSION: Identifying and treating STDs is an essential part of providing comprehensive preventive healthcare in sexually active patients. A detailed sexual history will help guide testing, such as obtaining sample specimen from all anatomic locations involved in sexual contact. This is especially important as STDs can lead to asymptomatic infections of the throat and anus.

THE PHYSICAL EXAM CLINCHES IT AGAIN: A CASE OF FABRY DISEASE CARDIOMYOPATHY IN A FEMALE PATIENT

Neyshia L. Rodriguez²; Lauren Block¹

¹Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY; ²Internal Medicine, Northwell Health, New Hyde Park, NY. (Control ID #3875941)

CASE: A 48-year-old woman with a medical history of Fabry Disease (FD), mitral valve prolapse, Wolf- Parkinson-White pattern, and SARS-CoV-2 pneumonia presented to the clinic for her annual examination. She had stable disease while on enzyme replacement therapy (ERT) since 2017 when genetic tests showed elevated globotriaosylceramide and cardiac MRI at that time confirmed normal ventricular size, and mild focal myocardial fibrosis.

Physical examination was notable for a grade 3/6 holosystolic murmur best heard at the left lower sternal border; a progression from 2/6 found on prior examinations. The remainder of the examination was unremarkable. During the visit, an ECG showed sinus bradycardia with lateral strain and voltage criteria consistent with left ventricular hypertrophy (LVH). The change in her systolic murmur and the ECG findings prompted further cardiac evaluation.

A transthoracic echocardiogram (TTE) revealed a 70% ejection fraction which was unchanged from prior studies but revealed new apical LVH. Cardiac MRI showed severe concentric LVH and myocardial enhancement in the basal-inferolateral walls consistent with fibrosis progression when compared to prior MRI. Cardiac Holter monitoring showed ectopy including PSVTs and wide complex rhythms. An AICD was placed. Treatment with Mavacamten is being discussed by the cardiology team.

IMPACT/DISCUSSION: Fabry Disease is a progressive, X-linked lysosomal disorder commonly presenting with neurologic, kidney, and cardiac manifestations. A poor understanding of the differences in the disease burden between men and women has led to delays in diagnosis and management of cardiac disease in female patients. For instance, patients with Fabry Disease Cardiomyopathy (FDC) present with LVH, fibrosis and dysrhythmias. Women typically present later in life, and although they can have a smaller degree of LVH, fibrosis develops irrespective of LVH relative to males. In addition, ECG shows bradycardia and shorter p-wave and QRS duration in females, but right bundle branch blocks were identified in males only. Yearly follow-up is recommended in patients with FDC with cardiac MRI, TTE, and 24-hour cardiac monitoring.

Although TTE helps with diagnosis in the presence of LVH, it does not assess for myocardial fibrosis. In fact, prior studies have found that 50% of females would have not been diagnosed with FDC without findings on MRI. For patients on ERT, routine visits are recommended every 6 months, and they should include basic blood and urine tests, and ECG. Finally, the Fabry Stabilization Index is a tool for assessment of clinical stability that has been validated for males and female patients.

CONCLUSION: Recognizing the differences by gender in disease progression in Fabry disease is imperative as cardiomyopathy is the leading cause of premature death in heterozygous FD females.

WORKING UP IRON DEFICIENCY ANEMIA: UNDIAGNOSED GASTROINTESTINAL STROMAL TUMOR AS A CAUSE OF GI BLEEDING IN YOUNG HEALTHY WOMEN Vanya Jain¹; You Wu²

¹Internal Medicine, Kaiser Permanente Northern California, Santa Clara, CA; ²Internal Medicine, Kaiser Permanente, Oakland, CA. (Control ID #3875495)

CASE: A 38 year old Chinese woman presented to the ER with acute coffee-ground emesis, melena, and hemoglobin of 6.5 g/dL. Endoscopy was unremarkable except for mild gastritis. Colonoscopy showed two small tubular adenomas which were removed. She was discharged on a proton pump inhibitor (PPI) and oral iron supplement. Follow up study with capsule endoscopy did not show any luminal abnormalities. Patient followed up with gastroenterology outpatient, and was only noted to have an episode of epigastric pain that responded to restarting PPI. One year later, she presented for routine check up with her PCP and her hemoglobin was at 5.9 g/dL despite regular iron intake and no further GI symptoms. H. pylori testing was positive and anemia was initially attributed to the H. pylori infection and heavy menstruation. However, at the same visit, the patient noted a small subcutaneous mass at the abdomen and was referred for an ultrasound, which showed a large liver mass. CT scan showed a 17 cm heterogeneous necrotic liver mass. PET scan showed an enhancing liver mass that could be a primary liver mass or a gastroduodenal mass potentially locally invading the liver. Subsequent FNA liver biopsy showed a gastrointestinal stromal tumor (GIST). Based on PET imaging, the tumor is determined to be invasive of the liver, but the primary source is unclear as there was no clear FDG avid mass in the GI tract. Patient was started on Imatinib and responded well with shrinkage of the tumor.

IMPACT/DISCUSSION: GISTs are rare connective tissue tumors in the gastrointestinal tract wall with worldwide incidence of about 1.2 per 100,000, the highest of which is reported in Hong Kong and China. Common presentations include GI bleeding, anemia, and abdominal pain, but they can also be asymptomatic. The most common primary site is the stomach, but because they arise in the submucosal layer of the GI tract, a GIST may not be visualized on endoscopy. This patient presented almost one year prior to being diagnosed with GIST, and was diagnosed only due to the palpable tumor at the abdomen. Her severe ongoing anemia was thought to be due to a combination of iron deficiency due to menstruation and H. pylori infection until abdominal mass work up demonstrated tumor. While iron deficiency in young women is most likely due to menstruation, a deficiency should be closely followed up to avoid masking other potential deadly causes.

CONCLUSION: Gastrointestinal stromal tumors are rare causes of GI bleeding, but even in a patient without endoscopic abnormality, they should be considered especially with persistent symptoms such as anemia and GI discomfort. In young women with iron deficiency anemia, causes of GI bleeding can be difficult to distinguish from menstrual bleeding and iron deficiency anemia should be followed up closely to ensure resolution with supplementation.

Innovation in Healthcare Delivery (IHD) - Acute Disease Management

COFE: AN HCA-DRIVEN COST-NEUTRAL TOOL FOR DELIRIUM

David Haak, John Gerstenberger, Santosh Reddy

University of Utah Health, Salt Lake City, UT. (Control ID #3872687)

STATEMENT OF PROBLEM/QUESTION: Delirium is a serious medical condition and significant source of healthcare expense in hospitalized patients, however evidenced based non-pharmacologic interventions are often limited by lack of existing resources and staff training.

DESCRIPTION OF PROGRAM/INTERVENTION: Multidisciplinary, non-pharmacologic interventions have been successful at reducing development of delirium and reducing total days of delirium in hospitalized patients. Prior successful interventions targeted several key domains which contribute to the development of delirium: cognitive impairment, sleep disturbances, visual impairment, hearing impairment, and immobility. Unfortunately, these interventions are resource intensive, involving multi-disciplinary teams and training volunteers.

To address these issues, we developed an intervention checklist implemented by healthcare attendants (HCAs). These HCAs were assigned to patients already requiring a close supervision panel (or “1:1”) due to the presence of altered mental status. The checklist included tasks within the following categories: Cognitive stimulation (Day/Night), Orientation, Facilitation of sleep, and Early mobilization, and was abbreviated as the “COFE” checklist. The intervention was implemented on a medical-surgical unit of an academic medical center located in the Mountain West region.

MEASURES OF SUCCESS: The aim of the project was to pilot test whether the implementation of a delirium treatment checklist would improve patient safety or add to costs. We hypothesized that with this intervention, we could improve safety outcomes such as falls and 30-day readmission without increasing costs.

FINDINGS TO DATE: 227 patients were observed during the baseline period, and 241 in during the intervention period. Both periods were 12 months in duration. There were no statistically significant changes found in falls (rate ratio = 1.87, P-value = 0.12), 30-day readmission rates (0.95, 0.87), or length of stay (0.95, 0.57). Manual data collection showed a decrease in HCA expenditures, as measured by a decrease in the average Cost Per Patient Day (CPPD) from $10.09 to $9.41. The total visit cost did not change significantly (rate ratio = 0.97, P-value 0.54).

KEY LESSONS FOR DISSEMINATION: We developed a novel, cost-neutral tool to address comprehensive treatment of delirium. As the tasks on our checklist are performed by an HCA who is already present for patient monitoring, no additional resources are required, and theoretical risks of the intervention are negligible. Our retrospective analysis showed that implementing this tool did not increase total cost and was associated with a reduced HCA cost. The study showed that implementation of the checklist did not result in a significant change in LOS, 30-day readmission, or falls. The study design had limited power to detect differences in these outcomes. In the future, we anticipate looking into other patient safety outcomes such as the use of physical restraints, pharmacologic restraints, location of discharge, and development of pressure ulcers.

Innovation in Healthcare Delivery (IHD) - Adolescent Medicine and Transitioning to Adult Care

A MULTIDISCIPLINARY CLINIC FOR YOUNG ADULTS WITH MEDICAL COMPLEXITY: CREATING A SUSTAINABLE, HOLISTIC, WELCOMING ADULT MEDICAL HOME Madeline Eckenrode

Internal Medicine/Pediatrics, UAB, Birmingham, AL. (Control ID #3877198)

STATEMENT OF PROBLEM/QUESTION:

Patients with complex health needs and disabilities are often marginalized within healthcare systems, where they have difficulty in finding medical providers who can provide quality, compassionate care that takes into account their health and personal challenges.

DESCRIPTION OF PROGRAM/INTERVENTION: Within the literature are numerous descriptions of patients with disabilities having limited access to quality healthcare. In that subset of patients, young adults with complex medical conditions of childhood who are transitioning from pediatric to adult healthcare face even more challenges. We know that their health outcomes decline during this transition period and that they have a lot of fear about transitioning to adult care, where their impression is that care is less patient-centered and holistic.

To combat this issue within our own large academic health system, we started the Staging Transition for Every Patient (STEP) program. The core of the program is the STEP clinic, a multidisciplinary outpatient medical home located within one of our adult outpatient facilities where young adults with medical complexity can be seen by internal medicine-pediatrics trained primary care providers, adult medical specialists (including neurology, pulmonary and physical medicine and rehabilitation), physical therapists, and social workers. Our aim was to create a welcoming medical home where patients can receive primary care, be connected to appropriate medical specialists, and work with our staff to develop a transition plan that takes into account their personal and family goals (an individualized transition plan - ITP).

Prior to starting our clinic, we administered surveys to pediatric providers in our health system to identify major needs and pitfalls in transition and worked to identify major areas of need. The areas of highest need were in patients with cerebral palsy and epilepsy. Because of this, we partnered with adult neurology and adult PM&R providers to join our staff so that patients with these extremely common issues could be seen during one clinic visit by these specialists.

MEASURES OF SUCCESS: Our clinic has been in operation since September 2020. We have collected qualitative data through patient surveys and focus groups.

FINDINGS TO DATE:

Parents enjoy having a “one stop shop” where they can discuss transition from a medical standpoint but also from a social standpoint, considering topics like day programs and in-home caregiving; as well as an economic standpoint, discussing insurance, disability, etc. They appreciate that our clinicians have relationships with physicians who are pediatricians and subspecialists as well as adult providers.

KEY LESSONS FOR DISSEMINATION: It is crucial to survey pediatric providers to understand what pediatric populations do not have adequate transition plans in place to begin building a transition program. Forming partnerships with willing adult subspecialists who have an interest in caring for young adults with complex care needs enables the creation of a care team that works together to provide compassionate care.

Innovation in Healthcare Delivery (IHD) - Career Development, Professionalism, and Wellness

THE RELATIONAL LEADERSHIP INSTITUTE: ENHANCING WELL-BEING, PSYCHOLOGICAL SAFETY, AND BELONGING IN ACADEMIC MEDICINE

Sarah Smithson^1,2; Kyle Turner³

¹Executive, Intend Health Strategies, Hillsborough, NC; ²Division of General Medicine & Clinical Epidemiology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; ³Pharmacotherapy, University of Utah Health, Salt Lake City, UT. (Control ID #3873702)

STATEMENT OF PROBLEM/QUESTION: Prevailing hierarchical leadership models in healthcare may create power imbalances and reduce psychological safety (the shared belief that team members can take interpersonal risks), further compounding burnout and impeding the Quadruple Aim.

DESCRIPTION OF PROGRAM/INTERVENTION: The Relational Leadership Institute (RLI) is a 3-month interprofessional, cross-generational leadership learning collaborative developed across three academic medical centers in partnership with a national non-profit organization. Launched in 2017, each site engages a cohort of up to 40 healthcare professionals/learners twice annually in a program combining traditional didactics, small groups, and coaching.The Relational Leadership model complements traditional leadership skills practiced in healthcare (focused on the “what” of our work) with skills that also emphasize the “who,” to improve individual engagement and team performance. The four domains of Relational Leadership, fostering authenticity, cultivating belonging, implementing a growth mindset, and nurturing interdependence, strengthen participants’ abilities to lead change within organizations. RLI offers strategies for engaging colleagues and communities to enhance psychological safety and advance health for all.

MEASURES OF SUCCESS: A mixed-methods evaluation including participant surveys and focus groups is ongoing.

FINDINGS TO DATE: Through a mixed-methods evaluation of over 500 participants at all 3 sites from 2017-2022, we found that 97% of respondents agreed or strongly agreed with the statement “I’ve learned practical skills that will help me in my work” and 94% agreed or strongly agreed that “I plan to use skills I have learned in the future.” High levels of psychological safety and trust developed among program participants; psychological safety is consistently identified as the program’s greatest strength. There were statistically significant improvements in Well-Being Index and sense of belonging from pre- to post-RLI, which were also sustained at 6-months post-program. Measures of sense of agency and advocacy doubled, and there were positive trends in organizational commitment and job satisfaction.

KEY LESSONS FOR DISSEMINATION: Leadership development efforts in academic medicine fail to prioritize relational models. Complementing existing leadership development with Relational Leadership fills a critical gap in improving the quality of care and provider engagement in our healthcare systems. RLI is an evidence-based program that develops actionable skills to enhance psychological safety, well-being, and belonging in interprofessional, cross-generational cohorts of healthcare workers/trainees. Specifically, RLI effectively develops skills to foster belonging and psychological safety in the clinical and learning environments. In addition, experiencing the program significantly improves well-being and belonging, with improvements sustained months after the course ends. Given portability of the program, plans are underway to expand RLI to other clinical and training sites in 2023.

Innovation in Healthcare Delivery (IHD) - Chronic Disease Management

A NEW TWIST ON THE SECOND OPINION: A MODEL TO HELP PRIMARY CARE PHYSICIANS IN MAKING DIFFICULT DECISIONS REGARDING OPIOID ANALGESIC THERAPY

Michael Picchioni

Medicine, Brown University, Providence, RI. (Control ID #3877119)

STATEMENT OF PROBLEM/QUESTION: Tremendous conflict arises between primary care physicians (PCP) and their patients suffering from chronic pain who have experience with opioid analgesics. Patients are often desperate for relief and become dependent on opioid analgesics while physicians are pressured in many ways to avoid such prescriptions. The unique relationship between PCPs and their patients makes facing this conundrum extremely perilous yet traditional practice models offer little to assist them. Referral to a Pain Specialist is one such option, but usually results in disappointment. First, they are a very limited resource in most communities and when found, the result is typically an offer for interventional procedures with limited efficacy or a recommendation that the PCP escalate opioid dosing.

DESCRIPTION OF PROGRAM/INTERVENTION: Second opinion is an option routinely available to patients who do not feel comfortable acceping a physician's recommendation. A model was created to provide a "second opinion" to the PCP which triangulates the decision making process in these difficult cases.

In this model a general internist with experience in chronic pain management provided a comprehensive and independent assessment of the patient's chronic pain condition and advised both the patient and their PCP with a non-binding set of recommendations.

MEASURES OF SUCCESS: - Greatly reduced frustration by staff, especially nurse case managers - Immense gratitude and a sense of indispensability of this service by PCPs - Widespread acceptance of unpopular clinical decisions by patients

FINDINGS TO DATE: Over a 10-year period over 500 Controlled Substance Review consultations took place. Nearly one third of the assessments led to recommendation for major changes expected to be unpopular with the patient and only one verbal conflict occurred. This was in a patient with schizoaffective disorder who returned shortly after with an apology and accepted the recommendations.

Most frequent recommendations were ongoing opioid analgesics be contingent on patient:

- engagement in concurrent mental health treatment

- engagement in non-pharmacologic modalities such as physical therapy

- adherence with treatment is treatment for OSA Other common recommendations were for:

- addition of adjuvant pain medications

- clarification of functional goals

In a handful of cases, PCPs who were uncomfortable with the treatment plan were provide support for continuing

A prior process in the same practice using a Case Conference model that was invisible to patients was far less successful

KEY LESSONS FOR DISSEMINATION: - While complex informed decisions are best made between patients and their PCPs, some are inherantly so charged that a neutral third party can be of great help in facilitating the process.

- An opportunity for a focused but thorough assessment is necessary for patients to accept undesired changes to their treatment plan

CULINARY MEDICINE SHARED MEDICAL VISITS IN A COMMUNITY CLINIC

Richmond S. Doxey⁴; Annie Galt³; Rachel P. Goossen¹; Kelly Stewart²; Lindsey Imber²

¹Department of Family and Preventive Medicine, University of Utah Health, Salt Lake City, UT; ²Nutrition Care Services, University of Utah Health Hospitals and Clinics, Salt Lake City, UT; ³School of Medicine, University of Utah Health Hospitals and Clinics, Salt Lake City, UT; ⁴Internal Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #3835003)

STATEMENT OF PROBLEM/QUESTION: Preparing meals and snacks at home is associated with more healthful eating, including higher intake of fruits, vegetables, and whole grains, and lower consumption of added oils, sugars and salt. Unfortunately, for many there are significant barriers to preparing foods at home, such as the lack of knowledge and confidence in culinary skills, lack of time, and potentially higher cost. Improved culinary training can lessen these barriers to increase the frequency of consuming healthful home- cooked meals. To address these barriers for patients in our clinic, we execute an ongoing series of shared medical visits with hands-on culinary instruction.

DESCRIPTION OF PROGRAM/INTERVENTION: We recruit and accept referrals for adult patients with metabolic disease and its complications. We have created a curriculum with recipes, shopping lists, and directions about how to set up and run the shared medical visit. We acquired necessary equipment for a pop- up kitchen with several stations. The team includes medical and nutrition students, attending physicians, and dieticians who work together to recruit participants, shop for the food, and set up and execute these shared medical visits. With instruction from the dieticians and physicians trained in culinary medicine, the patients, each at an individual cooking station, prepare a healthful meal, with a focus on both building culinary skills and healthy cooking techniques. Throughout the session, the physician and dietician foster discussion and teach about key culinary, nutrition, and medical topics, and the physician has 1:1 discussion with each patient about pertinent medical conditions.

MEASURES OF SUCCESS: We administered pre and post confidence surveys and solicited narrative feedback from the participants after the shared medical visits.

We will be tracking some biometric data as well.

FINDINGS TO DATE: Preliminary data and feedback from participants are encouraging. Patients commented that they felt more motivated to make changes, and some were starting to like fruits and veggies more. In addition, they liked learning knife skills and how to cook with less sugar, salt, and fat.

We plan to solicit feedback from past participants in a few months and use that to continue to refine our approach. We have learned through this experience that it takes significant teamwork and coordination to implement and run successful culinary medicine shared medical visits. These are well received by patients who now feel empowered to make changes.

KEY LESSONS FOR DISSEMINATION: Shared medical visits with a hands-on cooking component are:

1. Well received by patients.

2. Feasible in a community clinic

3. Require minimal equipment and few dedicated staff/clinicians to run

DIABETES OUTREACH BY TEXT (DOT) STRATEGIES AS A POPULATION HEALTH MANAGEMENT TOOL IN PRIMARY CARE

Marguerite Balasta³; Gaibriel De Guzman¹; George C. Floyd³; Martina Plag²; Sadie Friday²; Gillian Lautenbach³; Mohan Balachandran²; Anna U. Morgan³; Corinne M. Rhodes²

¹Department of General Internal Medicine, University of Pennsylvania, Philadelphia, PA; ²Medicine, University of Pennsylvania, Philadelphia, PA; ³Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #3857093)

STATEMENT OF PROBLEM/QUESTION: Proactive outreach is an important strategy in population health to engage patients in preventive testing and chronic disease management. Common methods include phone calls, mailers, and messaging through patient portals in electronic medical records (EMRs). These can be costly, labor intensive, time consuming, and yield relatively low results. In 2021 our centralized population health team ran a diabetes campaign directed at 608 patients from 3 primary care practices with uncontrolled diabetes defined as no A1c in the past year or last known A1c > 9. The reach rate was 31.5% via portal or phone call, using 508 total person-hours from a full-time population health staff member over 4 months. Text messaging provides an opportunity to improve reach, penetrance, and effectiveness of population health management in many areas such as medication adherence, smoking cessation, and mental health after cancer treatment. We hypothesized a bidirectional text-messaging platform to which most

patients already have access and will be a more efficient, less resource intensive than previous efforts.

DESCRIPTION OF PROGRAM/INTERVENTION: Our team partnered with Way-to-Health, a web- based platform which creates technologic engagement strategies for patients to improve health outcomes, to create a bidirectional text-based outreach protocol targeting patients with uncontrolled diabetes. A non- clinical population health staff member used the “Diabetes Outreach by Text” bot (DOTBot) to send bulk algorithmic text messages and was available for individualized patient responses. Initial targeted population was 667 patients without an A1c in the past year, which comprised 45% of patients with uncontrolled diabetes.

MEASURES OF SUCCESS: Success of engagement is measured by response rates and clinical outcomes, including number of appointments scheduled, labs ordered, and panel clean-up. We compare these measures to the diabetes outreach campaign in the same clinics to assess response.

FINDINGS TO DATE: DOTBot launched in mid-October 2022 and at time of submission, we reached 246 patients over 6 weeks with a 42.3% response rate via text compared to 31.5% via portal or phone call from 2021. In 2021 there were differences in reach of patients based on PCP type with 36.6% of attendings/nurse practitioner (NP) and 26.5% of resident patients responding. The DOTBot has increased reach but there is still a difference in response rate between attending/NP vs. resident patients at 54% and 39.9%, respectively. It has required less time from a population health associate averaging 4.8 hours vs 36.3 hours per week from previous year. To identify populations who best respond to text outreach, we will present stratified outcomes based on age, race, insurance status, and PCP type (resident vs. attending or nurse practitioner).

KEY LESSONS FOR DISSEMINATION: A text-based outreach strategy is an effective and efficient method to engage patients with chronic diseases such as diabetes. It is a scalable program which can be deployed for other population health management initiatives.

IMPLEMENTATION OF A TEAM-BASED HYPERTENSION CARE PROGRAM IN THE ERA OF TELEMEDICINE

Anuradha Phadke¹; Sandra A. Tsai¹; Amelia Sattler¹; Jimmy Dang²; Mark Ramirez²

¹Stanford University School of Medicine, Stanford, CA; ²Ambulatory Quality, Stanford Medicine, Stanford, CA. (Control ID #3873058)

STATEMENT OF PROBLEM/QUESTION: How can busy practices improve hypertension (HTN) care in the telemedicine era?

DESCRIPTION OF PROGRAM/INTERVENTION: Optimizing HTN care can reduce cardiovascular mortality and has financial benefit in value-based care arrangements. In early 2021, our 13-clinic primary care division formed a multidisciplinary HTN improvement team to conduct a structured quality improvement (QI) project . We adopted the National Quality Foundation definition of controlled blood pressure (CBP), which is <140/90 mmHg for the last blood pressure value within the past 12 months, whether self-reported or clinic-measured. We aimed to increase the proportion of 10,609 hypertensive patients with CBP from 66% to 73.7% over 8 months.

Our key improvement drivers were: 1) supporting patient self-management, 2) systematizing remote blood pressure (RBP) monitoring, 3) increasing accurate measurement, and 4) promoting process standardization.

Interventions included:

Centralized HTN outreach. Population health coordinators queried the HTN registry to identify patients with uncontrolled HTN. Through secure patient portal bulk outreach, they focused on obtaining accurate RBP measurements and offering care choices: lifestyle-change-focused educational material, referral to clinical nutrition, medical assistant BP check or a clinician visit.

Accurate BP values. We trained medical assistants to accurately check in-office BP, collect RBP readings during virtual touchpoints, and conduct stand-alone BP check visits using a standardized automated office BP check (AOBP) process.

Electronic medical record (EMR) advisory tool. We expanded an existing in-office high BP EMR advisory tool into select specialty clinics and developed a complimentary telemedicine visit EMR advisory tool.

MEASURES OF SUCCESS: Using EMR registry data, we tracked rates of CBP.

FINDINGS TO DATE: CBP rates rose from 66% to 78% over an 8-month period, reflecting improved control for 1,273 patients. Improvements temporally correlated with implementation of the centralized outreach program and BP collection process enhancements. Results have sustained over 18 months. The number of specialty clinics adopting the EMR advisory and monthly AOBP visit rates have been low.

KEY LESSONS FOR DISSEMINATION: Through a structured QI project, we developed, implemented, and sustained impactful team-based HTN care interventions without increasing primary care clinician workload. Our future work will focus on implementation of the telemedicine advisory tool and further expansion into specialty care.

PREDICTING HYPERTENSION CONTROL USING MACHINE LEARNING

Richard Cartabuke

Internal Medicine, Cleveland Clinic, Painesville, OH. (Control ID #3869741)

STATEMENT OF PROBLEM/QUESTION: The accurate prediction of hypertension control and evaluating the uncertainty in those predictions is essential to delivering clinical decision support to improve the care provided to hypertensive patients. Computing capacity has increased exponentially over the past several decades, and capabilities exist now to apply types of artificial intelligence, such as machine learning (ML), to improve patient care. Recently, our institution launched a multi-tiered effort to use ML and optimization modeling towards the following ends: 1) predict BP control in hypertensive patients 2) choose medication and dose combinations to achieve BP control and 3) predict cardiovascular events among populations treated for hypertension. This study addresses the first, hypertension control prediction.

DESCRIPTION OF PROGRAM/INTERVENTION: In this prognostic study, the outpatient electronic health records (EHR) of 398, 702 hypertensive patients treated by the Cleveland Clinic between January 1, 2015, and June 1, 2022, formed model training and validation cohorts. The main outcome was hypertension control within 12 months of a clinical encounter. Model performance was quantified using the area under the receiver operating characteristic curve.

MEASURES OF SUCCESS: The ML algorithm incorporated all the structured EHR data that a clinician would have had access to when they were determining BP treatment options. EHR data including vital signs, medications, comorbidities, laboratory results, left ventricular ejection fraction, outpatient clinical encounters and US census household income data were incorporated into the data model. We successfully incoporated data drift and model uncertainty into our efforts.

FINDINGS TO DATE: There are no published reports of using ML to predict control in patients currently on hypertensive pharmacotherapy, and therefore, this study that includes 398,702 patients and 10,564,174 clinical encounters is the first to do so. Reducing time to BP control is critical to reduce morbidity, mortality and the costs associated with poor control. A key study finding is that it is possible to predict with reasonably high accuracy (0.76 AUC) with high confidence whether a hypertensive patient will have their blood pressure controlled within 12 months from a clinical encounter. Although the AUC is 0.76, which is usually considered to indicate mediocre ML model performance, we believe that this AUC is surprisingly good considering the fluctuations in typical office BP measurements. Current control was determined to be most predictive of future control when compared to over 800 included patient features.

KEY LESSONS FOR DISSEMINATION: We developed a machine learning model to maximize performance for difficult to predict patient blood pressure control even when the data used to train such models drifts significantly over time. We incorporated a general method to quantify the uncertainty of machine learning predictions, which can be used in other machine learning driven clinical decision support systems (CDSS).

REDUCING RACIAL DISPARITIES AND IMPROVING BLOOD PRESSURE CONTROL RATES AT AN URBAN, UNDERSERVED RESIDENCY CLINIC

Eileen P. Storey¹; Virginia Hoch¹; Joseph Assali¹; Abhishek Surampudy¹; Christine Gallati²

¹Internal Medicine-Pediatrics, Christiana Care Health Services Inc, Wilmington, DE; ²Internal Medicine , Christiana Care Health System, Wilmington, DE. (Control ID #3875741)

STATEMENT OF PROBLEM/QUESTION: Though hypertension (HTN) is a leading cause of preventable cardiovascular disease, rates of blood pressure (BP) control remain suboptimal, particularly among Black patients.

DESCRIPTION OF PROGRAM/INTERVENTION: Data regarding patient BP control was accessed through an ambulatory dashboard maintained by our health system. Among the 2,858 patients from our residency practice with a diagnosis of HTN, only 45% had controlled BP (<140/90) as of June 2021. To address this, we implemented a multi-component standardized workflow at our clinic for patients with HTN. This included distribution of free home BP cuffs, standardized follow-up scheduling with allowance for virtual visits, and an encounter template for assessing BP control.

MEASURES OF SUCCESS: We matched 379 cuff recipients with patient information from the ambulatory dashboard. This group was then analyzed in detail for racial disparities in BP control and factors contributing to successful BP control.

FINDINGS TO DATE: The overall rate of BP control among matched patients improved from 17% at time of initial cuff distribution to 46% by June 2022. Racial disparities in BP control improved for cuff recipients with rates increasing from 15% (N=41) to 45% (N=126) and from 35% (N=15) to 50% (N=29) among Black and White patients, respectively. To identify factors contributing to successful BP control, 40 charts from the matched patient group (approximately 10%) were randomly selected for review. Among this subgroup, patients with controlled BP in June 2022 (N=20) were more likely to have had 2 or more follow-up visits within 6 months of enrollment (60%, 12/20) compared to uncontrolled patients (40%, 8/20). Among patients with uncontrolled BP in June 2022, there were several contributing factors: inadequate follow-up (8/20), acute or overriding medical concern (5/20), provider documentation error of reported home BP (4/20), medication non-adherence (2/20), and lost BP cuff (1/20).

KEY LESSONS FOR DISSEMINATION: We successfully implemented a standardized workflow to improve BP control among patients with HTN in our practice. This intervention improved BP control rates in participants while reducing racial disparities in BP control between Black and White patients. Adequate follow-up appears to be the most important factor for improving and maintaining BP control in our patient population.

THE ELIMINATING BARRIERS INITIATIVE – IMPLEMENTING AN INTERPROFESSIONAL PROGRAM TO IMPROVE POOR DIABETES CONTROL BY INCREASING PATIENT SELF- EFFICACY AND MITIGATING SOCIAL DETERMINANTS OF HEALTH

Jason Ehrlich¹; Hugo Ortega¹; Juliana Giraldo-Ramirez²; Omoakhe Tisor¹; Teresa Cantilli¹; Danielle Ezzo¹; Daniel J. Coletti³

¹Medicine, Northwell Health, New Hyde Park, NY; ²Internal Medicine, Northwell Health, Woodside, NY; ³Medicine, Northwell Health, Great Neck, NY. (Control ID #3875552)

STATEMENT OF PROBLEM/QUESTION: Can we improve diabetes control in patients by improving diabetes-related self-efficacy and reducing barriers to care?

DESCRIPTION OF PROGRAM/INTERVENTION: The Eliminating Barriers Initiative (EBI) was launched at an outpatient resident clinic in a large academic health center in the Northeast. The patient population is 30% uninsured, ethnically diverse with 30% limited English proficiency, and has high levels of medical and social complexity. Diabetes prevalence in the practice is >60%. The EBI targets those with A1C >9% as well as any patient whose health literacy challenges or complex social needs undercut optimal diabetes management.

Eligible patients participate in a 60-minute intake visit with an MD, NP, or RD/CDE. Patients undergo a detailed Social Determinants of Health (SDH) review and a diabetes self-efficacy assessment using the Perceived Diabetes Self-Management Scale (PDSMS). We identify patient strengths as well as barriers to care, and collaboratively develop a customized, specific set of diabetes-related goals and interventions.

The intake provider then schedules needed interventions with the interprofessional team. Our RD/CDE captains education in foundational diabetes concepts, nutrition, and devices. The on-site pharmacy team assists with medication optimization, including enrollment in cost-reduction programs. Social Work addresses behavioral health, equipment and transportation needs. Group patient visits center on lifestyle education and generate support networks.

Patients continue to follow up routinely with their PCP’s. The EBI team meets weekly to strategize each patient’s care, directing additional support to those with greatest complexity. Multiple inter-visit touchpoints are scheduled, leveraging virtual platforms to maximize support while minimizing disruption to patients' busy lives.

MEASURES OF SUCCESS: Patients are assessed with quarterly A1C, and with repeat SDH and PDSMS at 12 months. Success is indicated by reduction in A1C to under 9%, reduction in barriers to care connoted by fewer affirmative responses on SDH questionnaire, and increase in PDSMS self-efficacy scores.

FINDINGS TO DATE: 55 patients have enrolled in the program to date and 34 have completed at least one follow up A1C assessment. The vast majority of patients (30/34 or 88.1%) were able to improve their A1C control, from a mean of 11.23(SD=1.89) at baseline to 8.5 (SD=2.29) at 12 week follow-up (T=7.51, df=33, p<.001). 13/34 (38.2%) brought their A1C from >9.0% to below this key threshold. Initial PDSMS scores trend low as anticipated, highlighting potential for improvement via focused education and support.

KEY LESSONS FOR DISSEMINATION: 1) Effective interprofessional team collaboration is the heart of success. Clinics with comparable teams can adapt the model easily; others may require external partnerships.

2) Positive patient feedback on the highly personalized interventions suggests achievability of recruitment and retention.

3) Education approaches can be optimized by tailoring materials to patient demographics, languages, culture, and schooling.

THE MOBILE INSULIN TITRATION INTERVENTION PROGRAM TO TRANSITION FROM BASAL INSULIN TO A GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONIST (MITI-GLP1): USING DAILY SMS TEXT MESSAGES AND WEEKLY PHONE CALLS TO TRANSITION PRIMARY CARE PATIENTS WITH WELL-CONTROLLED TYPE 2 DIABETES FROM BASAL INSULIN TO A GLP1-RA.

Natalie K. Levy¹; Katie Nerlino¹; Sherlane B. Bongalos²; Alexis Dasilva²; Chinye N. Uzor²; Olubunmi o. Sonubi²

¹Medicine, NYU School of Medicine, Bellevue Hospital, New York, NY; ²Medicine, Bellevue Hospital Center, New York, NY. (Control ID #3874512)

STATEMENT OF PROBLEM/QUESTION: Transitioning a patient with well-controlled type 2 diabetes from basal insulin to a GLP1-RA can be labor intensive (multiple titrations) and in the short term can put the patient at risk for hypoglycemia (if there is a robust response to GLP1-RA and basal insulin isn’t lowered quickly enough).

DESCRIPTION OF PROGRAM/INTERVENTION: While basal insulin lowers blood sugar, it puts patients at risk for hypoglycemia and weight gain, and doesn’t offer the cardiovascular protection provided by GLP1-RAs. For many, it is advantageous to change to a GLP1-RA.

MITI-GLP1 supports this transition using the basic cell phone technology available to our safety-net patients. Patients are enrolled on a secure web platform that sends a daily SMS text asking ‘What was your fasting blood sugar this morning?’. The responses are scanned daily for hypoglycemia and patients are called once weekly for review of texted glucose levels, hypoglycemia, and GLP1-RA tolerability. Patients are then advised on if/how to lower their basal insulin and if/how to adjust their GLP1-RA. The process continues weekly until the patient is on the max-tolerated GLP1-RA dose (which usually allows a substantial decrease in the basal insulin dose, ideally to 0). This program is co-run by general internists (refer patients, provide titration recommendations) and our nurse partners (check for alarm values, make the titration phone calls.)

MITI-GLP1 is designed by the same primary care group that presented the original MITI program as a SGIM Plenary Talk in 2017. At that time insulin was our main injectable (original MITI was designed prior to the common use of GLP1-RAs) and we used a similar process (SMS texting and phone calls) to increase basal insulin until the fasting blood sugar fell to the desired range. Our group (primary care doctors and our nursing partners) has been carrying out original MITI for over 7 years and we are using our remote management

know-how to develop MITI-GLP1.

MEASURES OF SUCCESS: Measures will include the percent of patients that had: their GLP1-RA raised to max tolerated dose, their basal insulin lowered by 50% or greater, their basal insulin stopped completely, hypoglycemia and weight loss (any weight loss, % weight loss).

FINDINGS TO DATE: Our pilot program began in Fall 2022; we have enrolled 14 patients thus far. Of completed patients, 83% reached their max- tolerated GLP1-RA dose (5 of 6 patients). The same 83% had their basal insulin dose reduced by at least 50% and 66% (4 of 6) had their basal insulin stopped completely. Of 7 patients that are currently enrolled in MITI-GLP1 for at least 5 weeks we found that 85.7% (6 out of 7) have already had their basal insulin reduced by at least 50%. There has been no hypoglycemia. It is too soon to look at weight loss data. We are actively enrolling patients and will have larger, more complete data by May 2023.

KEY LESSONS FOR DISSEMINATION: A MITI-GLP1 program using basic cell phone technology can safely and effectively transition primary care patients with well-controlled type 2 diabetes from basal insulin to a GLP1-RA.

TRANSLATING IN-PERSON EXPERIENCES WITH CULINARY MEDICINE TO VIRTUAL CLASSES DURING COVID-19: A PRAGMATIC TRIAL COMPARING THE EFFECTIVENESS OF VIRTUAL CULINARY MEDICINE VS. VIRTUAL NUTRITION CLASSES IN PATIENTS WITH UNCONTROLLED DIABETES

Patricia M. Chen³; Molly McGuire¹; Jaclyn Albin¹; Milette Siler¹; Melissa Mendez²; Rebecca Chrasta²; Sandi Pruitt³; Michael E. Bowen^1,2

¹The University of Texas Southwestern Medical Center, Dallas, TX; ²Parkland Health, Dallas, TX; ³UT Southwestern Peter O'Donnell Jr. School of Public Health, Dallas, TX. (Control ID #3868858)

STATEMENT OF PROBLEM/QUESTION: Although culinary medicine (CM) classes are common, their impact on clinical outcomes in underserved patients and the translation of in-person curricula to virtual classes are not known.

DESCRIPTION OF PROGRAM/INTERVENTION: Based on our experience with a blended nutrition and hands-on CM model, we designed a pragmatic trial comparing the effectiveness of CM vs. nutrition classes in patients with uncontrolled type 2 diabetes (T2D). Prior to launch, the study pivoted from in-person to virtual classes due to the COVID19 pandemic. We identified eligible participants from the T2D registry and recruited from a community clinic in a safety-net health system. Eligibility criteria included: established primary care patient, T2D>12 months, A1c≥7% within 3 months, English or Spanish speaking, no nutrition visit within 12 months, and internet access with a video-capable device. All participants were offered food assistance in partnership with a food pantry, basic cooking equipment, gift card incentives, and technology tutorials. CM participants also received recipes, grocery gift cards, and basic pantry goods. We randomized participants 1:1 to a series of 6 virtual, language concordant (English or Spanish) CM classes with a bilingual, CM certified dietitian vs. 6 virtual, standard-of-care nutrition classes (English or Spanish) with a health system dietician.

MEASURES OF SUCCESS: The intended primary outcome was the between-group change in A1c. Due to challenges recruiting, engaging, and retaining participants, we shifted to focus on identifying barriers to participation, separately by study arm and primary language. Here, we report engagement (attend ≥ 1 class) and retention (attend ≥ 3 classes) for the 6-class series. Recruitment is ongoing.

FINDINGS TO DATE: After mailing study invitations, we called 687 patients from July 2021 to August 2022. Of 303 who answered, 46 (23 English; 23 Spanish) were randomized. Reasons for declining included scheduling conflicts, unreliable internet access or device, or not interested. Participants were 83% female, with a mean age of 51 years, and mean baseline A1c 9.0% (range: 7.0-12.3). Of the 22 CM participants, 9 completed the first class and 6 completed >3 classes. Of the 24 nutrition participants, 23 completed the first class and 18 completed >3 classes. For CM participants (10 Spanish; 12 English), engagement was higher in Spanish speakers (60% vs. 25%), but retention was similar (30% Spanish vs. 25% English). In nutrition participants (13 Spanish; 11 English), engagement was similar (100% vs. 90%), but retention was higher in Spanish speakers (85% vs. 64%).

KEY LESSONS FOR DISSEMINATION: Engagement and retention of patients with uncontrolled T2D in virtual CM and nutrition classes was challenging despite efforts to address potential barriers. The nutrition classes had higher engagement than CM. Once engaged, retention was similar for CM and nutrition, with higher rates for Spanish speakers. Patient-focused CM classes may benefit from engaging patients in co- design processes to adapt and optimize CM models and curricula.

Innovation in Healthcare Delivery (IHD) - Clinical Informatics and Health Information Technology

A CHATBOT-BASED ELECTRONIC PATIENT REPORTED OUTCOMES PROGRAM FOR PATIENTS RECEIVING CANCER TREATMENTS

Timothy Judson¹; Dileesh Divakaran²; Henrietta Tran⁷; Ali Maiorano²; Nancy Relkhelman²; Anobel Y. Odisho²; Michelle Mourad⁴; Smitha Ganeshan⁵; William Brown²; Logan Pierce⁶; Andrew Liu²; Aaron B. Neinstein³

¹Medicine, UCSF, San Francisco, CA; ²Center for Digital Health Innovation, University of California San Francisco, San Francisco, CA; ³Division of Endocrinology, University of California, Los Angeles, San Francisco, CA; ⁴Medicine, UT Southwestern Medical Center, San Francisco, CA; ⁵Department of Medicine, University of California San Francisco, San Francisco, CA; ⁶Medicine, University of California San Francisco, San Francisco, CA; ⁷Office of Population Health, University of California San Francisco, San Francisco, CA. (Control ID #3869395)

STATEMENT OF PROBLEM/QUESTION: Collection of electronic patient-reported outcomes (ePROs) has been shown in randomized control trials to reduce acute care visits, enhance patient quality of life, and improve overall survival. However, there are many technical challenges that have limited widespread implementation of ePROs.

DESCRIPTION OF PROGRAM/INTERVENTION: Upon beginning a cancer treatment (e.g. chemotherapy infusion), patients receive an introduction by SMS or email with a personalized link. The link launches a chat that prompts patients to report symptoms at designated intervals. For mild symptoms, patients are sent educational tips for self-management. Severe symptoms are sent to the cancer care team as electronic health record messages, and the team then calls or messages the patient to resolve them.

Barriers to implementation of ePROs include patient engagement, technical and clinical workflow challenges. The design of this ePRO program was meant to overcome all three. To improve patient engagement, we made chats brief and easy to access without need for login or password. When a patient reports a symptom, we “close the loop” by either providing them with self-management tips, or a phone call from the care team. To address technical barriers, the chat is integrated with our electronic health record system and we use a registry to identify patients. To address clinical workflow barriers, we use composite scoring to calculate overall symptom burden, and alert clinicians only when symptoms reach a certain severity threshold. The combination of these features makes this program unique compared to many of those described in the literature.

MEASURES OF SUCCESS: We are tracking patient engagement (activation rate, number of chats performed), provider satisfaction (via surveys), and utilization metrics (emergency department visits and hospitalizations).

FINDINGS TO DATE: In April-July 2022, we conducted a series of interviews, and did an alpha launch of the chat to get rapid feedback. Both enrolled patients in the alpha completed 4 or more chats during the 7 days. Findings from interviews included three key themes. Patients: 1) wanted the chat to help them understand whether or not their symptoms were expected; 2) felt vulnerable after their first infusion, and wanted a touchpoint in the first few days to build trust; 3) requested additional functionality, such as the ability to report free text symptoms. After addressing this feedback, the chat will be rolled out on a broader scale (~200 patients) in January 2023.

KEY LESSONS FOR DISSEMINATION: Electronic PRO programs may fail due to low patient engagement, technical hurdles, or clinical workflow disruptions. Specific elements of an ePRO program can help avoid these pitfalls and make ePRO programs more sustainable. By sharing early learnings from our program, we hope to enable other organizations to implement similar tools.

AN ITERATIVE APPROACH TO CLINICAL TRIAL EXCELLENCE WITH ENHANCED PATIENT SCREENING AND SAFETY MONITORING USING EPIC TOOLS

Lana Wahid¹; Valerie Renard²; Oluwayemisi Mohammed¹; Earl Schwark⁴; John C. Stover⁴; David Edelman⁵; Thomas L. Ortel³

¹General Internal Medicine, Duke University School of Medicine, Durham, NC; ²Hospital Medicine, Duke University Health System, Durham, NC; ³Division of Hematology; Department of Medicine and Pathology, Duke University Medical Center, Durham, NC; ⁴Duke Office of Clinical Research, Duke University School of Medicine, Durham, NC; ⁵Medicine, Duke University School of Medicine, Durham, NC. (Control ID #3875478)

STATEMENT OF PROBLEM/QUESTION: The COVID-19 pandemic and Operation Warp Speed created a rapid need to find therapeutics to treat COVID-19 disease. It led to creative collaborations and innovative ideas for clinical trials offered to hospitalized patients. Historically, Duke's inpatient research has not had a lot of custom build in Epic and had been using the same EHR format as the clinical setting. This lack of custom build led to a unique collaboration between principal investigators, clinical teams and Duke's IT Epic research analysts.

DESCRIPTION OF PROGRAM/INTERVENTION: Project occurred via 3 phases.

Phase 1 improved screening efficiency with creation of a PRD report for screening. We created specialized columns specific to study arm(s). Icons helped with quick visualization and considered staff who were color- blind. Another column used multiple complex CER rules that evaluated study-defined criteria related to COVID severity. It reduced screening time from 4-6 hrs daily to 1 hour each morning for each clinical trial. The impact allowed for early identification and approach of research participants for each trial.

Phase 2 focused on assessing safety for subjects on study while hospitalized. Keeping with theme of ITeration, the analysts created a system patient list that pulled admitted patients on Select Inpt RSH Studies.

This quick push of an automated list relieved burden of managing it manually. Alerts were developed as column build progressed. ITerative pieces culminated into heme and kidney column blocks with unique

icons. Hover bubble reports show data from custom columns, alerts, and lab results, with text explanations of how data is found. This work progressed with design of body system-based AE columns and associated hover bubbles.

Phase 3 is the transition of patients who are on study but now discharged from the hospital. This phase focused creating a dashboard or patient list to continue monitoring and assessing safety parameters post- discharge.

MEASURES OF SUCCESS: Top 3 measurable outcomes include subject enrollment maximization, enhanced patient safety monitoring, and financial impact due to improved productivity from research staff. Development of screening reports resulted in top enrollment. We became the 1 enrolling site internationally for each inpatient clinical trial. Elimination of delay of adverse event identification. The financial impact resulted in less research coordinator effort for an annual savings of about $270,000 per year for each trial.

FINDINGS TO DATE: Our collaboration continues and is now geared towards building solutions that are scaled to impact multiple research clinical trials across the health system.

KEY LESSONS FOR DISSEMINATION: The collaborative organization between the research team and Epic analysts was different than most build projects. The impact of the inpatient research list eliminated the time it took to open each patient’s chart and search vitals and safety labs. The rapid method of alerting the research team resulted in no missed safety issues, whereas prior, the clinical team notified the research team of abnormal labs.

BREAKING DOWN BARRIERS FOR CERVICAL CANCER SCREENING USING SECURE GROUP TEXTING

Md Shahnoor Amin¹; Belinda Joseph Benher²; Anupama Nair^1,2; Danielle Heidemann^1,2

¹Internal Medicine, Henry Ford Hospital, Detroit, MI; ²Wayne State University School of Medicine, Detroit, MI. (Control ID #3874288)

STATEMENT OF PROBLEM/QUESTION: Is a secure messaging system an effective tool to address barriers of time constraints and patient preference for a female provider in order to improve cervical cancer screening (CCS)?

In the past 40 years, CCS has significantly reduced the incidence of cervical cancer in the United States ¹. However, the proportion of patients without up-to-date CCS increased from 14.4% in 2005 to 23.0% in 2019². One barrier we identified to CCS is patient preference for a female provider to complete their pap smear.

DESCRIPTION OF PROGRAM/INTERVENTION: Our clinic has approximately 20 senior staff physicians and 118 residents. We have an underserved population of patients who are all insured. We use a team-based care model where our medical assistants will prepare patients who are overdue for a CCS at the beginning of the office visit if they are willing to complete their pap smear.

We piloted a HIPAA-compliant secure messaging group chat with 10 of our female primary care attending physicians. This group chat is available for any provider or support staff to use when a patient is due for a pap smear, and is willing to obtain it at their visit. This includes scenarios when a patient of a male physician prefers a female provider, or time constraints prevent a provider from doing the pap smear. When a message is sent, all 10 female providers will receive it, and if someone is available to help, they will respond to the group message. If no one is available, no response will be sent.

MEASURES OF SUCCESS: A positive outcome is defined as a message sent accompanied by a response; a negative outcome is a message sent with no response. Quantitative metrics to evaluate this tool include measuring the time elapsed between provider request and provider response, and number of responses. FINDINGS TO DATE: We piloted this project in 2021. Of 21 provider requests in 1 year, there was an 86% response rate. Average time to response was 2.3 minutes with median time 1 minute. Average number of responding physicians was 1.

KEY LESSONS FOR DISSEMINATION: This intervention conveniently meets patients at the point-of- care clinic setting to improve CCS by addressing barriers, which include time constraints, and patient preference for a female provider. In addition, we have broadened this tool to include interested residents in order to allow them the opportunity to gain procedural experience. This custom yet cost-effective tool can be used for similar preventative health screenings and other sensitive procedures/exams.

DEVELOPING BEST PRACTICES AND SCALING REMOTE PATIENT MONITORING OF BLOOD PRESSURE

Nina Singh¹; Natalie Henning¹; Emily Reindel²; Veronica Gragnano²; Amy Stein²; Christopher Mahoney²; Abbegail Bermudez²; Jackie Harootian-Abdelaziz²; Mariel Shull³; Lisa Anzisi³; Katharine Lawrence¹; Devin Mann^1,2

¹Population Health, NYU Langone Health, New York, NY; ²Medical Center Information Technology, NYU Langone Health, New York, NY; ³Clinically Integrated Network, NYU Langone Health, New York, NY. (Control ID #3867512)

STATEMENT OF PROBLEM/QUESTION: Remote patient monitoring of blood pressure (RPM-BP) can improve hypertension care and is recommended by the American Heart Association and American Medical Association. However, actualizing these recommendations has proven challenging due to the difficulty of coordinating between the ordering provider, patient, other health team members, vendors, and the electronic health record (EHR).

DESCRIPTION OF PROGRAM/INTERVENTION: We did semi-structured interviews to characterize baseline workflows at practices that used RPM-BP most heavily within an academic health system in the Mid-Atlantic region. We identified the most common pain points and designed workflow and EHR changes to address them. We tested these changes with clinical stakeholders and created an enterprise RPM implementation playbook with current best practices.

MEASURES OF SUCCESS: Qualitative measures of success included feedback from clinical stakeholders as we iterated workflows, EHR tools, and system-wide resources. Our main quantitative metrics included number of RPM-BP orders, proportion of patients submitting data, proportion of patients achieving BP control (<130/80), proportion of patients with BP control offboarded, and number of RPM-BP charges relative to number of orders.

FINDINGS TO DATE: Our health system has a growing RPM-BP program, with 4514 orders placed since program inception in 2018 (1809 in the past 12 months) and 1804 patients submitting data. The heaviest users of RPM-BP were internal medicine (37%), maternal fetal medicine (14%), and cardiology (10%).

Workflow-level pain points included patients (51%) not sending data after orders were placed and nurses not having a standardized RPM value triage process, method to identify nonadherent patients, or offboarding process. Interventions included redoing patient onboarding materials, implementing direct Bluetooth pairing, creating a RPM-BP response algorithm, building a report of nonadherent patients, and designing an offboarding workflow for patients with BP control.

System-level pain points included issues with low nurse bandwidth across multiple clinics, missed billing opportunities, and difficulty viewing metrics due to RPM’s disconnected EHR data structures. Interventions included exploring a centralized RPM model for groups of practices, redesigning the RPM encounter and reports in the EHR to facilitate easier visibility and completion of billing criteria, piloting a loaner blood pressure cuff program, and dedicating increased EHR and Reporting Analyst time to building metric reporting. Many of the changes outlined in our internal playbook are actively being implemented; we plan to report more detailed outcome data in the future.

KEY LESSONS FOR DISSEMINATION: RPM-BP implementation is complex due to the many stakeholders involved. Addressing pain points by building better workflows and software is critical to establishing best practices, and codifying these evolving best practices in a playbook can help scale them across the health system.

DEVELOPMENT OF A BILINGUAL SMARTPHONE APPLICATION AND ELECTRONIC HEALTH RECORD DATA DASHBOARD TO COLLECT AND DISPLAY PATIENT-REPORTED OUTCOMES FOR CHRONIC DISEASE MANAGEMENT IN PRIMARY CARE

Jane Jih, Jason Satterfield, Anthony Louie, Simona Carini, Billy Zeng, Tung T. Nguyen, Mitchell D.

Feldman, Ida Sim

Medicine, University of California San Francisco, San Francisco, CA. (Control ID #3868851)

STATEMENT OF PROBLEM/QUESTION: To bring patient-reported outcomes (PROs) collected via an English/Chinese smartphone app into real-time clinical care to be actionable for shared decision making in chronic disease management.

DESCRIPTION OF PROGRAM/INTERVENTION: In an academic health center adult primary care clinic in the California-Hawaii region, we developed a patient-facing smartphone app (mPROVE) in English/Chinese to collect and track PROs. The target population is patients with a diagnosis of depression or diabetes mellitus or hypertension not at goal at any time over the last 12 months.The app contains questionnaire-based PROs such as PROMIS physical function, fatigue, pain and sleep, PHQ-2, GAD-7, health-related social needs and medication adherence. PRO results are accessible via the BRIDGE data dashboard within the EPIC electronic health record (EHR) via SMART-on-FHIR. In between clinic visits, if a patient’s PRO exceeds a clinical threshold, their primary care clinician receives an EHR staff message. The mPROVE app uses the EPIC MyChart patient portal credentials to authenticate users.

MEASURES OF SUCCESS: 1) Development of a feasible and acceptable mPROVE iOS and Android app in English/Chinese; 2) Patient-generated PRO data accessible in an EHR data dashboard for clinicians; 3) Functional iOS and Android systems in field tests; 4) High user satisfaction in field tests.

FINDINGS TO DATE: We completed an iterative patient participatory design process to develop the mPROVE app in English/Chinese in iOS and Android. Patients liked the app visualization of PRO responses over time and desired out-of-app notifications. We are addressing EHR-BRIDGE data visualization authentication incompatibility. Two-week app field tests are in progress (iOS n=8; Android n=7). 80% of Android field testers reported that they believe the app will enhance communication with their clinician and improve their overall quality of care. Field testers described usage incentives such as increased use of relevant surveys during periods of illness or health concerns. Identified usage barriers included repetitiveness of survey questions and lack of push-notifications at time of field test. Technically, to address enterprise security concerns, we implemented a server behind the medical center firewall which introduced multiple sources of authentication and data transfer errors, as well as forcing a complicated user experience. This approach will be difficult to sustain or scale. Enterprise governance approval of this project raised questions of who in the health system should be coordinating capture of PROs from patients and how.

KEY LESSONS FOR DISSEMINATION: A participatory design process with diverse stakeholders is feasible and helps ensure an user-friendly interaction that patients will accept. While many patients assume PRO collection is solely for clinician use, a paradigm shift is needed to support patient agency in data-driven self-management. Scaling of digital approaches to integrate patient-generated data into clinical care requires coordinated system-wide technical and governance infrastructure.

EFFECT OF A TELEHEALTH NAVIGATOR PROGRAM ON VIDEO VISIT SCHEDULING AND COMPLETION IN PRIMARY CARE

Kevin Chen^1,2; Kenan Katranji¹; Khera M. Bailey¹; Brenda Aguilar¹; Michele Rains¹; Helena Mirzoyan¹; Shivali Choxi¹; Christine Zhang¹; Hannah B. Jackson¹

¹Office of Ambulatory Care and Population Health, New York City Health and Hospitals Corporation, New York, NY; ²Division of General Internal Medicine and Clinical Innovation, New York University Grossman School of Medicine, New York, NY. (Control ID #3872091)

STATEMENT OF PROBLEM/QUESTION: Patients in safety-net settings may face challenges participating in video telehealth compared with audio-only telehealth. Commonly cited barriers include patient familiarity with video platforms that may be used by health systems and uncertain attitudes towards virtual care. Does implementation of a telehealth navigator program to help patients prepare for telehealth visits beforehand affect video visit scheduling and completion in a safety-net adult primary care setting? DESCRIPTION OF PROGRAM/INTERVENTION: We hired two full-time, grant-supported staff to serve as rotating telehealth navigators at six community- and hospital-based facilities at a large, urban public healthcare system. They performed weekly outreach calls to patients with upcoming video visits to assess potential barriers to attendance and assist patients in overcoming them. They also provided on-site guidance for patients and staff around using the electronic health record’s integrated video visit platform and patient portal. They spent 2-4 months at each facility.

MEASURES OF SUCCESS: The primary outcomes were difference-in-differences changes in the: (1) proportion of telehealth visits scheduled as video visits (versus audio-only visits), (2) proportion of telehealth visits completed as video visits, and (3) non-attendance rates for audio-only and video visits at each intervention site compared with non-intervention sites within the health system.

FINDINGS TO DATE: There were 65,488 and 71,504 scheduled telehealth appointments at intervention sites and non-intervention sites, respectively, between October 1, 2021 and October 31, 2022.

The unadjusted difference-in-differences for the proportion of telehealth visits scheduled as video visits was 2.3% [95% confidence interval 0.7%, 3.8%]; after adjusting for monthly variation and clustering by facility, the difference-in-differences was 3.7% [-28.5%, 35.9%].

The unadjusted difference-in-differences for the proportion of telehealth visits completed as video visits was -0.6% [-2.2%, 1.0%]; after adjusting for monthly variation and clustering by facility, the difference-in- differences was 2.1% [-11.1%, 15.3%].

The unadjusted difference-in-differences for non-attendance for visits scheduled as audio-only visits was -3.0% [-5.2%, -0.8%]; after adjusting for monthly variation and clustering by facility, the difference-in- differences was -6.8% [-10.8%, -2.8%]. The unadjusted difference-in-differences for non-attendance for visits scheduled as video visits was -1.4% [-3.0%, 0.2%]; after adjusting for monthly variation and clustering by facility, the difference-in-differences was -4.0% [-6.8%, -1.1%].

KEY LESSONS FOR DISSEMINATION: Implementation of a telehealth navigator program may reduce non-attendance for telehealth visits (both audio-only and video). However, telehealth navigators may not have immediate effects on video visit scheduling and completion of visits using video.

NUDGES IN THE ELECTRONIC HEALTH RECORD TO PROMOTE APPROPRIATE DIABETES MANAGEMENT IN OLDER ADULTS – RESULTS FROM A LARGE PRAGMATIC CLUSTER RANDOMIZED CONTROLLED TRIAL

Hayley Belli¹; Andrea B. Troxel¹; Saul B. Blecker¹; Judd H. Anderman²; Christina Wong³; Tiffany R. Martinez³; Ratnalekha V. Viswanadham⁴; Safiya Richardson⁵; Catherine Pollak¹; Devin Mann³

¹Population Health, New York University Grossman School of Medicine, New York, NY; ²Quality Improvement, Family Health Centers at NYU Langone, Brooklyn, NY; ³Population Health, NYU Langone Health, New York, NY; ⁴Pediatrics, New York University Grossman School of Medicine, New York, NY; ⁵Deparment of Population Health, NYU Langone Health, New York, NY. (Control ID #3874325)

STATEMENT OF PROBLEM/QUESTION: Can the integration of behavioral economics (BE) principles and electronic health records (EHRs) using clinical decision support (CDS) tools reduce overtreatment of type 2 diabetes in adults ages 76 years and older?

DESCRIPTION OF PROGRAM/INTERVENTION: The American Geriatrics Society Choosing Wisely (CW) initiative promotes less aggressive glycemic targets and reducing pharmacologic therapy in older adults with type 2 diabetes. However, many providers may be unaware of these guidelines, resulting in overtreatment and increased risk of hypoglycemia in patients. Integrating BE principles and EHRs using CDS tools is a novel approach to raising awareness and adopting these guidelines. Behavioral economics studies the effects of psychological, social, cognitive, and emotional factors on the decisions of individuals, and BE nudges influence behavior at a largely unconscious level.

We employed a user-centered approach to develop a six-component BE-EHR module to interface with the New York University Langone Health (NYULH) EHR system. The six components of the intervention included: 1) a passive tailored advisory alert, 2) an alert window in the refills section of the EHR that appeared whenever a refill for diabetes medication was generated for study-eligible older adults, 3) a medication preference list in which metformin displayed at the top of first-line medications for type 2 diabetes, 4) a lab result nudge describing appropriate treatment guidelines for older adults whenever there is a new HbA1c lab result that is not consistent with CW guidelines, 5) a peer comparison email displaying CW compliance among patients at the provider-, clinic-, and NYULH-system levels, and 6) a gameshow-themed campaign email to bring awareness to the CW guidelines.

This abstract describes results from a fully powered, pragmatic, investigator-blind, cluster randomized controlled trial testing the effectiveness of the intervention in 66 outpatient NYULH clinics randomized 1:1 to receive 18 months of the intervention plus standard care vs. standard care only.

MEASURES OF SUCCESS: The primary study outcome was patient-level CW compliance, which was modeled longitudinally as a binary outcome using a three-level logistic mixed-effects model. EHR data from over 5,000 unique patients were included in analyses. Qualitative data from providers were also analyzed to identify themes relating to the acceptability of nudges.

FINDINGS TO DATE: We found no significant difference in CW compliance between the intervention and control groups at 6 (p=0.638), 12 (p=0.620), and 18 months (p=0.877).

KEY LESSONS FOR DISSEMINATION: EHR-based nudges require clinician engagement, an increasingly scarce resource due to the Covid-19 pandemic, burnout, alert fatigue, and limited opportunities within the EHR to deliver nudges at the right place and time. Using quantitative and qualitative study data, we will discuss lessons learned from delivering nudges embedded within a large healthcare system, and considerations for designing future BE-inspired interventions, especially those targeting healthcare providers.

POPULATION HEALTH APPROACH TO ADULT OBESITY; USING DATA TO PROMOTE EQUITABLE OUTCOMES

Hadeel Alkhairw^1,4; Nura T. Anwar²; Stan Kogan³; Karyn Singer²

¹Ambulatory Care/Elmhurst, New York City Health and Hospitals Corporation, New York, NY; ²Office of Ambulatory Care and Population Health/Chronic Disease and Prevention, New York City Health and Hospitals Corporation, New York, NY; ³Office of Ambulatory Care & Population Health, New York City Health and Hospitals Corporation, New York, NY; ⁴Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3877026)

STATEMENT OF PROBLEM/QUESTION: A registry is needed to track obesity metrics and identify disparities in prevalence, screening, and intervention.

DESCRIPTION OF PROGRAM/INTERVENTION: In the US, from 2017 to 2020, the overall prevalence of obesity is 42%. Obesity disproportionately affects non-Hispanic Black adults and Hispanic adults. Obesity is a chronic condition that can be managed with appropriate intervention and follow-up. If left unaddressed, obesity may lead to high blood pressure, heart disease, stroke, arthritis, type 2 diabetes, depression, sleep apnea, kidney disease, liver disease, gallbladder disease, pregnancy complications, and a higher overall mortality rate.

To identify the trends and gaps in care at a population level, an obesity registry was built. This registry captures patient level data on sociodemographics, vital signs, lab results, medication prescriptions and referrals to treatment pathways.

This registry has several process and outcome measures that were developed in collaboration with a system level adult obesity workgroup. These measures will enable us to monitor care processes, identify care gaps, compare outcomes from various intervention programs, plan population level interventions for quality improvement and address disparities.

Using the registry, we designed a dashboard and a patient level report. The patient level report is available in our electronic health record system and lets clinicians and population health staff pull their patient level data in real time. The dashboard permits clinical leadership and clinicians to monitor aggregate data and disparities for the key process and outcome measures.

MEASURES OF SUCCESS: Population-wide improvements in process and outcomes measures and a reduction in disparities across multiple domains.

FINDINGS TO DATE: Registries provide data for action and allow a centralized approach to population management. Generating patient level data readily available to clinicians empowers the frontline staff to quickly identify, treat, and advocate for patients. Producing aggregate level data visible and transparent to clinical leadership across the organization helps to drive continuous improvement and bridge equity gaps.

KEY LESSONS FOR DISSEMINATION: 1- Building a registry that incorporates sociodemographic data allows identification and tracking of disparities in process and outcome metrics.

2. The registry and relevant metrics should be built with key stakeholders such as a multidisciplinary Obesity Workgroup.

3. Both patient level and aggregate summary data should be leveraged and easily accessible for clinicians at all levels to empower to action.

Q4 HOUR VITAL SIGNS AND NEURO CHECKS: CAN OPTIMIZING CLINICAL DECISION SUPPORT DECREASE SLEEP DISRUPTIONS?

Lauren Eisner, Alexander Poulakis, Jennifer Lin, Oskar Wielgus, Sullafa Kadura

Medical School, University of Rochester Medical Center, Rochester, NY. (Control ID #3868682)

STATEMENT OF PROBLEM/QUESTION: Vital sign (VS) and neurological check (NC) orders contain clinical decision support (CDS) systems with frequency options to help clinicians align workflows with patient needs. However, these orders often default to q4, and clinicians may over-accept this default even if inappropriate, contributing to the overuse of hospital medicine resources and overnight sleep disruptions.

DESCRIPTION OF PROGRAM/INTERVENTION: At an academic medical center (AMC), VS and NC orders were pre-selected and defaulted to q4 without sleep-friendly radio button options. Qshift did not have an associated viewable schedule for providers and defaulted to 0800, 1600, 2400 on nursing worklists. We inserted two sleep-friendly radio buttons: q4 hour while awake (q4WA) (0600, 1000, 1400, 1800, 2200); and TID while awake (TIDWA) (0800, 1600, 2200). We removed the qshift radio button. Q4 hour default and remaining radio buttons were unchanged. At the start of each 2-week rotation, we reminded inpatient neurology unit (INU) residents to review and modify around-the-clock VS and NC orders if appropriate via Secure Chat. We gave 3 1-hour presentations to neurology residents and INU staff at the beginning of the intervention.

MEASURES OF SUCCESS: We defined the pre-intervention period as six months before the intervention (May-October 2021) and the post-intervention period as six months following (December-May 2022). Order frequency utilization and total NC and VS completed overnight (11 pm–7 am) were obtained through the EHR. Pre- and post-intervention data were analyzed using interrupted time-series analysis (ITSA) in R version 4.1.2.

FINDINGS TO DATE: Post-intervention, there was a significant decrease in ordering trends for sleep- disrupting VS and NC orders (q4 and qshift). At the AMC, q4 VS orders decreased by 15% (p<0.001), and q4 NC orders decreased by 17% (p<0.001). Qshift VS orders decreased by 77% (p<0.001), and qshift NC orders decreased by 55% (p<0.001). The results were more profound in the subgroup analysis of the INU (q4 VS and NC decreased by 54% and 48% respectively, and qshift VS and NC decreased by 83% and 87% respectively, p<0.001). Sleep-friendly orders (q4WA and TIDWA) increased from 0% to 6.7% and 7.8% of all VS and NC orders, respectively. Sub-group analysis of the INU was again more profound, with sleep- friendly orders increasing from 0% to 16% of both VS and NC orders. Additionally, total overnight VS and NC decreased by 11% and 17%, respectively, post-intervention at the AMC. The results were more profound on the INU (VS 45% decrease and NC 35% decrease, p< 0.001). The case-mix index was appropriately lower in the population with while awake orders (1.2749) versus around-the-clock orders (2.2684).

KEY LESSONS FOR DISSEMINATION: Passive CDS modifications significantly decreased sleep- disrupting orders, increased sleep-friendly orders, and decreased objective nightly disturbances due to NC and VS. These results were more profound on the INU, indicating that CDS changes, education, and Secure Chat reminders demonstrated a larger impact than CDS changes alone.

SECOND BRAIN FOR MIGRAINE - UTILIZING A SMARTPHONE AI TO PREDICT MIGRAINE ATTACKS

Ahmed A. Sandhu¹; Elizabeth J. Kim^2,3; George Koutras¹; Maryam Yousefi⁴; John Dedousis¹; Antonios Tsompanidis¹; Gulsen Babacan-Yildiz⁵

¹GME, CarePoint Health, Jersey City, NJ; ²Ochsner Medical Center, New Orleans, LA; ³The University of Queensland, Saint Lucia, Queensland, Australia; ⁴William Carey University College of Osteopathic Medicine, Hattiesburg, MS; ⁵Bezmialem Vakif Universitesi, Istanbul, Istanbul, Turkey. (Control ID #3875154)

STATEMENT OF PROBLEM/QUESTION: Monitoring and managing migraines is an active, full-time job for individuals with migraines.

DESCRIPTION OF PROGRAM/INTERVENTION: The current standard for identifying migraine triggers is selective recall and manual recording. This approach results in missing key triggers and misidentification, causing migraineurs to needlessly avoid activities they enjoy. However, there are physiologic changes at least 72 hours before a migraine attack. Utilizing these changes for benefit has been unrealistic due to the difficulty in measurement outside of a clinical setting. Yet these “biomarkers” can be collected via smartphones. We propose a self-adjusting, learning, explainable AI via an app (Migraine.AI) that can gather data and predict migraine onset, with subsequent identification of triggers. Here, our initial proof-of-concept blackbox AI underwent an observational study.

This study recruited 139 migraineurs with 8+ monthly migraine attacks. Participants received a blood pressure cuff, smartwatch, and downloaded the Migraine.AI app. They were asked to wear smartwatches, measure their blood pressure 3 times a day, and record a 20-second selfie. Participants reported their stress levels and nutrition daily. After a migraine episode, they reported migraine onset and migraine features (e.g., premonitory/prodromal symptoms, aura, intensity). Female patients' menstrual periods were also monitored. The data was parsed into 72 hours preceding each migraine attack and the migraine attack itself. The data was then separated into training and testing sets semi-randomly.

MEASURES OF SUCCESS: 1. Initial metric is demonstrating that a blackbox AI can predict better than chance when a migraine attack occurs.

2. When this reference is achieved, the next step is reproducing the prediction with an explainable AI.

3. An explainable AI will allow us to identify which factors (or "biomarkers") play an individualized role in migraines and to what degree they impact a person's migraines.

4. Beyond just prediction, we would then focus on interventional studies

FINDINGS TO DATE: The testing data included 840 migraine attacks. The blackbox AI was able to predict a migraine attack within 48 hours prior to its onset with 80% accuracy. Weighted Average F1 score was 0.72. When removing variables and re-training the AI, menstruation, lack of sleep, and stress appeared to have the highest weight in triggering a migraine. Preliminary analysis suggested that trigger chains are not the same for every episode, and could change for the same individual. Last, the collected data suggested attacks required multiple triggers in sequence.

KEY LESSONS FOR DISSEMINATION: Healthcare technology and its ability to measure biomarkers is underutilized. Our initial findings indicate the feasibility of the smartphone to help monitor and manage patients outside of a clinical setting; not just for migraines. Ideally, subsequent interventional studies where a user can take preventative or abortive interventions (both behavioral and pharmacological) can be done to increase the utility of new technologies in healthcare.

TRANSLATION OF EVIDENCE-BASED HOME BLOOD PRESSURE MONITORING GUIDELINES INTO PRACTICE THROUGH A MHEALTH APP

Cara Litvin^1,2; Steven M. Ornstein²

¹Medicine, Medical University of South Carolina, Charleston, SC; ²Stevara, LLC, Charleston, SC. (Control ID #3868844)

STATEMENT OF PROBLEM/QUESTION: While many mHealth apps are available to help users track their blood pressure (BP), no apps incorporate the full set of home blood pressure monitoring (HPBM) guidelines from the American Heart Association (AHA) to ensure accurate measurement at home.

DESCRIPTION OF PROGRAM/INTERVENTION: HBPM has been shown to provide a more reliable assessment of BP than in-office measurement, leading to more accurate diagnosis and appropriate treatment of hypertension. However, barriers to HBPM include failure of patients to adhere to proper measurement technique and accurately report the results, along with the time required by providers to instruct patients on the protocol. We sought to develop a mHealth app to guide patients to conduct evidence-based HBPM and share these results with their healthcare providers. Through an agile development approach employing user stories, the AHA’s standardized protocol for home BP measurement and monitoring was translated into app functionality. The resulting app, available for iOS and Android mobile phones, reminds users to take 2 BP readings one minute apart in the morning and evening for 3 to 7 days in a row. It includes video and text step- by-step instructions for proper positioning along with timers to ensure users rest 5 minutes before their BP is measured and repeat a measurement after 1 minute of rest. After 3 days of measurements, the app calculates a running average of the first set of morning and evening measurements, excluding additional readings at other times to avoid a skewed average. The app integrates electronically with several affordable, validated, Bluetooth-connected home BP devices or allows users to manually enter readings from any BP device. The app can be used independently, or users can choose to securely share their readings with a clinician practice by email or via the corresponding clinician portal. The HBPM app was piloted beginning in February 2021. Users were sought thru social media postings, advertisements and word of mouth, focusing on direct primary care physicians and local primary care practices in the Southern region who could easily implement new workflows into their practice.

MEASURES OF SUCCESS: To assess the feasibility of using this app to disseminate evidence based HBPM among real world patients during our pilot testing, we measured the number of users creating an app account, the number of users recording at least one BP reading, and the number of users completing at least one 3-7 day monitoring period.

FINDINGS TO DATE: During our pilot testing, 125 users created an app account. 75 users recorded at least one BP reading, and 47 completed at least one monitoring period.

KEY LESSONS FOR DISSEMINATION: We have demonstrated the feasibility of using a mHealth app to guide patients to adhere to guidelines for HBPM. Such apps may be an accessible resource to democratize accurate HBPM and sharing of readings with providers.

Innovation in Healthcare Delivery (IHD) - DEI, Health Equity, and Social Determinants of Health

"WE ARE EVERYWHERE": A MIXED METHODS EVALUATION OF COMMUNITY HEALTH WORKER INTEGRATION ACROSS AN ACADEMIC LEARNING HEALTH SYSTEM

Iris S. Cheng^1,2; Deepak Palakshappa¹; Jessica L. McCutcheon²; Nancy M. Denizard-Thompson³; Sherrie Wise Thomas¹; Yhenneko Taylor²; Rohan Mahabaleshwarkar²

¹Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC; ²Department of Internal Medicine, Atrium Health, Charlotte, NC; ³Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC. (Control ID #3871711)

STATEMENT OF PROBLEM/QUESTION: Little is known about best practices for community health worker (CHW) integration in a large, integrated health system.

DESCRIPTION OF PROGRAM/INTERVENTION: Community health workers (CHWs) are an innovative approach to care delivery and are increasingly being utilized in clinical settings to help improve quality of care and health outcomes among vulnerable patient populations through addressing and supporting social needs. Across one of the largest academic learning health systems in the US, CHWs serve in diverse capacities depending on their practice setting (inpatient, outpatient, community) and their health system division. We evaluated four unique CHW teams operating in two Southeastern cities to identify best practices for how CHWs could be used to improve healthcare delivery.

MEASURES OF SUCCESS: Using a mixed methods approach including surveys and focus groups with 29 CHWs, we evaluated CHW utilization, training, scopes of practice, referral/ workflows, experiences, and perceptions to inform health system processes for CHW clinical integration. Focus groups were audio recorded and transcribed, and we used an inductive content analysis approach to identify emerging themes. CHW demographics and practice patterns were measured using a written questionnaire. We also extracted data from the electronic health record (EHR) for all patients who had been referred to a team in the prior 6 months. We are in the process of comparing differences in demographics and clinical characteristics of patients served by the four CHW teams using descriptive statistics.

FINDINGS TO DATE: We found a notable degree of variability across CHW roles, training and credentials, referral pathways, workflows, and level of integration within the clinical care team. We also discovered differences in duration of patient engagement and CHW funding. CHWs performed a wide range of roles including addressing social needs (e.g., food insecurity, housing instability, transportation), securing prescriptions, navigating medical appointments, supporting healthy behaviors and providing emotional support. A digital community resource hub was often used. Common integration barriers identified included perceived low levels of knowledge among healthcare personnel about CHW competencies and roles within the organization as well as insufficient resources to meet patient needs - particularly related to housing and mental health care.

Additionally, CHWs sometimes served overlapping populations within the system.

KEY LESSONS FOR DISSEMINATION: CHWs perform a range of valuable services within the health system and operate at varied levels of integration with the clinical team. However, the standards for CHW programs must be clearly and consistently defined. Capacity building among care teams should aim to improve awareness of CHW roles and expectations of the services they provide. Health systems, including our own, would benefit from consistent training, standardized referral processes, delineation of the CHW scope of practice, and formal integration of CHW activities with clinical care.

BARRIERS AFFECTING PATIENTS OF A STUDENT-RUN CLINIC PRIMARILY SERVING THE DETROIT HISPANIC/LATINX COMMUNITY AND THE IMPACT OF A HEALTH FAIR ON STUDENT ORGANIZATION OUTREACH TO THIS POPULATION

Sanjana Rao, Lucas Edgren, Amanda Rodriguez, Diane L. Levine, Jennifer Mendez, Joel Appel

Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #3875060)

STATEMENT OF PROBLEM/QUESTION: What barriers to healthcare access affect the Detroit Hispanic/Latinx community, and how did a student-run health fair primarily serving this population impact the organizations involved?

DESCRIPTION OF PROGRAM/INTERVENTION: Amigos Medicos (AM), a Wayne State University School of Medicine (WSUSOM) student-run free clinic, provides screening services to the Hispanic/Latinx population in Detroit. Current literature shows this population faces health inequities. To understand the challenges faced by our patient population, we surveyed patients seen at the AM clinic. At this clinic, 2-3 medical student volunteers see an average of 4 patients weekly for 2 hours. Over six clinics, we have collected survey responses from nine patients. Results are presented as descriptive statistics.

Our response rate is approximately 38% and collection is ongoing. All respondents self-identify as Hispanic/Latinx. 66.67% do not have health insurance. 33% have DM, hypertension, or high cholesterol. 22% indicated that lack of health insurance, language barriers, lack of transportation, or long wait-time for appointments increased the difficulty of accessing healthcare. 22% said they previously have been unable to afford their medication. 22% reported that they believe Hispanics/Latinxs receive lower-quality healthcare than non-Hispanics/Latinxs. 11% reported the staff did not make them feel appreciated.

The responses demonstrate a need for health services targeting this population. To address this, we hosted a health fair in 2022 to connect this community to 7 other WSUSOM student-run organizations and 8 other Detroit organizations who provided resources, screenings, and referrals.

MEASURES OF SUCCESS: We reached out to relevant WSUSOM student organizations to participate in a screening fair. Four months later, we administered a 9-question survey to the student representatives from the participating organizations to assess their experiences. Results are presented as descriptive statistics.

FINDINGS TO DATE: Approximately 100 community members were seen at the fair. Eight of ten student organizations elected to participate. Survey response rate was 100%. All (100%) student organization representatives believed the fair brought increased awareness to the Detroit population about their respective organization. 38% reported the patient population of their respective organization has been diversified because of the fair. The most identified limitations were financial constraints (43%), limited space/resources (14%), and lack of volunteers (14%). In the free text response, other limitations were limited interpreters (14%) and inability to follow up (14%).

KEY LESSONS FOR DISSEMINATION: The Detroit Hispanic/Latinx community faces obstacles to receiving quality healthcare. Health fairs such as the one we hosted increase outreach to this community. Increasing funding for students to host these fairs and disseminate resources, providing follow-up for continuity care, and increasing the number of Spanish interpreters will likely improve the efficacy of future fairs.

BECOMING ANTI-RACIST: A GENERAL INTERNAL MEDICINE DIVISION’S PURSUIT

Crystal W. Cene¹; Tamara F. Saint-Surin²; Hannah Y. Coletti²; Gaurav Dave³; Carol Golin⁴; Shayla Mitchell Bigelow²; Neshaunda Burton²; Christine Gladman⁵

¹Medicine, University of California San Diego, La Jolla, CA; ²Internal Medicine, University of North Carolina System, Chapel Hill, NC; ³Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; ⁴University of North Carolina Chapel Hill, Chapel Hill, NC; ⁵Medicine, University of North Carolina, Chapel Hill, NC. (Control ID #3877308)

STATEMENT OF PROBLEM/QUESTION: After the death of George Floyd, a Division of General Internal Medicine at a southeastern academic medical center identified the need for an action plan to become antiracist.

DESCRIPTION OF PROGRAM/INTERVENTION: Ten faculty, clinical, and administrative staff formed a task force to engage the Division (N=83 faculty, clinical and administrative staff) in understanding perspectives on and implementing strategies to address racism. We used a combination of strategies, including facilitated group discussions during 5 quarterly meetings, survey data, and didactic lectures by external speakers to develop an anti-racism plan.

MEASURES OF SUCCESS: Survey response rate; feedback on educational sessions; and identification of priority areas and action items

FINDINGS TO DATE: The first two meetings provided space to debrief about recent national events, share stories of how racialized trauma impacts daily life, and educate on race/racism. Then, the task force distributed an online survey with open-ended questions on respondents’ experiences witnessing racism in patient care and in the workplace and perceived barriers to becoming anti-racist. We identified the following themes (survey response rate 65%): most experiences witnessing racism involved patients displaying racist acts towards clinicians/staff; most common manifestation of structural racism was lack of diversity among providers and leadership. Barriers to enacting change included lack of time, competing priorities, “zero-sum” thinking about sharing power and privilege, and low self-efficacy to enact systemwide change.

The division identified priority areas for action: increasing racial/ethnicity diversity of clinicians and leadership; enforcing policies that hold patients and staff accountable for discriminatory behavior; increasing support for Spanish-speaking patients, instituting training on anti-racism, microaggressions, and allyship; and addressing racism through quality improvement (QI) projects focused on closing racial/ethnic health disparity gaps.

In reponse to identified priorities, the Division: revised a system-wide policy on how to respond to patients displaying racist/biased behavior; hosted a case-based interactive discussion on micro-aggressions, followed by grand rounds and a special division meeting on implicit bias; and developed and implemented a QI project focused on addressing racism and advancing health equity in 4 population health metrics (hypertension control, diabetes control, colon cancer and cervical cancer screening). Task force work remains ongoing.

KEY LESSONS FOR DISSEMINATION: Engaging a GIM division in anti-racism work is possible with structured and sustained attention

COFFEE TALKS WITH FUTURE DOCS

Kelan Fogarty¹; Michael McShane²

¹Educational Affairs, Penn State College of Medicine, Hershey, PA; ²Internal Medicine, Penn State College of Medicine, Hershey, PA. (Control ID #3872155)

STATEMENT OF PROBLEM/QUESTION: Individuals, especially the elderly, in economically disadvantaged areas are disproportionately affected by low health literacy.

DESCRIPTION OF PROGRAM/INTERVENTION: Older adults (65 and older) with low health literacy have difficulty with the healthcare system which is associated with increased overall mortality. Moreover, low health literacy is associated with and disproportionately affects older adults and those of low socioeconomic backgrounds. In other words, an intersectionality of age and low economic status further complicates one’s ability to take appropriate healthcare actions to improve their health.

Snow Shoe is a community of fewer than 800 people in which the population is declining, and the remaining population is aging. Additionally, approximately 1 in 8 people live below the poverty line in the community. With the economic downturn, multiple institutions in the community left, including the only medical clinic (a Federally Qualified Health Center), pharmacy, grocery store, bank, and library. To increase local health literacy, we created a student-led initiative, Coffee Talks with Future Docs, that stemmed from Penn State College of Medicine community outreach which focuses on community and outpatient settings. Our initiative uses discussions that revolve around topics elicited from older adults at one senior center (e.g., diabetes, hypertension). The dialogue consists of medical student-led short talks and small group exercises utilizing pamphlet materials and appropriate medical equipment related to the talk. Questions are welcomed and encouraged. Sessions are ongoing during the pilot period from November 2022 through April 2023. Students meet with the senior center twice monthly.

MEASURES OF SUCCESS: Qualitative analysis is ongoing via the research team with planned exit interviews of participants at the end of the pilot period. Participants undergo a semi-structured interview focusing on understanding the impact on participants' overall health and well-being.

FINDINGS TO DATE: To date, we have held three events with the older adults focused on diabetes and hypertension. Initial qualitative feedback has been positive, including older adults in attendance asking to assist with marketing materials and inviting others to attend future events. We plan to continue to collect qualitative data to understand the implications of this intervention on the health literacy of the group for topics discussed.

KEY LESSONS FOR DISSEMINATION: A key takeaway includes that incorporation into a community requires establishing rapport and exposure. Once the people get to know the cause and begin to trust the project/intervention, more individuals may participate and potentially advertise on the program’s behalf.

COVID-19 MOBILE TEST TO TREAT: IMPLEMENTATION AND PROCESS EVALUATION IN A LARGE METROPOLITAN AREA OF THE MID-ATLANTIC REGION - JUNE 30, 2022 TO DECEMBER 10, 2022

Chris Keeley¹; Sarah Joseph Kurien²; Katherine Murphy²; Andrew Cook²; Jacob Watkins²; Andrew Wallach^3,2; Ashwin Vasan⁴; Theodore G. Long²

¹Ambulatory Care, New York City Health and Hospitals Corporation, New York, NY; ²Office of Ambulatory Care and Population Health, New York City Health and Hospitals Corporation, New York, NY; ³NYU Langone Health, New York, NY; ⁴New York City Department of Health and Mental Hygiene, Long Island City, NY. (Control ID #3877694)

STATEMENT OF PROBLEM/QUESTION: With certain neighborhoods being disproportionately impacted by COVID-19, a large metropolitan are in the Mid-Atlantic created the first mobile test-to-treat units inthe country.

DESCRIPTION OF PROGRAM/INTERVENTION: A large metropolitan area of the Mid-Atlantic was the initial epicenter of the COVID-19 pandemic in the United States (US). Early on, it was clear that certain neighborhoods within the area were disproportionately impacted. In response, the healthcare leaders created mobile COVID-19 testing units to specifically target these under-resourced neighborhoods and, then, followed with mobile COVID-19 vaccine units in order to further address equity. When oral anti-viral COVID-19 teatments (e.g. Paxlovid) became widely available, uptake rates across the US were disproportionately low in socially and economically disadvantaged communities. To expand access and uptake of Paxlovid, in June 2022 the healthcare leaders established the first mobile Test-to-Treat program in the US. The program works with locally-embedded community-based organizations to bring mobile units to impacted communities, guided by our area's Taskforce on Racial Inclusion and Equity (TRIE). Patients receive a rapid antigen test for COVID-19 and, if positive, are immediately evaluated by an on-site clinician. If eligible for treatment, they are prescribed and dispensed Paxlovid directly from the mobile unit. Units now offer COVID-19 PCR testing and rapid respiratory pathogen (RSV and influenza) testing. There are currently 75 mobile Test-to-Treat units in the area.

MEASURES OF SUCCESS: Key metrics of success include testing uptake, Paxlovid utilization, and whether deloyments can be implemented in areas needed to improve equity.

FINDINGS TO DATE: From June 30, 2022 to December 10, 2022, the mobile Test-to-Treat units administered 135,840 rapid COVID-19 tests. There were 16,079 positive tests, with 4,715 patients eligible for treatment. Among those eligible, 3,291 patients received Paxlovid. Over 75% of mobile Test-to-Treat locations were located in TRIE neighborhoods hardest hit by the pandemic. 62% of tests were in the TRIE neighborhoods. Of those area residents tested who self-reported their race or ethnicity, 34% were Black, 27% were Hispanic or Latino, 20% were White, 10% were Asian, 8% were Other or Multiracial and 2.3% were Native American, Native Hawaiian, Native Alaskan, or Pacific Islander.

KEY LESSONS FOR DISSEMINATION: Implementation of mobile Test-to-Treat units is feasible and can be used to improve equity in COVID-19 treatment for communities with lower access or utilization of treatment. They can also be used to help improve the uptake of oral anti-viral treatment for those at increased risk for severe disease from COVID-19. Patients universally valued the 'one-stop-shopping' experience.

DOCUMENTING PATIENTS’ DISABILITY STATUS IN THE ELECTRONIC HEALTH RECORD TO INFORM EQUITABLE CARE

Megan Morris¹; Kori Eberle²

¹General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; ²University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #3877231)

STATEMENT OF PROBLEM/QUESTION: Primary care providers need to systematically document patients’ disability status in the electronic health record (EHR) in order to ensure equity of care and provision of disability accommodations.

DESCRIPTION OF PROGRAM/INTERVENTION: Patients with disabilities are at significant risk for poor health and health care outcomes. For example, persons with disabilities have significantly higher rates of chronic conditions, including diabetes, hypertension, arthritis and asthma, even when controlling for other demographic characteristics. Numerous organizations call for documentation of patients’ demographic information (e.g., race/ethnicity) and social data (e.g., Social Determinants of Health) in the EHR. Documentation of such data in the EHR is essential for tracking quality of care delivered to marginalized populations and for developing and targeting interventions to address equity in care. Similarly, documentation of disability status in the EHR is critical to advancing equitable healthcare for persons with disabilities.

Recent federal policy statements and the Office of the National Coordinator for Health Information Technology require disability status documentation in the EHR. Consistent and accurate documentation of disability status is needed to track the quality of care provided and to identify patients who require disability accommodations. Without consistent documentation, disparities have no chance to be addressed.

To assist practices with documentation of patients’ disability status in the EHR, we embarked on a series of steps through our developed national collaborative. First, we conducted interviews with 15 healthcare organizations who are currently working to implement collection of disability status. Next, with a collaborative of diverse stakeholders, including patients, primary care teams, and an EHR vendor, we developed and disseminated a guide for health care teams on how to begin to implement documentation of patients’ disability status. Currently, through a NIH-funded grant, we are developing a standardized EHR build (in collaboration with a national EHR vendor) with associated workflow processes and systems for implementation in the primary care setting.

MEASURES OF SUCCESS: Through a stakeholder-informed process, we will develop an EHR build and a “menu” of implementation and workflow processes which will then be tested in a randomized control trial.

FINDINGS TO DATE: We have identified the questions to ask, training targets for staff and providers who will be documenting disability status, characteristics of a standardized EHR build, and options for how and when disability status can be collected in the primary care setting.

KEY LESSONS FOR DISSEMINATION: Lessons include: understanding of why disability status should be consistently documented in the EHR, a set of best practices for collection of disability status, including language to use with patients, training for staff, workflow processes for documentation, and ideas of how to use the data to provide equitable care to patients with disabilities.

DRIVING EQUITY THROUGH DATA: MOBILE COVID-19 TESTING PROGRAM IN A LARGE METROPOLITAN AREA OF THE MID-ATLANTIC REGION

Alexandra Chen²; Andrew Cook¹; Chris Keeley¹; Sarah Joseph Kurien¹; Andrew Wallach^3,1; Theodore G. Long¹

¹Office of Ambulatory Care and Population Health, New York City Health and Hospitals Corporation, New York, NY; ²Test & Treat Corps, New York City Health and Hospitals Corporation, New York, NY; ³NYU Langone Health, New York, NY. (Control ID #3876943)

STATEMENT OF PROBLEM/QUESTION: How might public healthcare systems drive equity in access to public healthcare emergency resources?

DESCRIPTION OF PROGRAM/INTERVENTION: In June 2020, a large metropolitan area in the Mid- Atlantic implemented a mobile COVID-19 testing program to provide PCR (and, later, rapid antigen) testing across the area. The program's focus from the beginning and through today was the equitable distribution of testing resources based on the use of data to drive deployments. The methods developed show how publicly- available data and accessible analysis tools can be utilized to drive key equity goals. We describe here our implementation results along with two case studies.

MEASURES OF SUCCESS: To measure equity and embed it within the program, the mobile testing team developed the following criteria. The deployment is in a Taskforce on Racial Equity & Inclusion (TRIE) zip- code. A designation for communities disproportionately impacted by COVID-19, and has a community-based organization (CBO) partner. The latter criterion was especially critical, highlighting the value of partnering with trusted community partners.

On a weekly basis, the program utilized publicly-available COVID-19 case rare data, testing rate data, insurance status data, and TRIE neighborhood status to review COVID-19 trends in all of the area's zip codes; a data table was then cross-referenced against the mobile program's schedule. This has allowd the team to identify whether and how to adjust deployments, ensuring that resources are delivered in a way that ensures equity among all communities.

FINDINGS TO DATE: Across the duration of the mobile program (June 2020 through present), 69% of mobile testing deployments have been to locations that met equity criteria, along with more than 75% of deployments in TRIE zip codes. Total test volume exceeds 2 million.

As two specific case studies, the first is zip code A (a large metropolitan area of the Mid-Atlantic region); post-Omicron surge, the team's data analysis identified outlier case rates in this TRIE zip code. To maximize reach, the program partnered with a local CBO to plan, prommote and implement a 2-day testing and vaccination deployment that reached over 100 residents. Another case example is zip code B (in the same large metropolitan are of the Mid-Atlantic region as 'zip code A' above): identified early in the pandemic as a zip code with high transmission and low testing, the team sent units on a recurring basis while building community partnerships. By April 2022, zip code B stood out with above-average testing rates and below- average transmission.

KEY LESSONS FOR DISSEMINATION: There is tremendous capacity for healthcare and other community-facing response teams to utilize publicly available data and partnerships with community organizations to deliver equitable services and effective interventions. This approach demonstrates that government and public sector organizations can be adaptable and move swiftly to meet community needs and achieve health equity.

ENHANCING PATIENT SAFETY BY ADDING PATIENT PHOTOS TO THE ELECTRONIC MEDICAL RECORD OF A PRIMARY CARE CLINIC SERVING NON-ENGLISH SPEAKING IMMIGRANTS

Duncan T. Reid^1,2; Mahri Haider^1,2; Eve Lake^1,2; Srirama Josyula^1,2; Rena Gosser^4,5; Chenwei Wu^2,3

¹General Internal Medicine, Harborview Medical Center, Seattle, WA; ²General Internal Medicine, University of Washington, Seattle, WA; ³Medicine, VA Puget Sound Health Care System Seattle Division, Seattle, WA; ⁴Department of Pharmacy, Harborview Medical Center, Seattle, WA; ⁵Department of Pharmacy, University of Washington, Seattle, WA. (Control ID #3871990)

STATEMENT OF PROBLEM/QUESTION: Non-Western naming conventions, linguistic differences, power dynamics, and other aspects of patient-provider ethnocultural distance can increase the risk of identification (ID) errors among non-English speaking immigrant patients. Locally, a review of hospital-wide patient safety reports revealed a number of rooming, order entry, and lab collection errors in which incorrect patient ID was causal or contributory. A multidisciplinary staff survey (N=38 respondents including physicians, pharmacists, medical assistants, and interpreters) conducted in the pilot clinic, which specializes in immigrant care, found that 79% recalled a patient ID error in the prior month. Staff also responded overwhelmingly that they have trouble identifying a patient by name alone (9.3 out of a 10-point Likert scale) and that a photographic reference, if available, would be beneficial (9.6 out of 10). However, at baseline, most patients served by the clinic did not have a high-quality profile photo.

DESCRIPTION OF PROGRAM/INTERVENTION: The pilot clinic serves non-English speaking immigrant patients, particularly those with complex healthcare needs, as part of a public medical center in the Pacific Northwest. Over the past two years, approximately 1,800 unique patients were seen in this primary care clinic. The intervention consisted of a systematic campaign to record and upload high-resolution color photos of empaneled patients into the clinic EMR (Epic Systems) as those patients presented for scheduled care. Images were captured onto a clinic-provided smartphone and personal devices using the secure EMR mobile application. Photos were added by medical assistants and providers.

MEASURES OF SUCCESS: Measures of success for this project were the proportion of total empaneled patients with a high-quality profile photo and the percentage of weekly clinic visits paired with a high-quality photo.

FINDINGS TO DATE: Pre-intervention, out of 1,745 unique patients seen in clinic within the previous two years, 540 (30.9%) had a high-quality photo, 354 (20.2%) had a low-quality image, and 851 (48.7%) had no photo. Over the subsequent 6 months, 880 high-quality photos were added (635 to profiles with no photo and 254 to profiles with low-quality images), representing a 163% relative gain and reaching 75.6% of empaneled patients, which had grown in number to 1,878. Pre-intervention, high-quality patient photos were available for <50% of clinic visits each week; by 6 months post-intervention, this proportion had risen to >90%. Over the same period, the clinic averaged 185 office visits per week and 4.6 photos uploaded each day. Fewer than 5% of patients declined to have their photo imported into the EMR.

KEY LESSONS FOR DISSEMINATION: This improvement project established the feasibility of adding photos to the EMR at the point of care to enhance patient safety among patients at-risk for misidentification. Replication of this practice in other clinics is being explored. Because the EMR is deployed throughout the health system, benefits may also spread passively to additional care settings.

GENDER DISPARITIES IN STATIN USE IN FEMALE PATIENTS WITH DIABETES IN PRIMARY-CARE PRACTICE SITES AFFILIATED WITH A MID-ATLANTIC MEDICAL CENTER

Keshia Toussaint¹; Alexander Garcia¹; Eena S. Lin³; Jenna Guma^2,1; Ricardo Jaime Orozco²; Elizabeth L. Lee^2,1; Ami Joshi^2,1

¹Medicine, Cooper University Health Care Level 1 Trauma Center, Camden, NJ; ²Internal Medicine, Cooper University Health Care, Camden, NJ; ³Rowan University Cooper Medical School, Camden, NJ. (Control ID #3873946)

STATEMENT OF PROBLEM/QUESTION: It has been well established that statin therapy reduces cardiovascular risk in both men and women. Guidelines recommend a moderate intensity statin use in individuals aged 40 or older with a cardiovascular risk. Despite this benefit, female patients are less likely to be on a statin. Female patients are also more likely to report subjective side effects and stop or switch statins than their male counterparts.

DESCRIPTION OF PROGRAM/INTERVENTION: As part of a taskforce to assess for racial and gender disparities, we reviewed our performance in the Merit-based Incentive Payment System (MIPS) quality measure from CMS for our diabetic patients at an accountable care organization in Southern New Jersey.

MEASURES OF SUCCESS: A 12 month an analysis of performance data from medical center affiliated- primary care practice sites from 2021 – 2022 showed that male patients with diabetes mellitus (DM) were statistically more likely to be on a statin than female patients with DM (p<.001). Of 3,905 male and female patients with DM, male patients had 29% greater odds of being on appropriate statin therapy compared to female patients (95% CI: 0.14- 0.47). We anonymously surveyed practice providers at these sites to assess barriers to achieving equity in statin therapy in our female diabetic population from June to August, 2022.

FINDINGS TO DATE: Providers were asked to rank barriers with 1 representing the most common barrier, and 7 being the least common barrier. We obtained survey data from 57 providers. Barriers identified by providers ranked by weighted average include: side-effects of statins (6.25), poor health literacy (5.27), medication cost (4.11), concern for possible pregnancy in women of child-bearing age (3.69), lack of prescription drug coverage (3.43), unstable/inadequate housing and living conditions (2.93), & poor working conditions for the patient (2.38). In the free text comment section of the survey, themes included lack of dietary information readily available for patient education in the office and misinformation about statin side effects.

KEY LESSONS FOR DISSEMINATION: In summary, the most common barriers perceived by our providers contributory to the gender disparity in statin for our female patients with DM have been identified and are consistent to reported barriers in the literature for statin use and prescribing. Prioritizing provider and patient education around statin side effects to fit the health literacy of our patients and reduce misinformation surrounding statin side effects are necessary next steps in this project aimed at decreasing health equity gaps within our primary care patients.

HEALTH E ENGLEWOOD HEALTH AND WELLNESS PROGRAM - A SOCIAL DETERMINANTS OF HEALTH (SDOH) INTERVENTION IN ENGLEWOOD, NEW JERSEY Veronica R. Jacome Lopez¹; Sharmela Brijmohan¹; Jennifer Yanowitz³; Dipal R. Patel²; Natasha Rastogi¹; Cindy varona³; Mekesha A. Samuel³

¹Internal Medicine, Englewood Health, Englewood, NJ; ²Dept of Medicine, Englewood Health, Englewood, NJ; ³Population Health, Englewood Health, Englewood, NJ. (Control ID #3867687)

STATEMENT OF PROBLEM/QUESTION: Improving healthcare delivery by addressing social determinants of health.

DESCRIPTION OF PROGRAM/INTERVENTION: The World Health Organization (WHO) defines social determinants of health as “conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.” The Health E Englewood Health and Wellness Program is a social determinant of health (SDoH) intervention developed to address social factors affecting the health of patients of the North Hudson Community Action Corporation (NHCAC), a Federally Qualified Health Center located in Englewood, New Jersey. The main aim of this integrated wellness approach was to educate and motivate participants from the local community by strengthening the development of healthy lifestyles and providing the necessary tools for positive behavior change.

MEASURES OF SUCCESS: Health E Englewood was a 4 consecutive weeks workshop series focused on 3 areas of health: physical, emotional, and nutritional wellness. Each session was built upon a set of skills to promote healthy living, including tips to get active, practical nutritional guidance, stress management skills, and budget-friendly healthy cooking tips.

The program targeted Spanish-speaking patients from NHCAC and was offered virtually via Zoom in Spanish. The population health team together with medical assistants and medical residents coordinated the recruitment of patients during routine clinic visits, using a screening questionnaire.

FINDINGS TO DATE: The Health E Englewood program was launched in October 2021 with 40 active participants. 63% of participants attended at least 3 of the 4 workshop sessions with at least 60% of participants reporting improved lifestyle changes after the program.

While fine-tuning our intervention for a particular population proved beneficial in the immediate post- intervention period, additional follow-up data collected 6 months later also indicated evidence of long-term benefits of the program. In the 6 month follow-up survey, most participants believed that lack of time and motivation were the major obstacles to implementing what they have learned. As an unintended benefit, participants also built their own social network in which they continued to share ideas even after the end of the program

KEY LESSONS FOR DISSEMINATION: The Health E Englewood program targeted a vulnerable population of the NHCAC Clinic, and proved beneficial in both the immediate and 6 months followed up later. Many similar programs have shown impressive benefits post-intervention but failed to show sustained benefits on later follow-up. We believe the success of this intervention is partly due to the fact that it was not a one-size-fits-all approach but was instead pioneered to be culturally competent with personalized guidance for barriers encountered. The intervention was also unique in that it was done virtually due to the global pandemic.

HUMANISTIC CHARTING: THE INCORPORATION OF A PATIENT’S “PERSON” INTO THE ELECTRONIC MEDICAL RECORD.

Christopher R. Montgomery^1,2; Susan Landon^2,4; Eric Wei²; Elizabeth W. Dzeng³

¹School of Medicine, University of California San Francisco, San Francisco, CA; ²Quality and Safety, New York City Health and Hospitals Corporation, New York, NY; ³Medicine, University of California San Francisco, San Francisco, CA; ⁴School of Medicine, New York University, New York, NY. (Control ID #3875460)

STATEMENT OF PROBLEM/QUESTION: Information related to a patient’s life outside the health care setting (i.e., their “person”), is often unavailable to health care workers (HCW) prior to a patient encounter and remains unavailable unless solicited from the patient.

DESCRIPTION OF PROGRAM/INTERVENTION: We used a three-phase, mixed methods study design to develop a standardized tool to empower patients to document key information about their life outside of the health care setting (i.e., their “person”).

Phase 1: Patient Voice

Semi-structured interviews were conducted with 38 patients from seven NYC H+H facilities to explore patients’ perspectives on what key information a HCW should know about their “person” in order to improve care experience and the HCW-patient relationship. Using Grounded Theory, codes and core themes were identified from interview transcripts.

Phase 2 Patient Choice

Using data from Phase 1, six focus groups with Patient Family Advisory Councils were conducted. Participants created the online tool through activities including voting, open-forum discussion, question design, and tool improvement.

Phase 3 Pilot/HCW Optimization

The Humanistic Charting questionnaire developed in Phase 2 was piloted in multiple health care settings. Pre- and post- surveys were collected from patients and key informant interviews were conducted with participating HCWs to obtain feedback on the tool design and information presentation. Currently ongoing.

MEASURES OF SUCCESS: The development of the Humanistic Charting Questionnaire using patient voice and patient choice as a first iteration of a novel process of patient-driven data collection.

Piloting of this tool in health care settings including: UCSF: Parnassus Emergency Department

NYC H+H: Harlem Hospital, Bellevue Hospital, Correctional Health Services

FINDINGS TO DATE: Of the 38 participants interviewed in Phase 1, only two felt their vision of themself aligns with how they feel seen in health care settings. Participant discussion of care experiences, barriers to care, social drivers of health, and treatment preferences illuminated a critical void in information accessible to HCWs. Initial findings from pilots demonstrate e overwhelmingly positive feedback from both patients and HCWs regarding information collected in the tool and its presentation. Considerations to establish and scale Humanistic Charting include integration into the electronic medical record, patient-barriers in tool utilization (e.g. primary language, literacy, computer/technology access), and modification to fit different populations.

KEY LESSONS FOR DISSEMINATION: With increasingly standardized health care encounters, too often we neglect to collect person-centered information. Working with patients—the true experts of themselves and effective care improvement—we designed an alternative method of data collection. Humanistic Charting is an innovative process of collecting information to enable HCWs to tailor the care provided to meet the individual needs of the person being cared for and, ultimately, improve health outcomes.

IDENTIFICATION OF PATIENTS EXPERIENCING HOMELESSNESS IN THE ELECTRONIC HEALTH RECORD—TOWARDS A MORE INCLUSIVE DEFINITION

Sarah A. Stella^1,2; Rebecca Hanratty⁵; Laura Podewils^3,4; Amy Keith³; Rachel Everhart⁵

¹Department of Medicine, Denver Health, Denver, CO; ²Department of Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ³Office of Research, Denver Health, Denver, CO; ⁴Colorado School of Public Health, Aurora, CO; ⁵Ambulatory Care Services, Denver Health, Denver, CO. (Control ID #3875042)

STATEMENT OF PROBLEM/QUESTION: People who lack stable housing experience fragmented care that is inefficient, expensive, and poorly coordinated across multiple healthcare and social service providers, and have worse health outcomes across a broad range of health indicators.

DESCRIPTION OF PROGRAM/INTERVENTION: There is a critical need for integrated data systems and tools to identify, coordinate care, and track outcomes for patients experiencing homelessness (PEH) across the continuum of care. We created an electronic health record (EHR) registry of PEH within a vertically integrated safety-net healthcare system. In creating this registry, we aimed to develop a more comprehensive and inclusive definition of homelessness through incorporation of additional indicators of homelessness available within the EHR beyond standard registration identifiers (i.e., check box or keyword “homeless” in address field). These indicators included geocoded data for addresses corresponding to regional emergency shelters, clinical diagnosis codes (i.e., Z codes), and relevant data on housing status from inpatient nursing, care management assessments, or outpatient health-related social needs screening

MEASURES OF SUCCESS: We conducted chi square analyses to compare sociodemographic and clinical characteristics of PEH identified in calendar year 2021 through newly incorporated EHR indicators versus those identified through standard registration processes alone. Multi-variable analyses were conducted to assess the association between method of identification of PEH (new indicators vs. standard indicator) and outcomes including utilization of the safety-net healthcare system, contact with homeless service providers in the Homeless Management Information System (HMIS), and mortality.

FINDINGS TO DATE: A total of 10,903 unique patients met the registry definition of homelessness in 2021, the majority (8400 individuals,77%) of whom were identified through only one data source, and 2512 (23%) more patients than identified through standard registration processes alone. Net new patients identified by additional indicators were more likely to be women (41.5% vs 24.8%, p<0.0001), differed by race/ethnicity (p<0.0001, Black: 24.8% vs 18.4% and Hispanic/Latinx 30.4% vs 25.0%), and were less likely to have a substance use disorder diagnosis (39.4% vs 54.3%, p<0.0001) but more likely to have a mental health diagnosis (56.1% vs 42.3%, p<0.0001). As compared to the PEH identified through standard registration processes alone, the newly identified PEH were less likely to be engaged with homeless services within HMIS (OR 0.69, 95% CI 0.63-0.77) despite experiencing similar rates of hospitalization in the past year and death.

KEY LESSONS FOR DISSEMINATION: Commonly utilized methods of identifying PEH within the EHR through information collected during patient registration processes may underestimate the true prevalence of homelessness. Recognizing alternate ways to identify PEH within the EHR may more comprehensively and inclusively identify PEH in need of intervention.

IDENTIFYING AND ADDRESSING BARRIERS TO PRIMARY CARE ACCESS IN THE EMERGENCY DEPARTMENT: A COMBINED PILOT APPROACH USING A SOCIAL NEEDS SCREENING TOOL AND COMMUNITY HEALTH WORKERS

Wenqiao Wang¹; Alexander L. Chu²; Vishal Patel²; Shreya Ahuja²; Brenda Garza^3,1; Snehal Patel⁴; Andrew Coyne⁶; Lawrence H. Brown⁶; Brandon S. Altillo⁵

¹Department of Population Health, The University of Texas at Austin Dell Medical School, Austin, TX; ²Department of Medical Education, The University of Texas at Austin Dell Medical School, Austin, TX; ³Health and Equity Department, The University of Texas at Austin, Austin, TX; ⁴Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; ⁵Population Health, The University of Texas at Austin Dell Medical School, Austin, TX; ⁶The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #3874761)

STATEMENT OF PROBLEM/QUESTION: At a high-volume academic safety net hospital in the southern region, there is no standardized process for identifying and following up on patients discharged from the emergency department (ED) with significant barriers to accessing primary care services.

DESCRIPTION OF PROGRAM/INTERVENTION: This protocol is a two-phase project that aims to facilitate access to primary care among patients being discharged from the ED. The first phase involves developing and piloting a social needs screening tool that evaluates how and to what extent various major social determinants may directly impact each patient’s ability to connect with a primary care physician (PCP). The tool was developed from existing, validated social needs assessment tools and modified so that it can be feasibly administered in an ED setting. The project is set to screen 200-300 patients age 18+ between February and June 2023.

The second phase aims to use data from the triage process to identify patients with significant social barriers and connect them with community health workers (CHWs) for primary care navigation and resource assistance. This involves deriving a social needs criteria by which patients with significant social barriers may be referred for and allocated CHW assistance.

MEASURES OF SUCCESS: Measures of success for the first phase of this project include:

- Improved understanding of the sociodemographic and clinical characteristics of our target population including their barriers to care

- Minimal impact on ED operational metrics including flow time of a patient through the ED Measures of success for the second phase of the project include:

- Increased proportion of patients scheduling appointment with a PCP within 30 days following ED discharge

- Patient-reported improvements in their barriers to care and ability to access their PCP

- Cost-savings analysis demonstrating reduced ED utilization in CHW-assisted cohort

FINDINGS TO DATE: An existing inpatient pilot program utilizes CHWs to help hundreds of patients with care coordination and health-related social needs. Our project will extend this program into the ED setting to better serve this population. To date, the first complete version of the social needs screening tool has been completed and reviewed by ED staff, inpatient hospitalists, and CHWs. The screening process is expected to take less than 10 minutes on average with minimal impact on ED operations. The project is currently awaiting IRB approval prior to pilot implementation in early 2023.

KEY LESSONS FOR DISSEMINATION: Few EDs in the US routinely screen for social barriers to primary care access and provide post-discharge follow-up and CHW assistance. Developing methods to screen for social barriers in the ED can be a practical and cost-effective means of identifying vulnerable patients that may benefit from long-term primary care management. Deploying CHWs in the ED setting can help redefine care delivery by directly addressing the systemic structural and social barriers to accessing primary care.

IDENTIFYING HEALTH EQUITY GAPS: A 12-MONTH LOOK BACK OF PRIMARY CARE HYPERTENSION METRICS IN AFRICAN AMERICAN AND LATINO POPULATIONS IN MID- ATLANTIC ATLANTIC REGION

Ricardo Jaime Orozco, Jenna Guma, Keshia Toussaint, Alexander Garcia, Savannah Faith Pedersen, Elizabeth L. Lee, Ami Joshi

Internal Medicine, Cooper University Health Care, Camden, NJ. (Control ID #3873218)

STATEMENT OF PROBLEM/QUESTION: Hypertension (HTN) is the leading preventable risk factor for cardiovascular disease (CVD) and all-cause mortality worldwide. Despite guidelines, there remains a significant difference in prevalence blood pressure (BP) control rates among different races and ethnicities. DESCRIPTION OF PROGRAM/INTERVENTION: CH is an academic medical center and accountable care organization where the HTN control metric is a Merit-based Incentive Payment System (MIPS) quality measure from CMS. It is met by if a patient (age 18+) with a history of HTN has BP 140/90 and below at any CH office visit (including subspecialty offices). In line with the much-needed national momentum to improve racial health disparities, CH has strategically added to our goals to include assessment of health quality gaps in our quality metrics. In 2021, CH began to measure any racial differences of the 3 largest racial populations of our primary care practices in SJ for 12 months. Patient communities represented a mix of urban, low- income cities and higher income suburban regions within SJ.

MEASURES OF SUCCESS: We identified a statistically significant difference with patients that identify as African American and Hispanic not passing the HTN control metric when compared to those to identify as White. White patients had 51% greater odds of passing the metric than Black patients. (95% CI 44 to 60% greater odds) and 30% greater odds of passing than Hispanic patients (95% CI 21% to 39% greater odds).

Following these results, primary care providers (in Internal Medicine and Family Medicine) were surveyed into the perceived barriers to reaching blood pressure. Providers were asked to rank the barriers with regards to the metric of BP control in African American and Hispanic populations.

FINDINGS TO DATE: The results were as follows: (ranked by total weighted average): non-adherence to medication 7.20, poor diet 7.06, poor health literacy of the patients 6.10, cost of medications 5.47, lack of prescription drug coverage for medications 4.78, unstable or inadequate housing/living conditions 4.16, poor working conditions for patient 3.67, taking the BP only once during an office visit 3.24, inaccuracy of the BP measurement during the office visit 3.22. There was also an optional free text response with one of the highest additional barriers identified by providers was language barriers.

KEY LESSONS FOR DISSEMINATION: This project highlights a how honing in on racial differences in primary care quality metrics can identify a health equity gap within a population. Additional takeaway for further implementation demonstrates how addressing a health care inequity must meet directly at the level of the providers as well as the patients. The next direction of this project includes surveying patients inquiring about their perceived barriers to hypertension control so that we can best decide an intervention that takes both patient and provider perspectives into account to maximize impact on our communities.

IDENTIFYING SOCIAL RISKS AND AUTOMATING DESIRED CONNECTIONS TO COMMUNITY SUPPORT VIA UNIVERSAL SOCIAL DETERMINANTS OF HEALTH (SDOH) SCREENING IN PRIMARY CARE (PC) WITHOUT ADDING WORK TO FRONT LINE TEAMS Lauren Galpin¹; Sheridan Green²; Arturo C. Madrid³

¹Primary Care, Colorado Permanente Medical Group, Denver, CO; ²Kaiser Permanente Colorado Institute for Health Research, Aurora, CO; ³KPCO Medicaid Care Delivery, Kaiser Permanente, Denver, CO. (Control ID #3875525)

STATEMENT OF PROBLEM/QUESTION: Does SDOH screening at well visits vs. any PC visit find different levels/patterns of SDOH risks, or levels of desired support?

DESCRIPTION OF PROGRAM/INTERVENTION: Our Western US healthcare system serves >500K members in 31 outpatient medical office buildings (MOB). 67% have commercial coverage, 21% Medicare, 8% Medicaid, 3% military, and 1% Children’s Health Insurance Plus. Before 2021, 7 Community Specialists (CS) connected at-risk members with community support via a provider-dependent, under-utilized referral- based system.

To find more members with social risks who want support, we began universal SDOH screening in 2021. We use standard questions from Epic with uniform data display in charts, and automate connection to CS for any patient who wants support. We limit screening to 4 SDOH (finance, transport, food, housing) as those domains' questions are the same for all ages and addressing them is within the scope of CSs. Screening in well visits went live at 2 PC MOBs 4/13/21. Auto-assigning the screener allows completion online prior to the visit, or via a tablet at the visit if not done prior. The screener has 8 questions to find risks, and 1 to assess desire for support. Any patient wanting support is automatically put on a report reviewed by CSs and outreached in 3-5 days. This happens without PC provider or staff work.

Due to the pilot finding lower risk levels than found in a 2020 survey, we changed auto-assign logic at 1 MOB on 4/8/22 to assign to any PC visit while 29 MOBs continued screens only at well visits

MEASURES OF SUCCESS: Screens done by MOB, coverage, race, ethnicity, language preference Of those screened, % at risk for any SDOH, % at risk for specific SDOH, % request outreach, with comparison between MOBs doing well-visit vs. any-visit screening

% MOB population screened

% outeach requests resulting in contact

Screening modality

Provider and patient experience

FINDINGS TO DATE: 4/8/22-12/1/22: 57544 PC screens completed; 6895 at 1 MOB doing any-visit screens (16% linked members) and 50649 at 29 MOBs doing well-visit screens (5% linked members)

Well-visit screens (29 MOBs):17% with at least 1 area at risk, 12% finance, 8% food, 6% housing, 2%

transport, 3% requested outreach

Any-visit screens (1 MOB): 22% with at least 1 area at risk, 16% finance, 11% food, 8% housing, 4% transport, 5% requested outreach

Steady monthly screening rates suggest sustainability of workflows

Providers concerned about screens adding time to visits found screens can be done outside their time in the visit. Most screens done online before visits

KEY LESSONS FOR DISSEMINATION: SDOH screening at only well visits reaches fewer patients with fewer risks who are less likely to request support.

Automated patient-desired connection to support reduces provider and staff work.

Displaying social risks in charts helps contextualize care plans and avoid plan failures due to identifiable barriers.

Standard SDOH screens with auto-connection to community support improves care and invites community- based partners to participate in healthcare.

IMPACT OF TELEHEALTH ON APPOINTMENT COMPLETION BEFORE AND AFTER THE COVID-19 PANDEMIC ACROSS PATIENT RACE AND ETHNICITY

Samuel O. Schumann, Courtney Kramer

Internal Medicine, Medical University of South Carolina, Charleston, SC. (Control ID #3877327)

STATEMENT OF PROBLEM/QUESTION: What was the effect of telehealth on appointment completion rate before and after the COVID-19 pandemic and comparing this effect across patient races / ethnicities from March 2019 through February 2021?

DESCRIPTION OF PROGRAM/INTERVENTION: The rapid expansion of telehealth due to the COVID-19 pandemic lead to a great experiment of whether the United States could scale its delivery of virtual healthcare. As the pandemic highlighted many issues of racial / ethical healthcare disparities, concerns were raised that telehealth widened disparity gaps because telehealth technology was not equally available to all people. This study examined the appointment completion rate at one academic internal medicine practice in the southern region stratified by race / ethnicity.

MEASURES OF SUCCESS: The primary measure of success was appointment completion percentage comparing in-person to telehealth appointments. Telehealth appointments were further sub-characterized as telephone or video visit. All appointments were then stratified by race / ethnicities, sex, age, and distance from the medical center.

FINDINGS TO DATE: 51,727 unique encounters at the aforementioned academic internal medicine practice were identified from March 2019 through February 2021. Appointment completion percentation in the pre-COVID era from March 2019 - February 2020 was 84.7% and appointment completion percentage in the post-COVID era from March 2020 - February 2021 was 87.3%. Non-black patients completed 93.2% of their encounters while black patients completed 82.3% of their encounters at UIM (p-Value < 0.001). In the post-COVID era Black patients (69.1%) more frequently scheduled in-person office visits than non-black patients (67.5%). Non-black patients (32.5%) more frequently scheduled telehealth visits, compared to black patients (31%). With regards to telehealth visits, non-black patients (27% ) more frequently schedule video visits compared to black patients (20.7%). 50.2% of black patients live in areas of poverty compared to

24.2% of non-black patients. Compared to non-black patients who made office visits, black patients who made telephone visits were 1.6 times (OR = 1.6, 95% CI: 1.18 – 2.256) more likely to complete this appointment.

KEY LESSONS FOR DISSEMINATION: Telehealth can be used to scale healthcare delivery in internal medicine practice without a drop in appointment completion percentage. Maintaining video visits and telephone visits is an important consideration to prevent widening healthcare disparities when using telehealth.

IMPLEMENTATION AND EVALUATION OF AN INNOVATIVE INPATIENT SOCIAL WORK- LED INTERVENTION FOR PATIENTS EXPERIENCING HOMELESSNESS

Erin Bredenberg¹; Michael Castallarin²; Amanda V. Johnson³; Sarah Mann³; Lauren McBeth³; Gregory Misky³

¹Hospital Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ²Hospital Medicine, VA Eastern Colorado Health Care System, Aurora, CO; ³Division of Hospital Medicine, University of Colorado School of Medicine, Denver, CO. (Control ID #3877307)

STATEMENT OF PROBLEM/QUESTION: Homelessness is a major public health issue and prevalence has increased since the onset of the COVID-19 pandemic. People experiencing homelessness (PEH) frequently have increased utilization of health services compared to their housed counterparts, including higher rates of hospitalization, increased hospital readmissions rates, and longer lengths of stay. To address the complex medical and social needs of PEH, hospitals must invest in creative programs to holistically support this vulnerable population. Here, we describe a novel hospital-based program to address the needs of PEH and present results of a qualitative program evaluation.

DESCRIPTION OF PROGRAM/INTERVENTION: In July 2021, a novel hospital-based social work-led housing transitions team (HTT) was implemented at a 678-bed academic hospital in a major metropolitan area of the United States. The HTT consists of three full-time social workers and a social work leader. HTT social workers liaise with partners in the community, directly engage with a subset of PEH with high healthcare utilization during a hospital stay, and provide guidance and support on housing-related issues for inpatient and outpatient social workers at the institution.

MEASURES OF SUCCESS: Quantitative Measures: We report the number of patients enrolled in the program during the first year and the number able to obtain stable housing as a result of engagement with the HTT.

Qualitative Evaluation and Analysis: One year after implementation of the HTT, we conducted a qualitative evaluation of the program’s impact. We created a semi-structured interview guide based on the Practical, Robust Implementation and Sustainability Model (PRISM). We interviewed 15 involved parties: three members of the HTT social work team, three social workers on other specialty services at the hospital, three patients who were served by the HTT, three social work administrators at the hospital, and three community partners in housing-related organizations. Qualitative results were analyzed using rapid qualitative methods.

FINDINGS TO DATE: Quantitative results: Between 10/2021-09/2022, the HTT was directly or indirectly involved in the care of 242 patients. Ten patients were able to obtain stable housing as a result of engagement with the HTT.

Qualitative results: Interviewees identified areas of success in two major domains: patient-related and institutional or systems-related. Patient experience was felt to improve in the form of improved trust in the healthcare system via the development of longitudinal relationships with HTT members, as well as improved coordination of care post-hospital discharge. Institutional- and systems-level impacts were manifested by strengthened relationships between the hospital and community organizations. Overall, interviewees were extremely positive about the impact of the HTT.

KEY LESSONS FOR DISSEMINATION: Novel strategies are needed to address the impacts of homelessness among hospitalized patients. Our program can serve as a model of one way to address the complex needs of this population

IMPLEMENTATION OF A LOCAL COMMUNITY WEB SITE DURING THE COVID-19 PANDEMIC, 2020-2022

Michael Vaysblat¹; Suhwoo Bae²; Pushpendra Patel³; Jason Lazar⁴

¹Medicine, North Shore University Hospital, Manhasset, NY; ²Internal medicine, Northwell Health, New Hyde Park, NY; ³Internal Medicine, Northwell Health, New Hyde Park, NY; ⁴Cardiology, SUNY Downstate Health Sciences University, New York City, NY. (Control ID #3876988)

STATEMENT OF PROBLEM/QUESTION: Our main objective was to provide the community of East Flatbush with a resource that informed them of the latest COVID-19 guidelines and resources locally available to address socioeconomic issues stemming from COVID-19.

DESCRIPTION OF PROGRAM/INTERVENTION: We created a website to serve as a central information relay for our local community in East Flatbush during the height of the COVID-19 pandemic in New York City. We launched COVIDBrooklyn.com in March 2020 to provide a current and easy-to- understand

resource on COVID-19. Studies have found an increasing trend in published health-related misinformation, with social media serving as a significant catalyst. We aimed to mitigate the rampant spread of misinformation on COVID-19 by serving updated information on guidelines from reliable sources including the New York City Department of Health and the Center for Disease Control and Prevention. We also provided information on community resources that were locally available during the height of the pandemic including food, housing, homeschooling, mental health, domestic violence, and financial support. The website was created by medical students spearheading a COVID Response movement in the setting of a new and ongoing pandemic.

MEASURES OF SUCCESS: We evaluated the implementation of our website using various modalities, including Google Analytics and surveys e-mailed to our visitors after subscribing to our newsletter. FINDINGS TO DATE: Over the website’s lifetime, Google Analytics reports 10,849 unique visitors with 19,284 page views. The number of views peaked in April-August 2020 at roughly 2,000 – 3,000 visitors per month, compared to subsequent months and years. Traffic peaked during media-reported waves of COVID-19, with 80% of referrals coming from accession via direct link, 15% via social media such as Facebook and Twitter, and 5% from search engines such as Google. Out of 857 e-mailed surveys ranging from April 2020 to July 2022, 259 responded yielding a 30.2% response rate. The survey included a “yes or no” question asking whether the reader had any difficulty understanding the information presented on the website, with 94% responding “no”.

KEY LESSONS FOR DISSEMINATION: Creating a functional website in a short span of time proved to be a challenge, but attracting our intended audience proved to be the most difficult. Our approach focused on community events where the website was discussed and flyers showcased its presence. Word-of-mouth drove most of our viewership as it came from a targeted audience that was motivated to learn more about COVID-19. Social media also played a role in driving visitors to the website as many community members shared the website on their personal social media pages. From our competitors, the best-performing platforms invested significant funding in advertising, which was one limitation of our project. Another major consideration of this project was the reading level of the audience. We targeted a 5th-grade reading level, as recommended by the Joint Commission for patient education materials.

MEDICAL STUDENT-LED INITIATIVE TO CLOSE THE DIGITAL DIVIDE IN HEALTHCARE Hannah Tang¹; Yilan Jiangliu¹; Michelle Lazar¹; Eileen C. Liu¹; Saaz Mantri¹; Edwin Qiu¹; Breanne Biondi²; Rebecca Mishuris^3,1; Pablo Buitron de la Vega^3,1

¹Boston University School of Medicine, Boston, MA; ²Boston University School of Public Health, Boston, MA; ³General Internal Medicine, Boston Medical Center / Boston University, Boston, MA. (Control ID #3874799)

STATEMENT OF PROBLEM/QUESTION: Is it feasible to identify and address patients’ digital health needs in primary care?

DESCRIPTION OF PROGRAM/INTERVENTION: The COVID-19 pandemic caused an accelerated digital transformation in healthcare that exacerbated existing disparities for marginalized communities. Data from Boston Medical Center (BMC), an academic safety-net hospital, showed that from April 2020 to May 2021, 46,023 patients with chronic illnesses had a digital health encounter scheduled. However, 17.6% of these patients did not have a telehealth-supported device and 18.5% did not have a device with internet. Thus, in June 2021, Boston University medical students began an initiative in 3 outpatient adult primary care clinics to help patients activate and navigate MyChart (online patient portal), connect patients with subsidized internet and phone services via the federal Affordable Connectivity Program (ACP), orient patients to telehealth digital applications, and refer to community-based digital literacy courses. To identify patient needs, students outreached patients during clinic visits and followed up by phone. Then, students used the BMC Thrive Directory, an online HIPAA-compliant community resource platform, to connect patients with programs and track outcomes metrics.

MEASURES OF SUCCESS:

Metrics included the number of patients:

- Outreached per month

- Requesting help for MyChart; with active accounts; and comfortable using the portal

- Requesting subsidized internet

- Requesting digital literacy training; connected to and enrolled in a class

FINDINGS TO DATE: Number of patients outreached increased from 5 per month in 11/2021 to 70 per month in 10/2022. From 11/2021 to 10/2022, 296 total patients were helped. Of those, 258 requested MyChart support; 95% now have active accounts and 94% feel comfortable using the portal. 57 requested subsidized internet support. 17 requested community-based digital training, of which 10 connected and 1 enrolled. Number of outreach staff increased from 8 to 16 from 11/2021 to 11/2022, allowing ongoing expansion to all adult primary care, including women’s health and refugee clinics.

KEY LESSONS FOR DISSEMINATION:

1) Use training videos and in-person shadowing to expedite student onboarding and standardize workflow

2) In-person support is more effective compared to phone calls due to increased patient engagement, process efficiency, and clinic staff involvement in referring patients

3) Community organizations lacked adequate resources to meet needs for digital literacy training

4) Since patients face multiple barriers after completion of the ACP application, having direct relationships with local internet providers and conducting phone follow-ups will help close the loop to ensure successful enrollment

5) Incorporate multiple languages into flyers, and utilize time in waiting rooms, exam rooms, and checkout areas for patient outreach

6) Collaborate with front desk staff, interpreters, medical assistants, and patient navigators, as well as medical, social work, and public health students to provide a multidisciplinary service-learning opportunity

MORE THAN A FOOD BANK: ADDRESSING FOOD INSECURITY ONE HEALTHY FOOD CENTER AT A TIME

Elizabeth Cuevas, Colleen Ereditario, Leanna Bird, Tori Vallana, Margaret Palumbo

Internal Medicine, Allegheny Health Network, Pittsburgh, PA. (Control ID #3877151)

STATEMENT OF PROBLEM/QUESTION: Growing evidence shows that social determinants of health (SDOH), including food insecurity, negatively influences health outcomes and leads to health inequities. DESCRIPTION OF PROGRAM/INTERVENTION: Five hospitals within a multi-hospital health system network in the mid-Atlantic region opened five Healthy Food Centers (HFC). They opened to bridge meal gaps by providing readily accessible and healthy food; to support lifestyle change through 1-on-1 nutrition education with a RD; to improve chronic conditions; to reduce medical complications; and to lower overall healthcare costs. Simultaneous to HFC implementation, the health system also began routine SDOH screening, including screening for food insecurity (FI) with the Hunger Vital Sign 2-question screen in the ER, inpatient setting, and in primary care offices. Providers were able to place a referral to the HFC in the EMR for patients who screen positive for FI. Patients were able to visit any HFC monthly to be assessed for nutritional needs, household FI, and other SDOH needs. Participants received food for the entire family with frequent emphasis on food needs for pregnant women, breastfeeding mothers, and those living with diabetes and heart disease. Staff also coordinated connections to community resources and were provided transportation access, cooking utensils, recipes, and prescription produce coupons.

MEASURES OF SUCCESS: Measures of success include total number of patients served, total number of household members served, and total number of meals provided. In addition, a post-food distribution patient satisfaction survey was conducted to ask patients about the utility of the food and impact on health and well- being. Finally, for patients who sought out services at the Healthy Food Center for at least 6 months, clinical metrics were collected including Hba1c, BP, and lipid panels to look for health impact in patients.

FINDINGS TO DATE: Over a 5 year period, 9,000 individual patients and 19,000 total persons (including patients and household members) were served, equating to over 190,000 meals distributed. Additionally, over 4,000 backpacks were made and handed out through a backpack program for children and seniors during the summer months. 86% of patients surveyed said it reduced their barriers to healthy food access and made them feel their provider was concerned about their nutrition status. 90% of HFC participants believe the program helped them obtain access to fresh fruits and vegetables and improve their health and well-being.

In terms of clinical metrics, patients with severe DM (Hba1c >9) had average Hba1c decrease of 1.2. For those with hyperlipidemia, patients with moderate disease (total cholesterol between 200-240) had an average 20-point reduction, and patients with higher levels of total BP by almost 10 points.

KEY LESSONS FOR DISSEMINATION: Screening patients for food insecurity is critical to impacting patients’ overall health. A hospital-embedded healthy food distribution center can make an impact on food insecurity and healthy food access in a local community.

REDUCING SEX DISPARITIES IN APPROPRIATE STATIN PRESCRIBING

Sheida Aalami^1,2; Melanie Green²; Jennifer Tunoa²; Jennifer Mecca²; Montana Halloway²; Anders Chen^1,2

¹General Internal Medicine, University of Washington System, Seattle, WA; ²VA Puget Sound Health Care System Seattle Division, Seattle, WA. (Control ID #3875238)

STATEMENT OF PROBLEM/QUESTION: Despite recommendations that all persons with diabetes take a statin to reduce the risk of atherosclerotic cardiovascular disease (ASCVD), review of data at a Northwest Region Veterans Affairs (VA) Medical Center revealed that female veterans with diabetes are prescribed statins at lower rates than their male counterparts.

DESCRIPTION OF PROGRAM/INTERVENTION: Review of the VA’s Electronic Quality Metric Portal (eQM) and Primary Care Equity Dashboard revealed that female veterans with diabetes at a Northwest Region VA Medical Center are prescribed statins at 6% lower rates than their male counterparts. This trend has persisted for the past two years and is consistent with national VA trends.

We assembled a multidisciplinary team and created a standard template for counseling on ASCVD risk reduction including statin recommendations, teratogenic medication counseling, and non-pharmacological recommendations. We downloaded the list of female veterans with diabetes who did not have an active statin prescription using the VA’s statin 7_EC measure, consistent with the Healthcare Effectiveness Data and Information Set (HEDIS) measure. We performed a focused chart review and telephone outreach to these veterans over a four month period.

MEASURES OF SUCCESS: We tracked the VA’s statin 7_EC metric stratified by sex. We also tracked outcomes for the specific veterans for whom chart review and outreach were performed.

FINDINGS TO DATE: Excluding veterans who did not have diabetes (current data definitions inappropriately include veterans taking antihyperglycemic medications for non-diabetes indications), had relocated, had a community care primary care provider, or were unable to be reached, outcomes are shown below.

Total female veterans failing eQM measure at beginning of intervention 176

Excluded from Intervention 100

Started on statin by outreach team 3

Started on statin by primary care team 9

Contraindicated 4

Declined 43

The disparity between performance on the statin7_EC in females and males closed since the beginning of our intervention, from 5.9% to 4.1% and was sustained over the 4 months since the beginning of the intervention. There was no change in the National VA disparity (7% to 7.1%).

KEY LESSONS FOR DISSEMINATION: The primary drivers for the improved performance relate to

administrative updates; properly documenting outside statin prescriptions and renewing expired medications. A small number of female veterans did choose to start a statin after our intervention and counseling.

Our data do not suggest substantial increase in statin prescribing from registry-based outreach and counseling. Reflections from clinical team members suggest that very few of the targeted patient population had not already received appropriate recommendations and counseling. Demographically, our female veteran population with diabetes is younger than our male population. This patient population has additional medication considerations including teratogenicity and, with different risk-benefit considerations, may choose to decline statins for ASCVD risk reduction.

THE EQUITY GAP AS SPECIAL CAUSE VARIATION, CLINICIAN-INITIATED OUTREACH Hadeel Alkhairw, Ekwutos Pauline Nwez, Michelle M. Lam, Joan Russo, Amy Harris, Rand A. David

Elmhurst/Ambulatory Care, New York City Health and Hospitals Corporation, New York, NY. (Control ID #3870702)

STATEMENT OF PROBLEM/QUESTION: Improve hypertension control rate for African American/ Black patients

DESCRIPTION OF PROGRAM/INTERVENTION: Our clinic, located in a heavily populated urban area, is hospital-based. Our patients are mostly Hispanics and South Asian immigrants. A small percentage of our patients are African Americans/ Black. We have a robust population health program and apply racially stratified continuous monitoring of chronic disease metrics like hypertension and diabetes control rates and quality of care indicators. The chronic disease team consists of clinical and non-clinical team members, including community health workers (CHW) and outreach staff. Our team identified a lag in the African American/ Black patients outcome improvement rate compared to the average clinic rate, resulting in a 5% gap (Chi-Square X^2 = 7.33, P value = 0.006). We utilized nurse practitioner-led phone visits for African American/ Black patients with uncontrolled HTN (n=50). The Nurse Practitioner is an African American/ Black immigrant who received training in empathic communication. 17 patients were able to check their blood pressure at home and provide readings that were deemed controlled. 33 patients were found to have uncontrolled hypertension or no access to blood pressure monitors, 10 of those patients were scheduled for same-day visits with the nurse practitioner, and 12 received appointments with their primary care clinicians. Patients were all offered nurse education appointments or enrollment in the CHW program as needed to meet their needs.

MEASURES OF SUCCESS: The project resulted in 1.5% improvement in the African American / Black patients' control rate on the population level (n= 311) in 2 months (Chi-Square X^2= 3.7 P-value = 0.05).

FINDINGS TO DATE: Racial stratification may be interpreted as a special cause variation of a healthcare delivery process involving system factors, population factors, or both. To reduce gaps, we need a new process to bring equitable outcomes regardless of the population size in that practice or the impact on the average outcome of all populations combined. Outreach by a culturally congruent clinician and reducing steps and time to access care, successfully addressed racial disparities for a historically marginalized population.

KEY LESSONS FOR DISSEMINATION: 1- Racial stratification may be interpreted as a special cause variation of a healthcare delivery process

2- Cultural congruity assists in engaging patients from racial minorities and marginalized population

3- Population stratification should result in an individualized, targeted approach to achieve equity.

UCONN HEALTH LEADERS: TRAINING THE NEXT GENERATION TO ADDRESS THE SOCIAL DETERMINANTS OF HEALTH

Christopher Steele¹; Henry siccardi¹; jacqueline Steele²; Zoha Sarwat¹; Erin Cova¹; Nivedha Natchiappan¹; Veronica Schmidt¹

¹University of Connecticut School of Medicine, Farmington, CT; ²Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #3848076)

STATEMENT OF PROBLEM/QUESTION: What impact can volunteers have on identifying and addressing social determinants of health (SDoH) for patients and how do they compare to trained medical staff?

DESCRIPTION OF PROGRAM/INTERVENTION: There are many barriers in a typical workflow that prevent providers from adequately screening patients for the SDoH. One solution is to involve students interested in medical careers to both perform the screening and address the barriers identified. To date, no study has described the impact volunteers have on screening for the SDoH and how effective they are compared to trained medical staff.

The University of Connecticut Health Leaders (UCHL) is a novel program that recruits volunteers interested in pursuing health careers and trains them to perform the SDOH screening with patients in both outpatient and inpatient settings. Each volunteer uses a pre-populated screener that includes questions on educational attainment, employment status, housing, access to food, utilities, childcare, cost of medications, transportation, insurance status, smoking status, veteran status, history of incarceration and preferred language. For those patients who screen positive, the screener automatically populates vetted resources in the community that address their barrier identified and the volunteer connects these patients to the resource during their visit. Those provided resources receive a check-in call to determine if they need further assistance at a later date. Ultimately, the screening information is passed on to the patient's care team. MEASURES OF SUCCESS: Measures of success are the number of patients screened, what percent screened positive, what resources were most accepted and ultimately, how well our volunteers identified SDoH barriers compared to trained medical staff.

FINDINGS TO DATE: From September 2021 to May 2022, volunteers across 3 clinics and 1 inpatient site approached 2,591 patients and screened 2,399 for SDoH. Of those screened, 1,130 (47%) had at least one SDoH related need and of those, 687 (61%) were interested in receiving resources. The most commonly identified SDOH needs were unemployment (18%), transportation (10%), preferred language other than English (10%), and housing insecurity (10%). The most accepted resources related to food insecurity (77%), medication cost reduction (69%), transportation (67%) and housing (60%).

Volunteers at one clinical site (n=523) were compared to the standard process for screening SDoH involving trained medical assistants (n=103). Except for primary language, UCHL volunteers were less likely to have missed patients for screening and identified more patients with SDoH needs with respect to unemployment, level of education, food insecurity, housing stability and transportation.

KEY LESSONS FOR DISSEMINATION: This is the first study of its kind to demonstrate that volunteers without formal medical training can effectively screen and address SDoH for patients. Programs like this may offer a novel way to get those interested in medical careers involved in patient care while improving our ability to address the SDoH.

UTILIZING CLINICAL PATHWAYS TO FACILITATE THE PROVISION OF GENDER AFFIRMING CARE IN PRIMARY CARE

Danielle F. Loeb^1,2; Micol Rothman³; Laura Macke⁴

¹Division of General Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY; ²Division of General Internal Medicine, University of Colorado, Denver, CO; ³Department of Endocrinology and Department of Radiology, University of Colorado, Denver, CO; ⁴General Internal Medicine, University of Colorado, Denver, CO. (Control ID #3875788)

STATEMENT OF PROBLEM/QUESTION: Primary Care Providers (PCP) report wanting to provide gender affirming care for transgender and gender diverse patients. However, the vast majority report the barriers of knowledge in the provision of care and familiarity with guidelines.¹

1) Shires DA, Stroumsa D, Jaffee KD, Woodford MR. Primary Care Clinicians’ Willingness to Care for Transgender Patients. The Annals of Family Medicine. 2018;16(6):555.

DESCRIPTION OF PROGRAM/INTERVENTION: As a part of a larger program of implementing gender affirming care in an academic medical system in the Mountain West, we developed Clinical Pathways for masculinizing and feminizing gender affirming hormone therapy. The Pathways were made available March 2022 to all primary care providers (PCPs) across the healthcare system, including family medicine, internal medicine, women’s health, and seniors. Additionally, attending physicians and residents in three general internal medicine clinics in the academic group also received didactics on the provision of gender affirming hormone therapy.

The Pathways were designed by a multidisciplinary team including internal medicine, family medicine, endocrinology, and pharmacy faculty. They were programmed by a physician informaticist using AgileMD software and then integrated into the Epic electronic health record workspace for all PCPs. Providers can navigate to these optional tools within Epic to access best practices in providing gender affirming care. The Pathways include electronic flowcharts with information on how to diagnose gender dysphoria; assess risks of complications of hormone therapy; and begin and safely monitor therapy. Pathways also include links to information on how to document to support insurance requirements; referral information for relevant subspecialists (i.e. speech therapy, gender affirming surgeries, etc.); and prepopulated orders with medication dispense quantities, necessary supplies, and indications.

MEASURES OF SUCCESS: We tracked usage of the Pathways, including the number of distinct users and the number of times each pathway was used.

We plan to evaluate prescribing patterns of users pre- and post- Pathway implementation to evaluate the correlation with Pathway use and patterns in prescribing gender affirming therapy. Among those who attended didactic sessions, we will compare prescribing patterns between those who used the Pathway and those who did not.

FINDINGS TO DATE: In the first eight months of use, the Feminizing Gender Affirming Care pathway was used by more than 60 distinct users over 230 times. In the same period, the Masculinizing Gender Affirming Care pathway was used by more than 50 distinct users over 150 times.

KEY LESSONS FOR DISSEMINATION: Clinical tools such as Pathways may decrease barriers to providing care to vulnerable populations, such as transgender and gender diverse patients. Pathways show promise in improving care delivery for other conditions commonly encountered in primary care.

Innovation in Healthcare Delivery (IHD) - Geriatrics and Palliative Care

EVALUATION OF COGNITION IN PRIMARY CARE: A PROGRAM TO INCREASE EARLY DETECTION AND MANAGEMENT OF DEMENTIA

Jaqueline Raetz¹; Annette L. Fitzpatrick¹; Basia Belza³; Sarah McKiddy³; Christina Park⁴; Barak Gaster²

¹Family Medicine, University of Washington, Seattle, WA; ²General Internal Medicine, University of Washington, Seattle, WA; ³School of Nursing, University of Washington, Seattle, WA; ⁴School of Public Health, University of Washington, Seattle, WA. (Control ID #3874363)

STATEMENT OF PROBLEM/QUESTION: The US healthcare system is ill-prepared for the large increase in dementia and cognitive impairment projected to occur in this aging population. DESCRIPTION OF PROGRAM/INTERVENTION: Primary care urgently needs a practical, efficient way to evaluate cognitive concerns, diagnose cognitive impairment, and provide high-quality care for affected patients. To meet this need, we developed the Cognition in Primary Care (CPC) program which includes a three-part CME, clinic workflow, and electronic medical record toolset to support primary care providers (PCPs). We present the results of implementing the CPC Program across 14 community-based clinics comprising a primary care network associated with a large academic medical center.

MEASURES OF SUCCESS: Evaluation of the CPC program includes: a) a post-CME evaluation; b) a 6-month validated survey on PCP knowledge, confidence and attitudes toward dementia diagnosis and care; c) and selected metrics extracted from the electronic health record (EHR) including use of digital tools and the number of cognitive assessments uploaded.

FINDINGS TO DATE: Post-CME evaluations completed by 38 PCPs described the sessions as high quality and relevant to their practice, with intent to use the content in their practices (4.4 on 5-point scale, SD 0.9).

Results of the 6-month General Practitioners’ Attitude and Confidence Scale for Dementia (GPACS-D) revealed high scores for knowledge and confidence to evaluate cognition but lower scores on attitudes toward managing and treating dementia. Those who took the CME doubled the number of cognitive evaluations they uploaded to the EHR per month (5.8 vs. 2.7.) We found high utilization of the EHR tools that were presented in the training, with 32.6 discrete utilizations per month of one of the newly developed EHR tools. With no additional marketing of the tools outside of the training, we also found significant uptake in use of the tools by those who did not take the training, suggesting a meaningful halo effect as a result of CPC program intervention.

KEY LESSONS FOR DISSEMINATION: Provider education when combined with an efficient workflow, EMR tools, and continued support can increase rates of cognitive evaluation and provider confidence in detecting and managing dementia.

EXRX: SEATED RESISTANCE BAND EXERCISE PROGRAM FOR OLDER ADULTS

Melissa S. Lee^2,1; Vaibhavi Solanki^2,1; Amara Shafi^2,1; Scott A. McGarvey^2,1; Nadia A. Williams²; Deborah O. Akinwumi⁴; Emanuela Aligwo⁵; Mohammed A. Kadir³; Andrew Chang^2,1; Nada Akkari^2,1

¹Internal Medicine, SUNY Downstate Health Sciences University, New York City, NY; ²Ambulatory Medicine, NYCH+H/Kings County, Brooklyn, NY; ³School of Medicine , The City University of New York Department of Cell Biology and Anatomy, New York, NY; ⁴Biomedical Science, The City College of New York CUNY School of Medicine, New York, NY; ⁵Biomedical Science, City University of New York, New York, NY. (Control ID #3876416)

STATEMENT OF PROBLEM/QUESTION: Older adults in our primarily Afro-Caribbean, Mid-Atlantic urban safety-net academic primary care practice want to improve flexibility, balance and strength but lack time and resources to do so.

DESCRIPTION OF PROGRAM/INTERVENTION: In a primary care practice where over half of our patients are uninsured or medicaid-eligible, long work hours and financial stressors are barriers to regular exercise. Patients over age 65 were engaged in a low-cost, sustainable, home-based, culturally-acceptable exercise practice.

21 patients participated (57% female, 43% male) in a pre-intervention survey. 90% felt physical activity is important to their health, 33% fell in the last year, 71% exercise ≥ 3x/week, 57% exercise alone, and 67% walk for exercise. The patients desired improved flexibility (95%), balance and strength (76%) and aerobic activity (67%). Although 57% never used resistance bands, 90% wanted to learn.

MEASURES OF SUCCESS: Pre-frail (ambulating independently, no memory impairment) older adults were referred for exercise by their primary care provider. Baseline assessment using STS (30-second sit to stand) and TUG (timed up and go), FES-I (falls efficacy scale-international), IPAC (international physical activity questionnaire) and PMIS (picture memory impairment screen) was performed. Medical students and resident physicians trained in motivational interviewing (MI) assessed readiness, barriers and confidence after demonstrating a brief seated resistance band exercise program. Patients received a culturally-sensitive exercise video and printed handout.

Telephone follow up using scripted MI prompts occurred 3 times over an average of 2 months to set and follow SMART goals, beliefs, knowledge and confidence in use of the program. FES-I, IPAC, STS and patient satisfaction were repeated at completion.

FINDINGS TO DATE: 53 patients aged 63 to 88 agreed to participate; only 48 completed the program. Average PMIS was 7/8. Many patients were at risk for falls: 65% had > 12 second TUG (avg 14.64 seconds),

53% had an abnormal STS. Paired t-test using SPSS (power 80%, α of 0.05) compared initial to final sit to stand, FES-I, IPAQ, and confidence in executing an individualized smart goal.

The average SMART goal was 4 times of weekly exercise. STS increased from the beginning to the end of the program t(46) = -2.804, p < 0.007, suggesting improved lower body strength. Fear of falling did not change: FES-I t(47) = 3.074, p =0.669. 29% anticipated barriers to exercise before beginning the program. After two months of exercise, 44% experienced barriers; the most common was time. 17% anticipated this could impede regular use of the exercise program before starting, and 31% noted time as a barrier to participation at program completion. 92% were likely/very likely to recommend the program to a family member or friend.

KEY LESSONS FOR DISSEMINATION: Engaging geriatric patients in low-cost, home-based exercises using MI and visual educational aids improves leg strength and endurance as measured by the STS. Sustainability requires time, motivation, and ongoing coaching.

IMPLEMENTING A MULTI-DISCIPLINARY, AGE-FRIENDLY INPATIENT CARE MODEL

Kari Hirvela³; Elizabeth Chapman^2,1; Blair Golden¹

¹Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI; ²Geriatric Research Education and Clinical Center, William S Middleton Memorial Veterans Hospital, Madison, WI; ³Nursing Practice and Innovation, UW Health, Madison, WI. (Control ID #3868795)

STATEMENT OF PROBLEM/QUESTION: The 4Ms (What Matters, Medication, Mentation, Mobility) is an evidence-based framework to guide the development of Age-Friendly Health Systems; however, the optimal implementation of 4Ms framework within hospital settings, including how to promote physician engagement, is less well defined.

DESCRIPTION OF PROGRAM/INTERVENTION: We developed and pilot tested a multi-disciplinary care model based on the 4Ms at a large academic hospital using the Plan-Do-Act-Check cycle for quality improvement. In the Plan phase, a stakeholder group with representation from nursing, hospital medicine, geriatrics, pharmacy, social work, occupational therapy (OT), and informatics identified care practices to address each of the 4Ms on 2 units, one medical and one surgical. Care practices included: 1) inclusion of “What Matters” in nursing rounds and documentation; 2) daily pharmacy review of high-risk medications; 3) mobility documentation by nursing and therapy; 4) creation of a patient list template within Epic to display 4Ms data; 5) weekly “delirium rounds” for patients on the trauma surgery service. Beginning in April ’21 (Do phase), these 4Ms interventions were implemented for inpatients over age 65. We tailored education and utilized champions for different disciplines.

MEASURES OF SUCCESS: We created an interactive evaluation dashboard to assess the impact of pilot during the “Check” phase, including 1) specific uptake metrics for each of the 4Ms and 2) patient outcome metrics (i.e., length of stay, falls). We have also gathered qualitative feedback via nursing focus groups, stakeholders, and champions for each role.

FINDINGS TO DATE: From Dec ‘21-Oct ‘22, a total of 1,039 (73%) older adults received 4Ms-informed care on the 2 units. Based on feedback, we have iteratively revised pilot flowsheets, patient list template and delirium rounding documentation. A patient flyer was created based on nursing input. Implementation challenges included low utilization of the patient list template by physicians and lower than desired provider- initiated adaptations to care plans. Feedback from hospitalists indicated that a barrier was that hospital medicine services are not geographically localized (and patients are spread across many units), whereas the intervention only occurred on 2 units. However, general stakeholder feedback was positive, and data has resulted in our system receiving Committed to Care Excellence recognition by the Institute of Healthcare Improvement. Efforts to improve physician utilization of the patient list template are underway. We are expanding the care model to a second hospital in our system, and plan to implement the care model across all units based on lessons learned. Future work will more closely examine the impact of this care model on patient outcomes, including delirium incidence and length of stay.

KEY LESSONS FOR DISSEMINATION: Implementing a multi-disciplinary, multi-specialty Age Friendly Care model was feasible and acceptable to staff. The lack of geographic localization among hospital medicine services was a barrier for a unit-based pilot.

Innovation in Healthcare Delivery (IHD) - Healthcare Delivery and Redesign

A PRIMARY CARE AND CARDIOLOGY COLLABORATION TO ENHANCE POPULATION LEVEL LIPID OUTCOMES

Yenith C. Gordillo, Natacha Johnson, Omar S. Alkhezi, Mary Merriam, Hannah Senftleber, Christopher P. Cannon, Lisa Rotenstein

Primary Care, Brigham and Women's Hospital, Boston, MA. (Control ID #3874341)

STATEMENT OF PROBLEM/QUESTION: In early 2022, multiple practices at Brigham and Women’s Hospital (BWH) were not meeting the goal of >85% of patients with cardiovascular disease (CVD) being on appropriate lipid lowering therapy. We asked whether a collaboration between primary care, cardiology, and pharmacy could enhance lipid management and achievement of related Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics

DESCRIPTION OF PROGRAM/INTERVENTION: We conducted a pilot in which we collaboratively reviewed primary care patients at three BWH clinical sites who had atherosclerotic CVD, LDL > 100 mg/dl and were not on any statin or an appropriate dose statin. Population Health Coordinators (PHC) who are embedded in primary care screened patients on the CVD registry and selected patients for review who met the above criteria. PHCs reviewed patient charts to identify the reason for the patient’s inclusion on the CVD registry, verified LDL value, and checked, to see if the patient was offered a statin, had evidence of intolerance to ≥3 statins, and/or had refused a statin recommendation.

Subsequently, a bi-weekly review was conducted with PHCs, a cardiologist, the primary care population health medical director, and a pharmacist to generate patient-specific recommendations for further management. Action items included booking follow-up appointments, repeat lab work, introducing/titrating meds, cardiology referral for complex cases, correspondence with the patient’s primary care physician or cardiologist regarding the patient’s case or regimen, or removing the patient from the registry if they were inappropriately assigned. One member of the multidisciplinary team took responsibility for completion of each follow-up item based on expertise and existing relationships within the institution.

We are currently adapting lessons from this pilot in order to scale a CVD lipid management review process across all primary care sites.

MEASURES OF SUCCESS: - Change in percent of patients who met HEDIS measure for lipid management in established CVD, as determined by BWH’s Quality Insights platform - Process iteration based on lessons learned

FINDINGS TO DATE: The multidisciplinary process we developed resulted in an absolute increase of 1.0% to 2.9% of patients meeting HEDIS lipid measure at the practice-level. For example, at one practice, the percent of patients meeting the lipid management metric increased from 84.4% to 87.3% over one month. Through this process, we also developed a menu of action items to be considered in every patient review.

This menu ranges from actions that can be taken by a non-clinician (i.e., place lab order if lipid testing is overdue) to referral to cardiology for more complex cases.

KEY LESSONS FOR DISSEMINATION: A multidisciplinary collaboration between primary care-based population health resources and cardiology can considerably impact lipid management outcomes. Careful review of clinic notes in statin intolerant patients is often necessary. This process is now being scaled across multiple sites in order to improve population health.

A QUALITY IMPROVEMENT MODEL FOR A VULNERABLE PROCESS: IMPROVING RATES OF CARDIAC STRESS TEST COMPLETION

Maelys Amat¹; Anjala Tess^3,4; Madeline Kramer¹; Ernest V. Gervino⁵; Scot B. Sternberg⁶; Mark D. Aronson¹; Russell Phillips²

¹Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Center for Primary Care, Harvard Medical School, Boston, MA; ³Medicine, BIDMC, Boston, MA; ⁴Harvard Medical School, Boston, MA; ⁵Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA; ⁶Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #3869628)

STATEMENT OF PROBLEM/QUESTION: Though heart disease is one of the leading causes of morbidity and mortality in the United states and cardiac stress tests have long been the standard of care for initial evaluation of cardiac symptoms, our institution, along with others, has noted high rates of incomplete tests or delays to test completion.

DESCRIPTION OF PROGRAM/INTERVENTION: Our baseline analysis noted that only 61% of all stress tests ordered at our institution are completed on time leading to significant clinical concerns and high likelihood of missed ischemic events. The current routine stress test scheduling process includes no proactive outreach and no active registry to ensure that patients with active stress test orders have scheduled their appointments.

We mapped the process and tracked a small sample of patients through it.

- Of all stress tests ordered, 71% are scheduled and most of those are scheduled within 14 days of the order

- Of those scheduled, 91% make it to completion within 45 days

- Of those that do not keep scheduled appointments, there still seems to be high rates of rescheduling

- The overall rate of completion within 45 days is 65% (correlating with known baseline data from

2018-2021)

These data suggested that improving the scheduling of patients would have the highest impact on completion rates.

MEASURES OF SUCCESS: The primary aim of this project was to increase stress test completion to 90%

by November 1st, 2023 from a baseline of 61%.

Additional aims included:

- Increase rate of stress test scheduling from 71 to 95%

- Increase rate of stress test completion for scheduled tests from 91 to 95%

- Decrease time from test order date to test completion date from 22 days to 14 days

We therefore planned to achieve our goal of a 90% stress test completion rate through outreach of patients with an active stress test order but who have not yet scheduled their test by day 14 from date of order. The goal of these outreach calls was two-fold: 1. review reasons behind inability to schedule the stress test, 2. connect patients directly with office phone staff for proactive scheduling within 24 to 48 hours.

FINDINGS TO DATE: We have collected more recent baseline pre-intervention data for a 3 month period (July to September). During this time, the average rate of stress test completion was 65%, consistent with our previously established baseline of 61%. We have begun proactive phone outreach of patients with an active order for a stress test who have not yet been scheduled by day 14. Of the 35 patients for whom outreach was attempted, 25 (71%) were reached and 17 (49%) were successfully scheduled for a cardiac stress test, increasing the rate of test scheduling from 64% percent to 81% percent.

KEY LESSONS FOR DISSEMINATION: In this large academic medical center-based primary care clinic, implementation of proactive outreach for scheduling of crucial diagnostic tests markedly increased test scheduling and test completion.

When performing a quality improvement project, process maps paired with data can provide a crucial window into how and when to best intervene.

A TEAM-BASED APPROACH TO IMPROVE THE CARE OF HYPERTENSIVE PATIENTS IN COMMUNITY HEALTH CENTERS

Arielle Elmaleh-Sachs^1,2; Antoinette Schoenthaler²; Doreen Colella^3,1; Franzenith de la calle²; Jacalyn Nay⁴; Isaac Dapkins^2,1

¹Family Health Centers, NYU Langone Health, New York, NY; ²Population Health, NYU Langone Health, New York, NY; ³Quality and Patient Care Services, NYU Langone Health, New York, NY; ⁴Patient Navigation Center, NYU Langone Health, New York, NY. (Control ID #3867828)

STATEMENT OF PROBLEM/QUESTION: Hypertension (HTN) management can vary based on health system, provider, and patient-driven factors, leading to disparities in HTN control.

DESCRIPTION OF PROGRAM/INTERVENTION: The project uses a health systems approach to integrate multilevel interventions into existing care processes for the delivery of high-quality HTN care in a network of community health centers in the Mid-Atlantic region. Using staggered implementation, front desk staff, medical assistants, nurses and primary care providers (PCPs) work collaboratively with the quality improvement (QI) team to develop standardized processes to identify patients with uncontrolled HTN who are non-adherent to their medications using electronic health record-embedded tools; provide patient training in home blood pressure (BP) monitoring and use of a patient portal; and deliver virtual health coaching for medication adherence and lifestyle modifications in a high-risk clinic. The high-risk clinic allows for regular appointments with patients to titrate medications, and to address urgent needs related to their HTN. Patients also receive assistance from Community Health Workers to address social needs and technology-related barriers. The QI team conducts onsite and virtual trainings in proper BP measurement, guideline-concordant protocols for evaluating BP, and real-time documentation. PCPs are trained on SmartSets to order remote BP monitoring, and nurses are trained on Bluetooth-enabled home BP device use, self-measured BP protocols and self-management support techniques. Chart review and interviews with staff allowed for rapid cycle QI initiatives to address inefficiencies and modify the workflow prior to implementation at other sites.

MEASURES OF SUCCESS: Measures of success include rates of HTN control (BP<140/90 mmHg) across all sites and improvement in BP for patients enrolled. Qualitative metrics include analysis of staff interviews and onsite observations.

FINDINGS TO DATE: The project is active at 5 sites, and overall HTN control rates increased from 65.4% pre-implementation to 74.4% at 6-months post-implementation. At enrollment, the mean BP was 150/84 mmHg (N = 212), and among those who have completed 6 months of follow-up (N = 65), the mean BP is now 138/80 mmHg. Qualitative analysis identified 3 themes: a need for a digital needs assessment before implementation; hands-on training facilitates protocol adherence; and nursing leadership is essential for staff buy-in.

KEY LESSONS FOR DISSEMINATION: A team-based approach to HTN care has created a cohesive process for identifying patients with uncontrolled HTN, with uptake of evidence-based guidelines, including structured BP measurement, delivery of self-management support and home BP monitoring, and achievement of HTN control in community health centers.

BARRIERS TO COMPLETION OF SCREENING MAMMOGRAPHY IN AN INNER CITY URBAN PRIMARY CARE PATIENT POPULATION

Nikita R. Chintapally, Olivia Perez de Acha, Jennifer Tran, Godwin O. Darko, Nnenna Oluigbo

Internal Medicine, MedStar Washington Hospital Center, Washington, DC. (Control ID #3872807)

STATEMENT OF PROBLEM/QUESTION: Breast cancer is the second-leading cause of cancer death among women in the U.S. It is estimated that only half of eligible women are screened. The age-adjusted breast-cancer mortality is about 40% higher among Black women than among non-Hispanic White women despite a lower incidence among Black women. As of December 2018, the 5-year breast cancer survival rate was 17% higher for White women than for African American women (90% vs 76%) in our urban area. This study looks at a primary care clinic that provides healthcare services for underserved wards of an urban area in an academic center in the East Coast. Most of the patient that we serve are minorities with lower socioeconomic status compared to other wards. We aim to identify the barriers to completion of screening mammography among women who are due for breast cancer screening and have already received a mammogram order/referral from their primary care provider.

DESCRIPTION OF PROGRAM/INTERVENTION: This was a prospective study involving all female patients aged 50 – 75 years old who presented to the primary care clinic, who were due for screening mammogram and have had a mammogram ordered in the past 12 months. Telephone surveys and electronic health record review of the eligible subjects was conducted. The psychosocial, socioeconomic, and structural barriers were measured and addressed by providing appropriate navigation. The telephone surveys were done over the span of 3 months (April-June 2022).This study received IRB approval from our institution.

MEASURES OF SUCCESS: Phone call answers, with active participation in the survey.

FINDINGS TO DATE: Of the 440 eligible patients identified, 258 (58.6%) subjects were successfully contacted by phone. Of those contacted, 91.3% had a mammogram ordered at a prior clinic visit within the past 12 months; 13.5% were up to date with their mammogram based on current screening guidelines; 19.2% had an upcoming mammogram scheduled at the time of their telephone survey, 67.3% of patients had no mammogram scheduled. The most frequently recorded barriers for non-completion of screening mammography were forgetting to schedule the appointment (23.5%), difficulty scheduling (13.2%), lost referral (6.6%), not having the phone number required to make an appointment (5.9%), as well as avoidance of hospital due to COVID pandemic (12.2%). 67.3% of patients were assisted with an individualized approach to help them schedule their next mammogram from who they were been interviewed.

KEY LESSONS FOR DISSEMINATION: We hypothesized that common barriers to completion of screening mammography could be attributed to poor literacy, fear of the intervention, language barriers, and limited access to transportation among others. Strikingly, the main barrier identified in 49.3% of the cohort can be grouped under difficulty navigating the system, which could be improved with institutional support, such as nurse navigators who could facilitate care coordination and help patients through their screening journey, and thus reduce the disruptive effect of missed screening mammograms.

BEHAVIORAL THERAPY IN OBESITY: A NOVEL LIFESTYLE INTERVENTION FOR WEIGHT LOSS

Raihan El-Naas^1,2

¹Internal medicine, Weill Cornell Medicine, New York, NY; ²Internal medicine, NewYork-Presbyterian Hospital Cornell, New York, NY. (Control ID #3849404)

STATEMENT OF PROBLEM/QUESTION: It is challenging to educate and encourage patients to make lifestyle adjustments (diet & exercise) to aid in weight loss in obesity.

DESCRIPTION OF PROGRAM/INTERVENTION: Per the CDC and NHANES, prevalence of obesity in US is 41.9% and cost of obesity is 173 billion USD. After reading about various Behavioural Therapy (BT) mechanisms as an approach to weight loss in Obesity, I wanted to create an easy-to-remember tool for clinicians & patients and came up with the "5Ss of Behavioral Therapy". These will be discussed briefly with patients in the outpatient setting during routine clinic visits.

1. Setting a SMART Goal: Specific, Measurable, Acheivable, Reasonable, and Time-bound. Often times, the advice we give patients such as "eat a healthy diet" is vague & does not stick with patients. Hence, setting a goal such as "Ensure that half of your daily lunch plate is vegetables" or "Go for a walk for 30mins/day atleast 5 days a week" can give patients a clear target to work towards.

2. Self-monitoring: Encouraging patients on monitoring their weight, diet & exercise through the use of food diaries or applications is crucial. In the National weight control registry, self-monitoring was consistently associated with successful weight loss.

3. Stimulus Control: Educating patients on recognizing enovironmental stimuli that trigger overeating is key. Most people tend to overeat unhealthy snacks because they are readily available on the counter top or the fridge so advising patients on replacing those with healthy snacks or fruits/vegetables makes them more likely to reach out for something healthy when they're hungry.

4. Style of Eating: Mindful eating (making eating an activity of its own instead of being preoccupied with another activity such as watching TV; focusing on food texture; chewing food slowly) makes patients feel more satisfied after a meal leading to less overeating. Food order is also a game-changer! Eating proteins before carbs can lower post-meal glucose & insulin levels.

5. Social Support: Family-based interventions can improve long-term weight loss so involving family members can assist patients through their weight loss journeys.

MEASURES OF SUCCESS: Qualitative measure: 1-min patient surveys during the 2nd clinic visit (3 months after initial discussion of BT). Survey will assess their satisfaction with the intervention & their retention of the various BT mechanisms.

Quantitative measures: Changes in weight, BMI, waist circumference, and HbA1c after 3 months.

FINDINGS TO DATE: The verbal feedback obtained from patients was great! Many patients reported that they now understand what "lifestyle interventions" or "diet and exercise" as approaches to weight loss entail. However, both the formal quantitative and qualitative measures are yet to be obtained.

KEY LESSONS FOR DISSEMINATION: BT is a powerful tool that can improve long term weight loss in obesity. When implemented correctly, the 5Ss of BT can empower patients to take charge of their weight loss journeys & aid them in understanding the lifestyle changes they need to make to promote weight loss.

CREATING INFRASTRUCTURE TO SUPPORT A LEARNING HEALTH SYSTEM THROUGH RAPID PROSPECTIVE EVALUATION

Michael Usher¹; Maya Peters²; Timothy Beebe²; Joseph Koopmeiners²; Geniveive Melton-Meaux²; Nathan D. Shippee³; Deborah Pestka²

¹Department of Medicine/Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, MN; ²Center for Learning Health System Sciences, University of Minnesota Twin Cities, Minneapolis, MN; ³Division of Health Policy and Management, University of Minnesota, Minneapolis, MN. (Control ID #3877296)

STATEMENT OF PROBLEM/QUESTION: The ability to quickly and rigorously test interventions is necessary for learning health systems (LHS) to iteratively generate evidence to be implemented into practice.

DESCRIPTION OF PROGRAM/INTERVENTION: We created the Rapid Prospective Evaluation (RapidEval) Unit to drive rapid, iterative learning that melds pragmatic trial designs and rigorous mixed- methods evaluation with the natural innovation occuring within the health system. This included creating a grassroots call for proposals (CFP) cycled biannually. When an investigator is selected, they receive methods consultation, regulatory support, project management, data and analytic support. A nimble clinical informatics infrastructure was created to support pre-study planning and subsequent analysis. Overall, the CFP process takes two months, followed by three months of planning, and then six months of implementation and evaluation.

MEASURES OF SUCCESS: RapidEval is evaluated across several dimensions: (1) Overall process: including number of projects evaluated with structured feedback, number of projects selected and initiated within 3 months and completed within a year. (2) Reach: including stakeholder engagement necessary to support a project, and number of patients impacted by a RapidEval Project. (3) Clinical outcomes, including primary and secondary measures and health disparities. (4) Implementation measures, evaluated through mixed methods.

FINDINGS TO DATE: Since its inception in November 2021, we have conducted three CFPs, receiving 49 applications, and 8 selected projects. Accepted projects span an array of disciplines (e.g., cardiology, oncology, neurology, pharmacy, primary care) and initiatives (e.g., improving telemetry guideline adherence, micro-education to improve sepsis care, improving equity in medication management, standardizing HIV Pre-Exposure Prophylaxis). Common themes of selected projects include integrating guidelines into practice through clinical decision support tools, and efficient targeting of health care delivery tools such as tele- medicine. Reach thus far has been broad, including over 40 health system leaders across the system, 700 practitioners, and over 30,000 patients impacted in the first year. Our primary finding observed across projects is that gaps in evidence, including within consensus guidelines is a significant source of provider variation, and can be addressed systematically and iteratively.

KEY LESSONS FOR DISSEMINATION: A key learning since beginning the RapidEval Unit is that organization and system-level support is critical to ensuring necessary resources are in place, so that a rapid timeline can be maintained. Furthermore, while the focus of many RapidEval proposals is on clinical effectiveness, a mixed methods approach that includes evaluation of implementation outcomes, such as adoption, fidelity, and acceptability, is essential for success. Finally, we find that rapid evaluation is a useful tool to promote grassroots engagement in practice improvement toward the creation of learning communities.

CROWDSOURCING QUALITY IMPROVEMENT TO REDUCE UNNECESSARY EMERGENCY DEPARTMENT VISITS

Christine Gladman^1,2; Charlyse Lyle²; Crystal Hoffman²; Dana Neutze³; Amy Shaheen²

¹Medicine, University of North Carolina, Chapel Hill, NC; ²UNC Health Care System, Chapel Hill, NC; ³Family Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC. (Control ID #3874097)

STATEMENT OF PROBLEM/QUESTION: Emergency department (ED) visits are a very common occurrence among patients attributed to primary care providers (PCPs), but system efforts have been limited to patients recently seen in the ED or admitted to the hospital.

DESCRIPTION OF PROGRAM/INTERVENTION: An established learning collaborative of primary care practices, comprised of 95 adult and pediatric practices caring for over 400,000 patients, sets annual goals for member practices and sought system solutions to reduce unnecessary ED utilization. The aim of this project was to understand what PCPs identify as drivers for ED use, the actions PCPs take to prevent future unnecessary ED visits, and to help identify system solutions for prevention of ED visits that could be tested and implemented. PCPs reviewed a report of up to five patients with a perceived avoidable ED visit in the past month. They were then asked to respond to a survey and identify what actions they took in response to their patients’ use of the ED. PCPs were given standard choices of actions believed to lead to decrease utilization and were also encouraged to submit free-text responses for ideas to prevent ED utilization.

MEASURES OF SUCCESS: Response rate, key drivers of and solutions for avoidable ED use.

FINDINGS TO DATE: In the initial distribution, 163 of 596 (27%) surveys were completed and took less than five minutes. The most common actions taken after review of patients with avoidable ED visits were requesting appointments with PCP (52%) or a care team member (22%) and providing patient education on how to seek non-emergent care (45%). The most commonly selected systemwide solutions to prevent ED visits were patient education for how to access timely care during (59%) and outside (61%) of business hours and patient education to call the practice before going to the ED (51%). Additional solutions offered by PCPs focused on drivers of effective and timely triage of patient issues, improved same day appointment access to primary care practices and availability of behavioral healthcare, and pathways to obtain urgent imaging that avoided the ED. Based on these responses, workgroups have been formed to create and implement solutions to focus on these areas of patient education and improving access to care for patients, including a streamlined process to obtain urgent imaging outside of an ED.

KEY LESSONS FOR DISSEMINATION: A survey of a large, established learning collaborative of PCPs allowed us to crowdsource key drivers of unnecessary ED use and to prioritize and develop systemwide efforts identified by PCPs. Through ongoing quarterly iterations of this survey, we are able to share these prioritized efforts with PCPs to incrementally address the complex and multifaceted problem of unnecessary ED visits. This effort has created a platform by. large healthcare system can begin to incrementally address the complex and multifaceted problem of unnecessary ED visits.

DESIGNING IMPLEMENTATION OF A SYSTEMWIDE EVIDENCE-BASED HEART FAILURE CARE PATHWAY

Aayush Mittal¹; Batool A. Shukr¹; Robert Behrendt⁴; Celeste Williams⁵; Sue Piatak³; Susan Craft²; David Willens¹

¹Internal Medicine, Henry Ford Hospital, Detroit, MI; ²Population Health, Henry Ford Hospital, Detroit, MI; ³Transformation Consulting, Henry Ford Hospital, Detroit, MI; ⁴Care Coordination and Patient Care Services, Henry Ford Hospital, Detroit, MI; ⁵Heart and Vascular Institute, Henry Ford Hospital, Detroit, MI. (Control ID #3875595)

STATEMENT OF PROBLEM/QUESTION: After multistakeholder design of an inpatient, outpatient, and home heart failure (HF) care pathway, our regional health system needed implementation plans to drive uptake of key HF care steps.

DESCRIPTION OF PROGRAM/INTERVENTION: Implementation plans are based on the AHRQ Learning Health System (LHS) framework and the Influencer change framework (Grenny, et al.). The LHS framework drives iterative care improvements via evidence application and ongoing learning from clinical performance data. The Influencer framework guides interventions that improve personal, structural, and social abilities and motivations to improve. The HF pathway included evidence-based interventions such as prescribing guideline directed medical therapy (GDMT), using universal health-literacy appropriate patient education materials, and referring appropriate patients to cardiology, home-based care, or palliative care. Our implementation design team consisted of clinician-educators, residents, nurses, data analysts, an instructional designer, and a management engineer. Interventions include: 1) Driving buy-in by redesigning the pathway with facilitated teams of 100 clinicians and leaders from all disciplines and care venues; 2) Improving HF knowledge via education modules on our learning management system; 3) Audit and feedback of pathway uptake metrics; and 4) EMR tools to facilitate ordering of pathway steps. Education objectives are to update clinician knowledge on new HF nomenclature, GDMT, and descriptions of key steps in the HF care pathway. Rollout of these interventions is currently in progress.

MEASURES OF SUCCESS: Clinician and executive qualitative feedback on content, usability, and design via unstructured interviews and our system wide HF governance structure. We will use the RE-AIM framework for evaluation of implementation.

FINDINGS TO DATE: 1. The pathway design process engaged teams over 3 years despite competing priorities from COVID.

2. System wide education requires addressing differing resources across care settings and payors.

3. Defining which patients have HF by EMR data allowed real-time identification in hospitals, but challenges remain for outpatient and ED settings.

4. Specialty and location-based governance may be siloed, causing diffusion of ownership of implementation.

KEY LESSONS FOR DISSEMINATION: Implementation plan design for the HF care pathway was successful due to:

1. Use of the AHRQ LHS and Influencer change frameworks facilitated more in-depth planning for spread and sustainability of clinical change.

2. Multi-stakeholder teams for sustained engagement across care siloes.

3. Executive sponsorship for system integration and local accountability.

4. Management engineer to coordinate multiple, diverse teams.

5. Instructional designer for effectiveness of education.

DEVELOPING AND IMPLEMENTING AN INNOVATIVE APPROACH TO PROVIDING LANGUAGE CONCORDANT CARE FOR PATIENTS WITH LIMITED ENGLISH PROFICIENCY IN ACADEMIC GENERAL INTERNAL MEDICINE PRACTICES.

Taru Saigal¹; Dhuha M. Alwan¹; Jennifer Garrison²; Jeffrey S. Miller³; Jodi Grandominico¹; Daniel E. Jonas¹

¹Internal Medicine, The Ohio State University, Columbus, OH; ²General Internal Medicine, The Ohio State University, Columbus, OH; ³Interpreter Services (Medical Center), The Ohio State University, Columbus, OH. (Control ID #3870010)

STATEMENT OF PROBLEM/QUESTION: Despite compelling evidence for improvement in health outcomes when providing language concordant care (LCC), where the patient and physician speak the patient’s preferred language, it remains underutilized and often unavailable for persons with Limited English Proficiency (LEP).

DESCRIPTION OF PROGRAM/INTERVENTION: Persons with LEP are less likely to receive preventive care, less satisfied with their care, and more likely to have healthcare-related adverse events despite using qualified interpreter services. LCC enhances patients’ understanding of their disease, satisfaction, and shared decision-making; improves health outcomes and adherence; and decreases emergency room visits. Our institution’s total medical interpreter services utilization is high, comprising over 134,000 encounters for ~16,000 unique LEP patients annually, who speak 102 unique languages. To address the large need to provide care for persons with LEP, we designed a program to optimize the delivery of LCC by (1) evaluating the linguistic diversity of the physician workforce in our division of general internal medicine with 72 faculty physicians, (2) matching the existing linguistically diverse physician workforce with LEP patients that speak the same language, (3) advertising to enhance awareness, and (4) creating a dashboard for our LCC patients to track utilization of preventive services and trends in diabetes mellitus (DM) and hypertension control. At the outset, 15 physicians could speak 14 different languages (and dialects) well enough to conduct clinical practice (Spanish, Nepali, Arabic, Russian, Mandarin or Cantonese, Japanese, Bengali, Urdu, Vietnamese, Hindi, Punjabi, Kannada, Gujarati, Tagalog, and Visayas).

MEASURES OF SUCCESS: Increase in LCC (number of patients and encounters), utilization of preventive services, achievement of DM and hypertension goals, and patient satisfaction.

FINDINGS TO DATE: At baseline, before intentional physician-patient matching, 293 patients with LEP are seeing physicians able to provide LCC. Among patients with LEP, 58% were overdue for an annual preventive visit (n=118/281). Out of patients eligible for various preventive services (based on national recommendations), colorectal cancer screening was overdue in 41.5% (n=64/154), cervical cancer screening in 47.2% (n=68/144), breast cancer screening in 51.7% (n=60/116), influenza vaccine was overdue in 27.6% (n=79/286) and COVID-19 vaccine in 8% (n=25/281). DM was present in 40/186 (21.5%) and hypertension in 66/186 (35.4%) patients with LEP. For FY21, patient satisfaction survey completion was dismal for languages other than English and Spanish (Russian, n=14, Somali, n=2, and 0 for others). We will do a longitudinal follow-up to compare the achievement of BP and Hb1AC goals, preventive care, and completion of patient satisfaction surveys over one year.

KEY LESSONS FOR DISSEMINATION: LCC appeals to LEP patients, and institutional enablement of this low-cost pathway using existing resources could improve patient outcomes and satisfaction and reduce health disparities.

DEVELOPMENT OF PATIENT REPORTED OUTCOME MEASURES VIA MODERATED FOCUS GROUPS FOR THE HIGH NEED MEDICALLY AND SOCIALLY COMPLEX HOSPITALIZED PATIENTS

Michael D. McCann¹; Kemberlee Bonnet²; Patricia B. Miller⁴; G. Schlundt³; Francis Balucan¹

¹Medicine, Vanderbilt University Medical Center, Nashville, TN; ²Psychology, Vanderbilt University College of Arts and Science, Nashville, TN; ³Psychology, Vanderbilt University, Nashville, TN; ⁴Vanderbilt University Medical Center, Nashville, TN. (Control ID #3876562)

STATEMENT OF PROBLEM/QUESTION: Patient-centered Patient Reported Outcome Measures (PROMS) for the high need hospitalized population of patients need to be developed.

DESCRIPTION OF PROGRAM/INTERVENTION: The hospitalized high need patients at an academic tertiary care hospital are enrolled into the Interdisciplinary Care Program who's team focus on reducing utilization. This feasibility pilot was designed to better understand how to optimize team-based care models for the high need hospitalized patient population. We conducted five focus groups with 12 enrolled patients that were audio-recorded and transcribed. A hierarchical coding system was developed and refined using the focus group facilitator’s guide and preliminary review of the transcripts. Transcripts were coded by experienced qualitative researchers, and analyzed using an iterative inductive-deductive approach.

MEASURES OF SUCCESS: As a feasibility study, success was determined by attendance and engagement. Additionally, being able to develop a conceptual framework of drivers of health care utilization (PROMS) via qualitative research methods mentioned above is another goal of the study.

FINDINGS TO DATE: Unfulfilled personal values can lead to over utilization of the healthcare system. We identified instrumental (altruism, self-reliance, and consistency) and terminal values (companionship, self- esteem, and sense of accomplishment), as well as intrinsic and extrinsic motivators for behaviors. Patients value consistency, due to environmental instability, which they fulfill by seeing the same staff in the hospital setting. Patients reported that this familiarity provided a sense of companionship. The need for consistency was met by ease of accessibilty of the medical team.

Self-esteem was facilitated by altruistic behaviors. The interdisciplinary care program intrinsically motivated patients to adhere to the program because they felt that by helping others, they were also helping themselves. Extrinsic motivators included positive feedback and evidence of success. Motivation to adhere to the program was facilitated by positive responses as “astounded” by this supportive resource. Some patients reported decreased utilization since enrollment in program, which provided them with evidence of personal success.

Participants independently followed up with program-provided resources, which facilitated a sense of self- reliance. The social worker on the team can facilitate employment resources to patients, as unemployed patients reflected that prior job stability facilitated self-esteem and a sense of accomplishment. Patients were also given health education materials which facilitated independent thinking and discernment as to what constitutes the need for healthcare utilization.

KEY LESSONS FOR DISSEMINATION: People navigate health care, much like the world, based on their personal values. By identifying unmet patient values, person-centered strategies can be provided to fulfill and align those values with useful behaviors, which can lead to patient outcomes that can reduce health care utilization.

DO PRIMARY CARE VIDEO VISITS SATISFY PATIENTS?

Daisuke Hasegawa³; Danielle Tepper³; Dustin Kee⁴; Alfred Burger^3,5; Matthew Weissman^1,2

¹Internal Medicine/Pediatrics, Mount Sinai Beth Israel Hospital, New York, NY; ²Medicine and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY; ³Medicine, Mount Sinai Beth Israel Hospital, New York, NY; ⁴General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ⁵Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3875349)

STATEMENT OF PROBLEM/QUESTION: During the COVID pandemic, there was a rapid uptake of telemedicine at Academic Medical Centers (AMC), however to date, there has been limited literature on patient satisfaction comparing patient satisfaction of people seen in an AMC primary care clinic via telehealth versus in person visits.

DESCRIPTION OF PROGRAM/INTERVENTION: The use of telehealth has grown rapidly since 2020, raising questions about the quality of that care as well as patient satisfaction and desire for that modality of care. To answer this question we reviewed all patient satisfaction survey responses from September 25th, 2018, when we initially started to use video telehealth visits in our clinic, to June 14th, 2022. Our health system uses a private vendor to survey patients within 24 hours of a visit. Patients receive a text-based link to a 10-question survey, which scores all questions on a 5-point Likert scale. We looked only at our primary care practice at an urban hospital in an underserved neighborhood in the Mid-Atlantic region. We performed a retrospective analysis comparing the patient experience scores for three provider-focused questions between in-person and video visits.

MEASURES OF SUCCESS: We assessed patient responses to three key provider-specific questions:

-How likely are you to recommend our practice to a friend or loved one?

-How would you rate the quality of time spent with your doctor?

-How well did the clinical team explain your care to you?

FINDINGS TO DATE: Among a cumulative 9,862 responses (8,866 in-person and 996 telehealth) the mean (standard deviation) of age was 59.0 (13.7) in in-person and 56.0 (6.1) years in telehealth. Moreover, 2,824 (31.9%) in in-person and 302 (30.3%) in the telehealth were male. 5,365 (60.5%) in in-person and 840 (84.3%) in telehealth were seen by faculty members. There was no statistically significant difference on these three questions between the in-person and telehealth groups. (Q1 4.66 vs 4.62 p 0.99; Q2 4.76 vs. 4.68 p

0.65; Q 3 4.71 vs 4.63 p 0.32). This parity persisted even on subgroup analysis or were in favor of telehealth visits after the initial start-up period for English or non-English speakers; Age 65 or older or Age less than 65; gender listed in the EMR; and for patients seeing residents or faculty.

KEY LESSONS FOR DISSEMINATION: Our findings demonstrate that patients are satisfied by video visits and practices should feel comfortable expanding their video visit practices (and studying them). Further study is warranted to assess if telehealth is an equivalent option for those who are particularly at risk including older, non-English speaking, or with limited tech and health literacy.

EFFECT OF ECONSULTS ON PRIMARY CARE PHYSICIAN WORK EXPERIENCE AND CAREER SATISFACTION

Kevin J. Goist¹; Shalina Nair²; Victoria Cannon²

¹Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #3873895)

STATEMENT OF PROBLEM/QUESTION: Can the use of an eConsult program improve the work experience and career satisfaction of academic primary care physicians?

DESCRIPTION OF PROGRAM/INTERVENTION: A report from NASEM in 2020 concluded that Primary Care is the only medical discipline where a greater supply produces improvements in population health, longer lives, and greater health equity. Unfortunately, the AAMC estimates a shortage of 21000-55000 primary care physicians in the United States by 2023. There is significant evidence to demonstrate that Primary Care is underfunded and underappreciated. The COVID pandemic revealed myriad challenges facing Primary Care physicians and shed light on the fact that the interest amongst trainees in a career in Primary Care is waning. This has led to poor career satisfaction and burnout, with some studies finding that upwards of 80% of primary care physicians experience symptoms of burnout. We sought to determine if use of electronic consults (eConsults) in Primary Care would help improve career satisfaction and work experience. We created a survey of seven questions and distributed this survey to all attending and resident physicians in the Division of General Internal Medicine and Department of Family and Community Medicine at a midwestern academic medical center who practice outpatient medicine. Five answer options for each question were offered on a Likert Scale ranging from strongly disagree to strongly agree. We received 49 responses from attending physicians and 29 responses from resident physicians from our initial survey in 2019, with repeat survey results from 2022 pending at the time of this submission.

MEASURES OF SUCCESS: We collected all responses to the survey and assessed the qualitative results of two specific questions: 1. The use of eConsults enhances my ability to care for patients as a primary care physician; 2. The use of eConsults has improved my work experience and career satisfaction as a primary care physician.

FINDINGS TO DATE: Initial survey data/year 4 survey data:

The use of eConsults enhances my ability to care for my patients as a primary care attending physician, somewhat-to-strongly agree: 100%/TBD; The use of eConsults has improved my work experience and career satisfaction as a primary care attending physician, somewhat-to-strongly agree: 98%/TBD.

The use of eConsults enhances my ability to care for my patients as a primary care resident physician, somewhat-to-strongly agree: 100%/TBD; The use of eConsults has improved my work experience and career satisfaction as a primary care resident physician, somewhat-to-strongly agree: 93.1/TBD.

KEY LESSONS FOR DISSEMINATION: Use of an electronic consultation program can enhance the work experience and career satisfaction of primary care physicians. There is a perception from these primary care physicians that use of electronic consultation enhances their ability to provide care to their patients. Programs that enhance the work experience and satisfaction of primary care physicians can be vital resources to improving primary care physician well-being and reducing burnout.

EFFECT OF TEXT MESSAGE REMINDERS IN A RAPID RANDOMIZED CONTROLLED TRIAL TO IMPROVE PEDIATRIC IMMUNIZATION RATES

Holly Krelle²; William King^2,1; Leora I. Horwitz^2,1; Sarah Tsuruo^2,1; Kyra L. Rosen^2,1; Nate Klapheke^2,1

¹Population Health, NYU Langone Health, New York, NY; ²Population Health, NYU School of Medicine, New York, NY. (Control ID #3875681)

STATEMENT OF PROBLEM/QUESTION: To use rapid randomized tests to improve vaccination rates among urban, underserved children of 0-2 years cared for in a federally qualified health center (FQHC).

DESCRIPTION OF PROGRAM/INTERVENTION: Pediatric immunization rates fell markedly during the pandemic and have been slow to recover. An urban FQHC in a large academic health system used a series of rapid, iterated randomized trials to test a series of different text interventions. The trials were quick and ran entirely in the background, avoiding burden to frontline staff.

We tested three rounds of texts. After each round, we interviewed parents to identify facilitators and barriers, and planned the next round accordingly. R1 compared an ‘A’ text focused on Covid-19 safety and a ‘B’ text focused on the benefits of vaccination. R2 compared a basic vaccine reminder to no text. Parent feedback suggested that the content of the messages was less important than the timing: messages had to be received at a time conducive to action. Reminders were also important. Therefore, R3 compared two texts 42 hours apart (at noon and 6pm) to no text. Each round included parents of children aged 0-2 years, randomized into two arms in a 1:1 ratio. Children were eligible if due or overdue for at least 1 out of 10 vaccines.

MEASURES OF SUCCESS: Primary outcomes were appointment scheduling (at 1 and 3 days after first text) and overdue vaccines given at 85 days. Appointments made and overall vaccines given were compared with two-tailed Fisher’s Exact Tests. Vaccines received per subject were compared using Poisson regression. Statistical significance was set at 0.05.

FINDINGS TO DATE: Rounds 1 and 2 showed no difference either in appointment scheduling rate or in vaccination rate. In R3, parents of 1,034 children were randomized into two arms of 517 each. 3.1% of parents in the intervention arm made appointments within 1 day of the 2nd text, compared to 0.8% of parents in the control arm (p=0.01). Intervention arm children received an average of 0.4 vaccines each, compared to 0.3 in the control arm (p=0.02). Overall, 7.0% of overdue vaccines in the intervention arm were administered, compared to 5.5% in the control arm (p=0.02).

KEY LESSONS FOR DISSEMINATION: This study shows that a low-cost intervention (two text message reminders, 42 hours apart) can significantly improve pediatric vaccination rates for an at-risk population. But, the first two rounds produced null results, even though the interventions were evidence-based and had showed success in other settings.

This shows the importance of developing learning healthcare systems that are able to, quickly and cheaply, test multiple iterations – identifying interventions that are effective for their local context, at a particular time. Many systems have the capability to do this – we used our existing text message systems and measured routinely captured outcomes. The additional resource came from non-frontline staff (primarily data analysts).

EVALUATION OF A MULTIDISCIPLINARY PRIMARY CARE-BASED TRANSITION CLINIC FOR PATIENTS NEWLY INITIATING BUPRENORPHINE FOR OPIOID USE DISORDER

Sonia Sehgal¹; Laura Stolebarger²; Annika M. Hansen¹; Nicola E. Lanier¹; Luke M. Garcia¹; Michael A. Incze²

¹School of Medicine, University of Utah Health, Salt Lake City, UT; ²Internal Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #3868825)

STATEMENT OF PROBLEM/QUESTION: Despite substantial investment in promoting access to opioid use disorder (OUD) treatment, opioid overdose mortality continues to increase. While the reasons for this are multifactorial, a persistent deficit in evidence-based treatment access remains a crucial factor. As access to addiction specialty care is limited, several innovative programs have been evaluated to increase access to medication treatment for OUD (MOUD) in non-specialty settings including hospitals, jail/re-entry programs, and emergency departments (ED). Once initiated on MOUD, it is incumbent to continue treatment from one health care setting to the next. However, care transitions represent high-risk periods for patients with OUD. Dedicated transition clinics leveraging multidisciplinary supports may improve linkage to care and retention in primary care-based MOUD treatment.

DESCRIPTION OF PROGRAM/INTERVENTION: In order to improve linkage to longitudinal primary care-based MOUD from a low barrier ED-based buprenorphine initiation program at a single academic hospital, we developed a weekly multidisciplinary MOUD transition clinic (SPARC) including nurse care manager, peer navigation, clinical pharmacist, and physician team members. The aim of the clinic is to provide short-term intensive support to patients referred to primary care-based MOUD and eventual 'warm hand-off' to PCPs for longitudinal MOUD. The clinic follows a nurse-led model, with care coordination routinely taking place between clinic sessions led by a nurse care manager with a dedicated clinic cell phone.

MEASURES OF SUCCESS: Among patients who participated in our ED-based buprenorphine initiation program, we compared linkage to care, retention in treatment, and provision of recommended harm reduction services such as infectious screening and naloxone provision between referral to the SPARC transition clinic vs referral directly to primary care.

FINDINGS TO DATE: From October 2021-October 2022, 62 patients were referred to our transition clinic (SPARC) vs 26 patients referred to directly to primary care (PC); 61% of SPARC referrals attended an initial visit vs 46% referred to primary care; Of those who established care, 90% (SPARC) vs 50% (PC) were engaged in MOUD care at 1 months; At 3 months 75% (SPARC) vs 30% (PC); at 6 months 60% (SPARC) vs 25% (PC); 79% (SPARC) completed infectious screening vs 33% (PC); 100% (SPARC) received naloxone vs 67% (PC); 35 learners participated in SPARC representing a wide range of clinical disciplines.

KEY LESSONS FOR DISSEMINATION: As MOUD initiation happens in a wider array of innovative healthcare settings, supported care transitions will play an increasingly import role in establishing long-term MOUD and improving quality of care. Housing these interventions within primary care can provide needed support to PCPs encouraging uptake of high-quality primary care-based MOUD, thus improving access, convenience, and whole-person care for people with OUD. Future analysis can explore cost effectiveness and optimal composition of transition teams.

FIELD HOSPITAL DEMONSTRATES SIGNIFICANT BENEFIT DURING COVID-19 PANDEMIC Hammad Saif¹; Wara Lounsbury¹; Caroline Hamm^1,2; Ian Brown^1,2

¹Schulich School of Medicine and Dentistry, Western University Schulich School of Medicine and Dentistry - Windsor Campus, Windsor, ON, Canada; ²Windsor Regional Cancer Centre, Windsor, ON, Canada. (Control ID #3873356)

STATEMENT OF PROBLEM/QUESTION: At the height of the COVID-19 pandemic in Canada, there were serious concerns regarding the allocation of healthcare resources (e.g., beds, staff and equipment) which required an examination of barriers preventing elderly patients from being discharged and compromising patient flow in a large community hospital.

DESCRIPTION OF PROGRAM/INTERVENTION: Our retrospective chart review examines the barriers to discharge of 514 COVID-19 positive patients aged > 65 from November 1st, 2020 to January 31st, 2021 at large community hospitals in a moderate-sized city. We included analysis of utilization of a field hospital which was a temporary facility created to handle the increased flow of patients due to the pandemic. MEASURES OF SUCCESS: Basic patient demographics, comorbidity assessment using the Charleston Comorbidity Index, COVID-19 severity score, length of stay at each hospital including the field hospital, discharge disposition, length of stay in ICU, duration of O₂ dependence in hospital and COVID-19 status were all assessed.

FINDINGS TO DATE: Examination of the median Length of Stay by the location of discharge revealed that the greatest length of stay occurred when a patient was discharged to a long term care home. This identified a possible area of improvement and a discharge barrier. as long term care homes would not accept back their residents from the hospital if the home was currently undergoing a COVID-19 outbreak. Furthermore, there were delays associated with waiting for a negative swab in order to return to one’s retirement or long term care home.

Median length of stay was similar between hospitals in Windsor, ON, with the greatest length of stay occurring at the field hospital. The 13.5 day median LOS at the field hospital signifies the length of time and bed space that these patients would otherwise have occupied at an acute care hospital. Based on this finding at least 2403 hospital days were potentially saved over a period of 3 months by the creation of the field hospital. This number likely represents patients waiting to be repatriated to their LTC facility, given it was patients with prolonged stays that were sent to the field hospital. Furthermore, there was no compromise in patient care at the field hospital as patients who were sent there were clinically stable with discharge delays.

KEY LESSONS FOR DISSEMINATION: 1. The creation of field hospitals preserved acute care facility resources that could be otherwise used for additional patients by managing active and recovering COVID-19 patients without dminishing the qualtiy of patient care and reducing costs to the hospital.

2. Having a lack of alternative location of discharge for patients residing in long-term care homes would force hospitals to continue utilizing critical healthcare resources otherwise stable patients.

IDENTIFYING AND ADDRESSING UNMET TRANSPORTATION NEEDS TO REDUCE NO SHOWS TO PRIMARY CARE APPOINTMENTS

Sara Abrahams¹; Atrejo "Trey" Patridge²; Jonathan S. Lee³; Jane Jih^1,4

¹Medicine, University of California San Francisco, San Francisco, CA; ²UCSF Health, San Francisco, CA; ³Sutter Health, Sacramento, CA; ⁴UCSF Multiethnic Health Equity Research Center, San Francisco, CA. (Control ID #3873031)

STATEMENT OF PROBLEM/QUESTION: To identify and address unmet transportation needs of primary care patients that miss appointments at a General Internal Medicine clinic in the California-Hawaii region.

DESCRIPTION OF PROGRAM/INTERVENTION: Transportation barriers leading to missed primary care visits adversely impact patient health outcomes. Current programs to address transportation needs have limited scope and capacity. A pilot project of unmet health-related social needs in our multiethnic, urban practice with high language diversity demonstrated 11% of patients had unmet transportation needs, potentially contributing to the 13% clinic no show rate. This spurred clinic leadership to engage with quality improvement leaders to explore transportation interventions to reduce no show rates.

MEASURES OF SUCCESS: Quantitative measures include: a) reduced no show rate among patients with transportation barriers; b) measures of patient chronic disease management. Qualitative measures include: a) patient/clinician satisfaction; b) incorporation and sustainability of intervention into clinic workflow.

FINDINGS TO DATE: First, we conducted a pilot, randomized controlled trial of 46 patients with high no- show rates and upcoming scheduled visits. Intervention group patients received a mailed visit reminder and taxi voucher with instructions on its purpose and use 2 weeks prior to the scheduled visit. Comparison group received a mailed visit reminder only. There was no significant difference in no show rate between the two groups. Follow-up calls with the intervention group showed uncertainty about how to use the taxi voucher; patients with transportation barriers expressed they would have used a taxi voucher.

Since transportation barrier screening was not routinely done in the clinic, we then implemented a multi-level intervention to integrate transportation barrier screening into workflow. This included transportation needs screening reminders on check-in sheets, reminders during care team huddles, and food incentives for staff. Transportation screening increased from 0% to 15% of patients in 7 weeks. We found 13% of screened patients had unmet transportation needs. Qualitative interviews of patients with transportation needs identified lack of automobile access, cost, safety concerns, and unreliability of taxis as transportation challenges. All patients interviewed felt that clinic-arranged rides via a rideshare application would reduce barriers to visits.

Currently, we are working on a proof-of-concept pilot to address transportation needs for patients with high no show rates and high burden of chronic disease via pre-arranged rideshare. We aim to demonstrate the financial sustainability of such an intervention to generate clinical revenue to offset cost of roundtrip rideshares.

KEY LESSONS FOR DISSEMINATION: Interventions to increase transportation barriers screening can be difficult to sustain and scale without institutional resources. Implementing interventions to address health inequities should consider their financial impact which influences intervention sustainability within the clinic.

IMPACT OF PHARMACIST-LED MEDICARE ANNUAL WELLNESS VISITS FOR A GERIATRIC CLINIC

Lauren M. Lam¹; Bethany Delk¹; Karen L. Starr²; Justin Mutter²

¹Pharmacy, UVA Health, Charlottesville, VA; ²Division of General, Geriatric, Hospital & Palliative Medicine, UVA Health, Charlottesville, VA. (Control ID #3872920)

STATEMENT OF PROBLEM/QUESTION: During calendar year 2021, of the nearly 1,100 patients empaneled at a single geriatric clinic, only 21% received a Medicare Annual Wellness Visit (AWV).

DESCRIPTION OF PROGRAM/INTERVENTION: The AWV is a fully-covered preventative-health benefit offered to Medicare Part B enrollees. Since their introduction in 2011, AWVs have only seen modest growth in delivery to an estimated 15-19% of beneficiaries. An AWV may be performed by a licensed health professional, including pharmacists working under supervision of a physician. Clinical pharmacists are uniquely qualified to conduct AWVs given their knowledge of medications and disease state management. Studies have shown significant clinical, educational, and financial benefits for patients, clinicians, and clinics with pharmacist-led AWVs. In order to increase delivery of AWVs and to evaluate potential benefits for an outpatient geriatric clinic affiliated with an academic health system in the mid-Atlantic region, a pharmacist- led AWV pilot was implemented in 2022. During the AWV, the pharmacist completed a comprehensive medication history, reviewed medical and family history, conducted a cognitive impairment screening, and made collaborative clinical interventions. Personalized advice for chronic conditions, preventative services, and advanced care planning was also provided.

MEASURES OF SUCCESS: Metrics collected include: number of medication history discrepancies, clinical interventions, referrals, immunization recommendations, and education services provided as well as charges rendered and collections received.

FINDINGS TO DATE: Between Mar 12, 2022 and Nov 1, 2022, 22 AWVs were conducted by a pharmacist. An average of 3.4 medication history discrepancies (range = 0-11), including 0.5 clinically significant discrepancies, were identified per encounter. Twenty-one clinical interventions were completed, with initiation of new therapy occurring most frequently (N=10). Labs were recommended or collected at

50% of the visits. Fifty-two vaccines were recommended including patient-appropriate pneumonia, shingles, and COVID-19 series. Referrals were placed for preventative screenings or specialists for 86.4% of patients. Education on lifestyle, disease state, medications, and point-of-care testing was provided for 34 medical conditions. Finally, over $23,000 in charges were submitted to payors with a total of $4,819 (~$220 per visit) in revenue collected after adjustments.

KEY LESSONS FOR DISSEMINATION: The data collected for this pilot suggests that an interprofessional practice design with pharmacist-led AWVs has the potential to increase completion rates of AWVs and clinic revenue. These benefits are not limited to AWVs, as more provider time may be freed to invest in other services, including acute care needs, for their patients. The pharmacist-led AWV delivery model is the optimal choice for practice sites given a pharmacist’s robust medication knowledge and skills in identifying adherence barriers, addressing medication safety concerns, and implementing drug therapy as part of a patient’s comprehensive care.

IMPLEMENTATION OF A PHARMACIST-SUPPORTED HOME BLOOD PRESSURE (BP) MONITORING PROGRAM IN A PRIMARY CARE PRACTICE STAFFED BY INTERNAL MEDICINE RESIDENTS

Jessica R. Singer¹; Maria H. de Miguel⁵; Nadine Dandan⁶; Kelsey B. Bryant⁴; Nadia Liyanage-Don³; Adina Fraser⁸; Rakhi Kalra⁷; Hye Gi Shim³; Nathalie Moise²; Ian M. Kronish¹

¹Medicine, Columbia University Medical Center, New York, NY; ²Department of Medicine , Columbia University Medical Center, New York, NY; ³Internal Medicine, Columbia University Irving Medical Center, New York, NY; ⁴Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ⁵Department of Medicinw, Columbia Univeristy Medical Center, New York, NY; ⁶Pharmacy, NewYork-Presbyterian Healthcare System Inc, New York, NY; ⁷New York Presbyterian, New York City, NY; ⁸IT, NewYork-Presbyterian Healthcare System Inc, New York, NY. (Control ID #3874498)

STATEMENT OF PROBLEM/QUESTION: Although remote BP monitoring using wireless devices that integrate data into the electronic health record (EHR) is an evidence-based approach to improving BP control, the feasibility of implementing such a program into a resident primary care practice is not known.

DESCRIPTION OF PROGRAM/INTERVENTION: The setting is an academic internal medicine (IM) clinic staffed by >100 residents and 20 attending physicians. The clinic serves a primarily Spanish-speaking, publicly-insured patient population in New York City. A multistakeholder team comprised of physicians, pharmacists, and implementation scientists partnered with the hospital’s digital innovation team to create HomeTrackBP, a pharmacist-supported home BP monitoring program for patients of IM residents. Key components include 1) easy referral through an EHR order; 2) home delivery of wireless BP devices to patients free of charge; 3) home BP data including average BP easily visible in EHR; 4) pharmacist televisits focused on correct home BP measurement, medication reconciliation, and antihypertensive titration according to an algorithm; 5) pharmacist dashboard to ensure patient follow-up; 6) telehealth nurse monitoring for severely elevated BP readings; 7) referral of patients with resistant hypertension to a weekly telehealth hypertension clinic staffed by IM residents and an attending; 8) bi-weekly problem-solving meetings to optimize program design and solve implementation challenges.

MEASURES OF SUCCESS: - Proportion of residents that refer ≥1 patient to remote BP monitoring program

- Number and representativeness of patients referred to and engaging in the program

- Pre-post changes in average home BP

- Proportion of patients with controlled home BP 6 months after referral

- Resident satisfaction with hypertension training and confidence in managing hypertension with home BP

data

- Program sustainability

FINDINGS TO DATE: Between Jan 2021– May 2022:

- 74% of residents (N=96) referred at least 1 patient

- 200 patients (mean age 68 +/- 13 years, 59% women, 55% Spanish-speaking) were referred

- 74% of referred patients meaningfully engaged in the program (took ≥5 home BP readings; no differences in age, gender, or language between patients who did and did not engage

- 46% of patients had home BP <140/90 in the first week of monitoring, suggesting substantial white coat effect

- Mean home BP declined from 142/80 in week 1 to 134/75 in week 12 to 135/76 in week 24

- Using a cutpoint of 140/90, home BP was controlled in 66% of patients at 12 wks and 88% of patients at 24 wks

- Residents reported high satisfaction with their experience in the telehealth hypertension clinic

- The program will continue to be offered in 2023

KEY LESSONS FOR DISSEMINATION: The escalation threshold for home BP values should be set leniently to avoid unnecessary unscheduled phone calls to patients and clinicians

RPM programs must be fully embedded in the EHR

A multistakeholder team must meet regularly to problem solve challenges

IMPLEMENTATION OF A SELF-MEASURED BLOOD PRESSURE (SMBP) PILOT PROGRAM Rosemary Farahmand¹; Laken Barkowski²; Marc L. Cohen¹; Christopher Jiang¹; Ruthie Olowoyeye¹; Michael K. Rakotz²; Neha Sachdev²; Kristine Sullivan¹; Katherine M. Tighe¹; Hannah Walley¹; Stephen P. Juraschek¹; Jennifer L. Cluett¹

¹Beth Israel Deaconess Medical Center, Boston, MA; ²American Medical Association, Chicago, IL. (Control ID #3875809)

STATEMENT OF PROBLEM/QUESTION: Guidelines recommend using self-measured blood pressure (SMBP) readings for the management of hypertension (HTN) but the ideal approach for a sustainable, equitable, scalable SMBP monitoring program is not known.

DESCRIPTION OF PROGRAM/INTERVENTION: We implemented a technology-enabled SMBP pilot program that allows for remote HTN management at a large academic primary care practice in New England. The program utilizes existing roles within the practice including population health specialists (PHS), a registered nurse (RN) and primary care physicians (PCP), all of whom received role-specific training on evidence-based use of SMBP. PCPs identify and refer eligible patients during usual care visits. Interested patients return for an intake visit during which a RN teaches best practices for SMBP and provides a home blood pressure (BP) device that is paired to a remote BP monitoring technology platform. Patients perform twice daily SMBP readings for one week per month. The PHS creates a note in the electronic medical record that summarizes the data. The PCP remotely reviews the note, creates a care plan and bills CPT code 99474. PHS and/or RNs communicate the care plan to the patient by phone or secure patient messaging. This process is repeated one week per month until goal BP is achieved for 2 consecutive months. At 6 months post- enrollment, patients return for a final in-person visit to determine the impact of SMBP on office BP.

MEASURES OF SUCCESS: We present number and demographic characteristics of patients who were referred, enrolled and completed the 6-month program. We use logistic regression to determine if there are statistically significant differences in program enrollment or completion by race and age. We will present percent of patients achieving goal BP and correlation of SMBP readings to final office BP as well as reimbursement for asynchronous SMBP review by payor type.

FINDINGS TO DATE: To date, there are 94 referred patients (50% female, 21% black, age range 26-83 years old with mean 57.6) and 70 (74%) have attended an intake visit or have one scheduled. Of the 55 (59%) patients who attended an intake visit, 9 completed the program, 41 are actively enrolled, and 5 dropped out. Sixteen (17%) of referred patients declined or did not respond to outreach after PCP referral. Neither age (OR 1.02, 95% CI 0.99-1.06) nor black race (OR 0.44, 95% CI 0.13-1.50) was associated with enrollment status after referral. Monthly reimbursement for CPT code 99474 averages $11.99 (range $0-$33.21). Findings will be updated to include the percent of patients achieving goal BP upon program completion, correlation of final SMBP readings to office BP, and average reimbursement by payor type.

KEY LESSONS FOR DISSEMINATION: 1. Leveraging existing practice roles and ensuring that SMBP program workflow aligns with other core work for each team member can facilitate expansion of an SMBP program.

2. A technology-enabled virtual SMBP monitoring program can be used to engage a diverse group of patients in achieving their target blood pressure goals.

IMPLEMENTATION OF CARE TEAM BASED PROTOCOLS TO ADDRESS INBOX MESSAGES IN PRIMARY CARE

Matthew Mulligan

General Medicine, The University of Utah School of Medicine, Salt Lake City, UT. (Control ID #3873284)

STATEMENT OF PROBLEM/QUESTION: Inbox messages for primary care physicians (PCPs) are associated with burnout, and volume increased significantly during the COVID-19 pandemic. Little evidence exists on addressing inbox messages.

DESCRIPTION OF PROGRAM/INTERVENTION: In one academic primary care clinic (6 PCPs, 1 clinical RN, 1 pharmacist, and a medical assistant (MA) pool) we used a multi-disciplinary workgroup to create five standardized processes using existing care teams to address common inbox messages. In October 2021, we implemented the standardized processes for general message flow, lab results questions, medication questions, paperwork requests, and referral requests.

MEASURES OF SUCCESS: Qualitative data from surveys emailed to PCPs (n=6, 100% response rate) and MAs (n=8, 75% response rate) in December 2021 was combined with comments from the implementation process. Data on message volume, touches, and routing was collected from Epic. Data was aggregated in a 4-month before intervention period (May 2021-August 2021) and a 4-month after intervention period (November 2021- February 2022). We compared data from the clinical site with standardized inbox processes to a similarly sized academic site that did not implement the processes.

FINDINGS TO DATE: Inbox messages are a significant concern for PCPs; 5 out of 6 PCPs felt burnout from inbox management and felt that inbox messages are a pain point most/all of the time.

Development of care team processes for inbox management was straightforward with early buy-in from staff and clinic leadership, but implementation of standardized processes was challenging. MAs felt limited support from PCPs and patients. Themes were identified by MAs that help explain the lack of perceived support included: change and inconsistency; patients not respecting care teams; and PCPs undermining MAs. MAs suggested that PCPs needed to set boundaries, although PCPs noted difficulty in adhering to processes (“if it gets to my inbox I will address it”). Half of PCPs reported an improvement in inbox management by MAs.

The clinic site with standardized processes had a decrease in the number of PCP touches per encounter from 1.84 before the intervention to 1.42 after the intervention; this increased from 1.65 to 1.82 at the site without processes. The percentage of message encounters routed to PCP decreased from 58% to 47% at the site with processes, compared to an increase from 58% to 63% at the other site.

KEY LESSONS FOR DISSEMINATION: Despite the small size, implementing standardized processes for inbox messages using existing care teams in a primary care setting is a effective method to address a significant source of burnout for PCPs and could be adopted at other clinical sites. However, many barriers were identified that must be addressed for effective implementation. Our next step is to disseminate this work to other clinical sites.

IMPROVING ACCESS FOR ACUTE LOW COMPLEXITY COMPLAINTS: AN INNOVATIVE “SAME DAY” TELEHEALTH CLINIC EMBEDDED WITHIN A MULTISITE URBAN ACADEMIC GENERAL INTERNAL MEDICINE (GIM) PROGRAM

Dhanu R. Bhat¹; Jodi Grandominico¹; Neeraj H. Tayal³; Daniel E. Jonas²

¹General Internal Medicine, The Ohio State University, Columbus, OH; ²Internal Medicine, The Ohio State University, Columbus, OH; ³Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID

#3869455)

STATEMENT OF PROBLEM/QUESTION: Low complexity, acute medical complaints often exhaust finite and precious office visits and do not always need an in-person office visit.

DESCRIPTION OF PROGRAM/INTERVENTION: Access for acute illness was a problem in our GIM clinics. We experienced overutilization of physician templates for low complexity acute visits. Physicians struggled to accommodate these visits and would overbook to meet demand leading to stress and exhaustion. Patients when not seen were sent to urgent cares which increased the total cost of care.

In early 2020, The “Same Day” Telehealth Clinic (SDTC) was developed to accommodate low complexity acute complaints. 5 primary care physicians from our GIM clinic pool were recruited and assigned one half- day. Patient panel sizes for them were reduced appropriately. The clinic operates M-F from 1-5 PM to allow triage nurses adequate time to identify patients. SDTC schedule has twelve 20-minute visit slots. Physicians work closely with a central RN triage team through real-time communication: Epic Chat and Microsoft Teams. The RN triage team has been empowered to schedule patients into SDTC when they deem an in- person evaluation is not required. The triage team obtains the consent for the telehealth billing. Due to the rapid expansion of telehealth during the COVID public health emergency, telehealth services have been reimbursed by many insurances. This expanded revenue stream helped support this clinic business model. The model for the program required revenue to cover the salary for physicians only. There is no overhead cost, as the team works remotely. A financial projection indicated a minimum of 9 billable visits per session to cover expenses. Patients are seen through a video platform or telephone call depending on preference. Success of this model has prompted us to expand services through winter months of FY23 to account for anticipated surge in URI cases based on prior year’s data.

MEASURES OF SUCCESS: Number of patients seen, no show rate, financial performance, medical diagnoses treated, patient satisfaction and physician surveys within GIM.

FINDINGS TO DATE: Since the clinic started, 2400 patient have received care. No-show rate is 7%. In current FY, July 2021-22 total charges and payments have been $228,000 and $124,000, respectively. Top 3 E/M codes billed: 99213, 99214, 99442. Top 5 categories of symptoms by primary diagnostic code billed are Acute URI, COVID-19, Rash, Hypertension and UTI. Based on the patient and provider surveys, both are enthusiastic and appreciate the convenience of telehealth and timely access. Based on the financial data, the clinic is performing well without the expenses of office overhead.

KEY LESSONS FOR DISSEMINATION: Timely access to acute and affordable care can be provided via a same day telehealth model. Faculty appreciate care provided by their colleagues. Patients have access to care in their homes, limiting the spread of infectious illnesses to others in the healthcare system. The model is financially sustainable and easily scalable to respond to anticipated surges in communicable disease.

IMPROVING HYPERTENSION MANAGEMENT THROUGH A DEVICELESS REMOTE MONITORING PROGRAM AT A SAFETY-NET RESIDENT CONTINUITY CLINIC

Chaitra Banala¹; Elyse Lopez¹; Vandana G. Shah²; Andrica McDade⁴; Krystal Gamarra⁴; Georgette Boozer⁴; Thega G. Abraham⁴; Lee Lu³

¹Internal Medicine, Baylor College of Medicine, Houston, TX; ²Medicine, Baylor College of Medicine, Houston, TX; ³Internal Medicine, Baylor College of Medicine, Houston, TX; ⁴Harris Health System, Houston, TX. (Control ID #3875526)

STATEMENT OF PROBLEM/QUESTION: Can a deviceless remote blood pressure (BP) monitoring program be used to improve BP control in a safety-net resident clinic?

DESCRIPTION OF PROGRAM/INTERVENTION: Patients in a safety-net resident clinic were enrolled in a deviceless remote BP monitoring program starting May 2022. Patients were included based on the following criteria: active diagnosis of hypertension, average BP readings >140/90, adults 18-85 years old, eligible county or private insurance coverage, and commitment to participate in regularly scheduled coaching calls and video visits. Patients were excluded if they were pregnant, had end stage renal disease, unstable or untreated mental illness, lacked stable housing, were actively receiving cancer treatment, or resided outside the county. Each patient received a home BP monitor and education about proper use and positioning of the monitor. Patients were required to check BP at least 3 times per week. A monitoring platform called CareSignal obtained BP measurements from patients through easy-to-use text messages and phone calls through any device the patient had available. BP readings were integrated into Epic in real time and were monitored by a team of licensed nurses serving as patient care coordinators. This allowed for real time notification of out-of-range readings for rapid triage by licensed nurses and subsequent primary care physician notification and intervention if needed. Coordinators provided additional support by assessing patients’ current knowledge of hypertension and addressing their social determinants of health. Patients self- reported taken and missed doses, prompting them to identify barriers to medication adherence.

MEASURES OF SUCCESS: Our process indicator was long-term engagement (percent of patients who responded to at least 1 message per month) of those who enrolled. Our outcome measure was change in average clinic BP for those enrolled.

FINDINGS TO DATE: The intervention was launched in May 2022. As of November 14, 2022, 188 patients were enrolled in the program. Ninety-seven patients, or 52%, of those who enrolled were actively engaged. There was a steady decline in average clinic systolic BP readings over the course of the 7 months of our intervention. Average clinic systolic BP dropped 12 mmHg, from 149 in May to 137 in November. Average diastolic BP remained unchanged at 80 in both May and November.

KEY LESSONS FOR DISSEMINATION: This unique, holistic approach allowed for real time BP monitoring and early intervention, early detection of potential problems, self-identification of barriers to medication adherence, and ultimately empowerment of patients through better hypertension health literacy.

IMPROVING MEDICINE LENGTH OF STAY (LOS) AT A MID-ATLANTIC VA WITH AN INTERDISCIPLINARY APPROACH INVOLVING UTILIZATION MANAGEMENT

Heather Hopkins^1,2. ¹Medicine, Washington DC VA Medical Center, Washington, DC; ²Medicine, The George Washington University, Washington, DC. (Control ID #3874343)

STATEMENT OF PROBLEM/QUESTION: Many physicians within the VA system decide to admit patients to inpatient medicine without utilization management (UM) feedback, leading to inappropriate admission decisions that affect LOS. Furthermore, observation (OBS) status is not effectively used for patients admitted with ambulatory care sensitive conditions (ACSC). We aim to improve the overall medicine LOS and increase appropriate OBS usage by creating a forum for effective UM communication with providers and improve the rate of concurrent UM reviews.

DESCRIPTION OF PROGRAM/INTERVENTION: Our facility is an academic VA medical center with 175 beds and ~4000 yearly completed UM med admission reviews. The 6 inpatient medical teams consist of a hospitalist, pharmacist, social worker (SW), case manager (CM), resident, 2 interns, and medical students from 4 local academic affiliates. UM nurses are assigned to each team and perform reviews on ~80% of patients who are admitted.

Multiple interventions were undertaken simultaneously over an 8-month period. These were created from review of baseline data on LOS, OBS utilization, % of patients meeting acute admission criteria, and OBS to acute conversion %. Groups of stakeholders including UM nurses, CM, SW, and physicians met regularly to design and implement the following processes in a multidisciplinary effort.

UM nursing group was expanded to have representation for each of the 6 inpatient medical teams UM nurses were added to the existing interdisciplinary discharge rounds (IDR) group A script was created for and implemented in IDR to include UM feedback

Physicians were educated on UM purposes and practices via ongoing meetings and written handouts ED and medicine physicians were given educational handouts regarding OBS utilization and ACSC conditions

Medicine physician utilization management advisor (PUMA) was added to existing IDR group

MEASURES OF SUCCESS: 4 quantitative measures were assessed before and after initiation of the above interventions. These include the average LOS for acute medicine patients, the % of OBS reviews meeting criteria, the % of acute reviews meeting criteria, and the % of patients who were converted from observation to acute admission. These performance metrics are collected through Pyramid Analytics, utilizing the NUMI InterQual criteria.

FINDINGS TO DATE: Interventions began in Nov and Dec of 2021. Average LOS for acute medicine patients decreased from 6.81d in Dec to 4.72d in June. Percentage of acute admission reviews meeting criteria improved to 81%. OBS utilization improved with 77% of OBS reviews meeting criteria while still meeting national metrics for obs- to-acute conversion %(19.5% for FY21; within national goal of <25%).

KEY LESSONS FOR DISSEMINATION: Adding UM nurses to real-time, regular multidisc discussions of admitted patients results in improved LOS data for patients.

Educating physicians about the role of UM optimizes physician level of care decision-making and hospital resource allocation.

Challenges remain with integrating UM nurses into the ED admission process for prospective level of care decision-making.

IMPROVING METABOLIC OUTCOMES AMONG PATIENTS WITH FOOD INSECURITY AT AN URBAN PRIMARY CARE CLINIC

Tamara Goldberg²; Raul Chibas Sandoval¹; Juan F. Vasquez Mendez³

¹Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Internal Medicine, Mount Sinai St. Lukes West, New York, NY; ³Internal Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY. (Control ID #3875098)

STATEMENT OF PROBLEM/QUESTION: While self-management apps have been shown to reduce A1c and improve self-care among people with diabetes, their use and impact among low-income, food-insecure populations has not been well studied.

DESCRIPTION OF PROGRAM/INTERVENTION: Food insecurity disproportionately affects Black and Hispanic populations from low-income backgrounds and is associated with poor glycemic control. The goal of our project is to improve metabolic outcomes for patients at an urban Federally Qualified Health Center (FQHC) with both an HgA1c ≥ 5.7 and food insecurity through providing complimentary access to a dual English-Spanish language lifestyle self-management app.

Our patient population consists of Black (45%) and Hispanic (31%) patients, with 58% living at ≤ 100% FPL. 12% have diabetes and 22% of patients have an A1c >9, and 26% of residents in the local neighborhood reported food insecurity in the last year.

Between 08/05/2021 and 09/23/21 announcements were made during pre-clinic huddles about the connection between food insecurity and diabetes and the opportunity for complimetary access to a self-management app. Patients were screened for participation by both resident physicians at the time of visits as well as two physician project team members . Once screened, patients were scheduled for an in-person visit for app download and to answer any questions.

MEASURES OF SUCCESS: To measure the success of our program, we tracked HgA1c levels as well as patient attitudes toward the initiative over a one-year period.

FINDINGS TO DATE: Between 10/07/21 and 09/30/22, over 300 patients with an HgA1C ≥ 5.7 were identified and 21 patients enrolled in the initiative. By the end of the one year period, 73.6% of patients (n=14) had at least one A1c checked from baseline. Among those, the average A1c went from 7.9 % pre- intervention to 7.5 % (-0.4%)at the end of the one year study period. But if adjusted by survey follow up, average A1c went from 8.5% to 7.5% (-0.8%).

52.6% of the patients enrolled (n= 10) completed at least one follow up survey. Among those who completed the survey, 70% (n= 7) reported increased self-efficacy from using the app. Among the follow up surveys Dietary plans was the most favorite app feature, followed by Recipe discovery.

Those with the highest survey completion rate also had the greatest reduction in A1c over the study period.

KEY LESSONS FOR DISSEMINATION: Use of a self-management smartphone app among patients with increased A1c and food insecurity at an urban FQHC shows promise in improving diabetes control when coupled with motivated users. Challenges include patients not answering calls consistently, no-show rate to medical appointments, and that many patients are not proficient in modern technology. To enhance the self- management for our patients in the future, we will focus on the features most valued by our participants such as dietary plans and recipe discovery.

IMPROVING PHYSICIAN CONFIDENCE IN PRESCRIBING OF NOVEL COVID-19 ORAL ANTIVIRAL MEDICATION THROUGH USE OF EHR-EMBEDDED PHYSICIAN SUPPORT TOOLS AND PHARMACIST CONSULTATION

Kevin J. Goist¹; Kelli D. Barnes¹; Jodi M. Grandominico-Bradford²; Neeraj H. Tayal³

¹Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²Internal Medicine, The Ohio State University, Columbus, OH; ³Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #3874397)

STATEMENT OF PROBLEM/QUESTION: The introduction of novel COVID-19 antiviral medications presented challenges for primary care physicians related to patient eligibility, drug-drug interactions, and dosing adjustments impacting physician confidence and creating delays in prescribing.

DESCRIPTION OF PROGRAM/INTERVENTION: The FDA authorized nirmatrelvir/ritonavir under EUA for treatment of mild-to-moderate COVID-19 in patients at high risk for progression to severe infection. Prescribing is complex. Prescribing was opened to all faculty at an academic medical center in May 2022. A multifaceted approach to support faculty was introduced. An EHR-embedded physician support smartphrase was developed, including vital clinical information for prescribing, EUA information, drug contraindications, and a hyperlink to a drug interaction checker. Pharmacist developed educational videos on prescribing were created. Pharmacist collaboration was offered through two pathways: (1) Electronic consultation (eConsult) program: placed by the PCP when medication lists were accurate for same day recommendations. Consults were reviewed for appropriate indication, renal dosing, hepatic function, relevant drug-drug interactions, and any contraindications to use. Prescribing advice was relayed to the patient by PCP. (2) Pharmacy referral: Placed by the PCP for patients needing an in-depth medication review and telehealth consultation with a pharmacist. Prescribing recommendations were reviewed with and approved by the PCP and the pharmacist enacted the treatment plan and educated the patient. October 26^th 2022, the monoclonal antibody program was closed making oral antiviral medications to treat COVID19 increasingly important.

MEASURES OF SUCCESS: Numbers of (1) nirmatrelvir/ritonavir prescriptions; (2) ordering physicians; (3) Pharmacy eConsults and referrals; (4) Videos viewed. Percent of eConsults and referrals resulting in nirmaltrevir/ritonavir vs MAB, percent eConsults and referrals completed same day. Likelihood of use of novel services at program outset and as pandemic evolved. Pending is survey of physicians on perception of prescribing confidence at outset, satisfaction with physician support tools, and pharmacist collaboration. FINDINGS TO DATE: May-December 1, 2022, there were 58 views of educational videos and ~1400 unique nirmatrelvir/ritonavir prescriptions by 116 GIM providers. 62 Pharmacy eConsults requested: 93.6% appropriate for completion and 89.8% answered same day. eConsult recommendations: 47/59 (79.6%) nirmatrelvir/ritonavir, 7/59 (11.8%) monoclonal antibody (MAB) treatment, 8/59 (13.5%) no treatment. 10 total Pharmacy visits/referrals for possible nirmaltrevir/ritonavir prescribing, 70% completed same day, 60% received nirmaltrevir/ritonavir, 20% received MAB treatment, 20% no treatment.

KEY LESSONS FOR DISSEMINATION: A multidisciplinary approach to complex drug prescribing can facilitate improved physician comfort as well as timelier and broader prescribing practices. Leveraging a multidisciplinary healthcare team can unburden primary care physicians when complex, novel therapeutics arise.

IMPROVING POST-DISCHARGE CARE FOR PATIENTS WITH LIMITED ENGLISH PROFICIENCY: A MULTIDISCIPLINARY STUDY TO STRENGTHEN THE CONNECTION BETWEEN PATIENTS AND THEIR PRIMARY CARE TEAM AFTER HOSPITALIZATION

Maelys Amat¹; Leonor Fernandez²; Timothy Anderson¹

¹Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Medicine, Beth Israel Deaconess Medical Center, Waban, MA. (Control ID #3869622).

STATEMENT OF PROBLEM/QUESTION: The post-hospitalization period is a vulnerable time for all patients, with risks of adverse events, lapses in care and rehospitalizations.These risks may be increased for patients with limited English proficiency (LEP) who face high barriers to accessing equitable care. DESCRIPTION OF PROGRAM/INTERVENTION: The use of transitional care management (TCM) services, consisting of post-discharge nursing phone outreach within 2 days of discharge and primary care clinic follow up within 14 days, has been associated with reductions in mortality, readmissions, and total costs. TCM adoption is low nationally, and also at our academic medical center-based primary care clinic. We conducted focus groups with recently hospitalized LEP patients and interviews with primary care physicians

(PCPs) to identify barriers in delivering equitable post-discharge care and solicit stakeholder recommendations for improving existing care processes.

MEASURES OF SUCCESS: Our focus group questions explored communication between the patient and their primary care team after discharge, how well the patient’s needs were met, what the clinic did to address these as well as any barriers they encountered in this process. Our goal was to increase by 20% the percentage of LEP patients who received TCM services within 14 days of being discharged by August 2023.

FINDINGS TO DATE: We conducted 1:1 interviews with 8 clinicians which yielded the following overarching conclusions:

- There is significant variation in the clinician experience of post-discharge visits depending on whether the patient was admitted “internally” or at an external hospital.

- There is clear consensus that an ideal workflow entails virtual outreach from a nurse/pharmacist before a post-discharge visit with their PCP

- There is a lack of consensus around the added value of telehealth for post-discharge care visits

We conducted 4 telephonic focus groups with a total of 11 patients with LEP who were recently discharged. Languages included Russian, Spanish, Mandarin, & Cape Verdean. These yielded the following key findings:

- There are varied experiences for LEP patients in perceived ease of post-discharge communication and care

coordination

- Many experienced delays in communication with the clinic, leading to a preference for direct communication with their PCP

- There is a clear need for streamlined access to interpreter services

Both LEP patients and their PCPs agreed on the importance of frequent communication on discharge, readily available interpreter services and enhanced health education/care coordination services to help through this vulnerable time.

KEY LESSONS FOR DISSEMINATION: We highlight the importance of engagement of support staff in the post-discharge time, as health education and medication management are key to successful return home and often best addressed by non-physicians.

We urge primary care clinics to consider streamlined interpreter services and language concordant staff with the ability for the patient to reach interpreters directly and help them address their needs.

IMPROVING PRIMARY CARE ACCESS FOR RURAL WOMEN VETERANS: THE BOOST TEAM

Jenny K. Cohen^1,4; Lindsey Monteith²; Tara Stacker¹; Michaela McCarthy²; Mayan Bomsztyk^3,1; Abigail Wilson¹; Jennifer Childers³; Tanvir Hussain^3,1; Jeffery Kohlwes^1,4

¹General Internal Medicine, San Francisco VA Health Care System, San Francisco, CA; ²Denver/Seattle Center of Innovation, Veterans Health Administration, Washington, DC; ³VISN21, Pleasanton, CA; ⁴University of California San Francisco, San Francisco, CA. (Control ID #3872152)

STATEMENT OF PROBLEM/QUESTION: It is estimated that women Veterans will represent 18% of the Veteran population by 2040, however, there are concerns that women Veterans are not receiving timely, accessible, high-quality, health services.^1-2

DESCRIPTION OF PROGRAM/INTERVENTION: To improve access for rural women Veterans, we created the “Boost Team,” a telehealth outreach service whose goal is to connect women in the San Francisco Catchment (SFC) to Veterans Health Administration (VHA) services. We conducted a needs assessment between 9/2021 and 2/2022 interviewing staff/administrators (n=20), clinicians (n=15), and women Veterans (n=12) in rural community-based outpatient clinics (CBOCs) in VISN 21, and women Veterans not enrolled in VHA (n=3). Interviews occurred by phone or video. Interviewees were informed about the Boost Team and asked, “What should we know about your experiences in order to try to make this work successful?” The Precede-Proceed Framework was used to organize themes.³

Our findings informed the creation of an outreach playbook and team composition. The Boost Team will include a Medical Service Administrator, Nurse Practitioner (NP), and a Veteran Peer Support Specialist. Team members call Veterans and provide clinical care, education on resources, and assistance obtaining VHA primary care.

In 3/2022, we piloted the Boost Team, calling 12 women Veterans within a 150-mile radius of our rural pilot CBOC. During calls, the clinician, an NP resident, reviewed the Veteran’s chart, elicited wellness goals, and provided real-time care. Existing Patient Aligned Care Teams were leveraged to assist in coordination. Veterans were invited to share feedback about the experience. Clinical care was documented in the record, workload credits were allocated, and patients did not have a co-pay.

MEASURES OF SUCCESS: We tracked call attempts, referrals and labs ordered, follow-up appointments, and overall Veteran satisfaction on a de-identified secure dataset.

FINDINGS TO DATE: Our needs assessment uncovered educational and access gaps for Veterans, staff, and clinicians. Those gaps informed our outreach efforts. Seven out of 12 rural women Veterans were reached in 3/2022. Of those, all reported positive experiences with the outreach call, had at least one care need met during the call, requested assistance arranging follow-up, and 6/7 had at least one referral placed.

KEY LESSONS FOR DISSEMINATION: Our pilot suggests that clinician outreach efforts can engage rural women Veterans in VA healthcare and close health literacy and system-based practice gaps. We hired a Boost clinician, are creating patient education material, and developing a strategy to do outreach to rural women Veterans not currently enrolled in VHA. Iterative qualitative data collection will further tailor the program to best address the needs of rural women Veteran in VISN 21. Although we are focusing on SFC, we aim to share our findings more broadly to improve access to gender-specific healthcare services among rural women Veterans.

IMPROVING RESIDENT CONTINUITY OF CARE AT AN URBAN FEDERALLY QUALIFIED HEALTH CENTER

Sharel Nadine Sadud-Armaza²; Salvador A. Caceros Diaz²; Errol C. Moras²; Bailey G. Perry²; Tamara Goldberg¹

¹Internal Medicine, Mount Sinai St. Lukes West, New York, NY; ²Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3876606)

STATEMENT OF PROBLEM/QUESTION: How can we improve resident physician continuity of care by 20% over a 12-month period at an urban Federally Qualified Health Center (FQHC)?

DESCRIPTION OF PROGRAM/INTERVENTION: Continuity of care (COC) has been shown to increase patient satisfaction and trust, improve health outcomes, and reduce healthcare costs. However, our resident-based practice faces challenges in improving COC due to the variability of resident schedules (X+Y schedule system), frequent resident turnover, and lack of standardized scheduling workflows. A resident pre- intervention survey (n=30) indicated that, while all participants considered COC essential for their patients, 86.7% perceived that more than half (>50%) of their patients were unknown to them.

To improve provider continuity, beginning in July 2022, we designed and implemented a standardized Primary Care Giver (PCG) assignment algorithm to correctly assign patients to their resident providers in the EMR. In December 2022, we identified on-site scheduling workflow gaps and established priority areas for future interventions including; a focus on individual patient-physician continuity, an overbooking protocol, and proper documentation of follow-up instructions in progress notes.

MEASURES OF SUCCESS: Our main outcome will be the Continuity of Care Index (COCI) measured at 0, 6, and 12 months among all adult patients seen by resident physicians. Process measures include; the percent of PCG assignment accuracy and appropriate documentation of follow-up instructions in the progress note. The impact of our interventions on resident perceptions of continuity will be assessed through post- intervention surveys.

FINDINGS TO DATE: Between July 2022 and December 2022, COCI increased from 0.50 to 0.64 among adult patients seen by resident physicians. Accuracy of PCG assignments improved from 80% to 93% between December 2021 and October 2022, representing a 13% rise compared to the previous year. Upon review of scheduling data, the inclusion of a provider name in the follow-up section of the last encounter note improved continuity compared to no name listed (31% vs. 13%).

KEY LESSONS FOR DISSEMINATION: Data to date suggests that implementing a provider assignment algorithm and standardizing scheduling procedures can improve COC at an FQHC-based residency practice. Challenges include accounting for patients who require short-term follow-up, patient-based barriers to scheduling in advance, and standardizing practices at our centralized call center. Future directions include assessing patient perception regarding COC and stratifying data by self-identified race/ethnicity to ensure we are not furthering scheduling disparities.

IMPROVING THE CONTINUITY CLINIC EXPERIENCE DURING INTERNAL MEDICINE RESIDENCY: A RESIDENT-LED REDESIGN OF OUTPATIENT LABORATORY AND IMAGING FOLLOW-UP

Brian J. Louie, Preeya Bhakta, Christine J. Park, Kristen Lavere, Rosa Schmidt, Vandana G. Shah, Lee Lu

Department of Internal Medicine, Baylor College of Medicine, Houston, TX. (Control ID #3874367)

STATEMENT OF PROBLEM/QUESTION: How can we improve continuity clinic in-basket management for internal medicine (IM) residents?

DESCRIPTION OF PROGRAM/INTERVENTION: IM residency programs are designed to provide trainees with comprehensive inpatient and outpatient experiences. Outpatient training includes follow-up of laboratory and imaging results, or “in-basket management.” However, with the residency schedule, attention to in-basket management outside of clinic hours can be challenging.

Based on a survey sent to the residents assigned to a continuity clinic in a safety net healthcare system (n=36), only 60% checked their in-basket on a weekly basis during difficult wards and Intensive Care Unit (ICU) rotations. Barriers to in-basket management included different Electronic Health Record (EHR) systems at the affiliated clinical sites and lack of time.

In August 2022, we implemented a novel cross-coverage system that allows for peer-to-peer in-basket management during dedicated outpatient clinic hours by 1) modifying our firm system and 2) redesigning the “nurse STAT” resident’s responsibilities. Prior to intervention, residents were randomly assigned to one of the four clinic firms, and the “nurse STAT” resident responded to medical emergencies at the clinical site, in addition to having their own patient panel. With the new design, residents at the continuity clinic were divided into one of four “firms” based on their clinic day. Additionally, the “nurse STAT” resident no longer has a patient panel and instead spends time cross-covering the in-baskets of co-firmmates on ICU, wards, and vacation.

MEASURES OF SUCCESS: Our primary outcome measure is improvement in the rate of in-basket results addressed within two weeks. Our goal is to achieve a 95% completion rate by 6 months after intervention.

FINDINGS TO DATE: Prior to intervention, approximately 74% of in-basket results were addressed within two weeks. One month after initiation of the new cross-cover system, the rate increased to 82%. After intervention, the four-month average is 86%.

KEY LESSONS FOR DISSEMINATION: To reduce the burden of managing outpatient and inpatient duties, IM residency programs should consider having an assigned resident cross-cover in-basket results accrued during their colleagues' continuity clinic. This system would ensure any laboratory and imaging results are addressed promptly. Furthermore, residents gain valuable educational experience in cross-covering their peers in-baskets, a tool that is vital to professional development.

INTEGRATING BEHAVIORAL HEALTH INTO AN ACADEMIC PRIMARY CARE PRACTICE: CHALLENGES AND OPPORTUNITIES DURING THE COVID-19 PANDEMIC

Eric P. Sun²; Erin Staab²; Daniel Yohanna¹; Fabiana Araujo¹; Mim Ari²; Lisa Vinci²; Neda Laiteerapong²

¹Psychiatry and Behavioral Neuroscience, University of Chicago Division of the Biological Sciences, Chicago, IL; ²Medicine, University of Chicago, Chicago, IL. (Control ID #3875365)

STATEMENT OF PROBLEM/QUESTION: The COVID-19 pandemic has highlighted and exacerbated mental health needs in the primary care setting; social distancing needs have posed new challenges for integrating behavioral health (BH) care.

DESCRIPTION OF PROGRAM/INTERVENTION: Within an academic primary care practice (18 faculty/resident combined full-time equivalents; 26,000 unique patients/year; 40,000 encounters/year), BH integration began in 2015 with the following interventions implemented through 2020: clinical decision support tools, treatment algorithms, depression screening, co-located behavioral medicine clinic, and BH training for providers. Following the COVID pandemic in March 2020, the behavioral medicine clinic was moved to virtual, and in-person trainings and warm handoffs were suspended. In October 2021, the Collaborative Care Model (CoCM) was implemented for patients age 12 and older with major depression and anxiety. In this evidence-based model, a licensed social worker in consultation with a psychiatrist provides initial diagnostic assessment, care management, psychiatric consultation, and brief therapy via telehealth. MEASURES OF SUCCESS: Provider perceptions of primary care-BH integration assessed via survey at baseline (Sep 2015, 77% (N=30/39) response), pre-pandemic (Feb 2020, 67% (N=29/43) response), and two years into the pandemic (Jul 2022, 70% (N=31/44) response). Domains measured were systems integration, integrated practices, and training integration (score range 0-100). Additional items measured: provider satisfaction (5-point scale, strongly disagree to strongly agree).

FINDINGS TO DATE: Pre-pandemic, integration measures in the surveyed domains were at their highest level since project inception and significantly higher than baseline. Systems integration was 71.8 (SD 10.4) (vs. 54.9 (SD 9.7), p<0.001), integrated practices was 77.3 (SD 10.3) (vs. 57.8 (SD 11.9, p<0.001)), and training was 78.7 (SD 11.1) (vs. 54.0 (SD 13.7, p<0.001)). Two years into the pandemic, measures decreased in all three domains: systems integration, 67.0 (SD 9.6, p=0.07); integrated practices, 67.8 (SD 8.6, p<0.001); and training integration, 66.5 (SD 7.8, p< 0.001). These scores were still higher than baseline. Satisfaction with degree of improvement in BH integration (% agree/strongly agree) also decreased during the pandemic: baseline, 50%, pre-pandemic, 90% , and 2022, 70%. About half of providers thought that BH services were integrated into the clinic workflow in 2022, compared to 86% pre-pandemic. However, CoCM was well- received, as 76% of providers said CoCM improved access to mental health care and 87% said they would recommend CoCM to colleagues. The behavioral medicine clinic resumed in-person care in October 2022.

KEY LESSONS FOR DISSEMINATION: The COVID pandemic significantly impacted BH integration in primary care. However, it was also possible to expand integrated BH services with CoCM during the COVID pandemic. Ongoing assessment of the level of BH integration is important to determine areas affected by changes in clinical practice and address issues in a timely manner.

INTEGRATING MENTAL HEALTH TREATMENT INTO PRIMARY CARE USING THE COLLABORATIVE CARE MODEL

Heather Huang²; Brandon Huynh³; Zoe Moss²; Shanda Wells⁴; Mark Micek¹

¹Department of Medicine, University of Wisconsin-Madison, Madison, WI; ²Department of Medicine and Department of Psychiatry, University of Wisconsin-Madison, Madison, WI; ³School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI; ⁴UW Health, Madison, WI. (Control ID #3875101)

STATEMENT OF PROBLEM/QUESTION: Primary care physicians (PCPs) report difficulty meeting the mental health needs of their patients and inadequate access to specialty psychiatry services.

DESCRIPTION OF PROGRAM/INTERVENTION: UW Health, a large academic medical center based in Madison Wisconsin, designed and implemented the Collaborative Care (CC) program which integrates mental health treatment for depression and anxiety into primary care clinics. CC is an evidence-based model that adds a Behavioral Health Care Manager (BHCM) and Team Psychiatrist (TP) to the primary care team. BHCMs practice within primary care clinics and utilize behavioral activation strategies and brief psychotherapy to help patients reach their goals. PCPs identify eligible patients and are encouraged to perform a warm-handoff to the BHCM at the time of referral, as this improves program engagement. The TP works with the BHCM and PCP to provide input on patients’ care plans and medications.

MEASURES OF SUCCESS: Program measures included the number/proportion of patients enrolled in CC, the proportion with a warm-handoff, the proportion with TP input, and the proportion with clinical response (defined as >50% reduction of PHQ9 or GAD7 scores). We also compared Urgent Care, ER, and Hospitalizations for CC enrollees in the year prior and the year after CC enrollment.

FINDINGS TO DATE: The CC program was implemented in all 23 adult primary care clinics between 5/2019 and 8/2022, and a total of 19,278 were enrolled through 11/30/2022. In the past 12 months (12/2021-11/2022), 7,782 patients were enrolled, which represents 7.0% of number of patients with a depression or anxiety in these sites. Of those enrolled in CC between Jan-Aug 2022, 35% completed a warm handoff. Patients spent a median of 104 days in the CC program, and 32% had TP input. Treatment response was achieved in 51% for depression and 54% for anxiety after an average of 6.5 and 7.0 months, respectively. Compared to the year prior to enrollment, CC patients had 52% reductions in Urgent Care, 49% reductions in ER, and 63% reductions in inpatient care utilization the year after program discharge.

Despite the successes of the program, significant variability in referral rates were noted between clinics (>2.5-fold) and physicians (>8-fold). We are currently undertaking a qualitative evaluation among high and low performing clinics to determine the barriers and facilitators to referring eligible patients to CC and performing a warm handoff. This evaluation will also determine how CC impacts PCP wellness.

KEY LESSONS FOR DISSEMINATION: CC is an evidence-based care model that integrates mental health treatment into primary care clinics. At UW Health it has improved clinical outcomes for patients with depression and anxiety and decreased health care utilization. An ongoing qualitative evaluation will determine barriers and facilitators to optimizing referrals into the program, and investigate how the program impacts PCP wellness.

LEAVING (AMA) SO SOON - OPPORTUNITIES FOR IMPROVEMENT

Warren Gavin¹; Jason Russ¹; Vinod Kumar¹; FNU JAYDEV²; Areeba Kara¹

¹General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN; ²Internal Medicine, Indiana University School of Medicine, Indianapolis, IN. (Control ID #3869929)

STATEMENT OF PROBLEM/QUESTION: Few studies have evaluated the reasons why patients leave AMA and how these reasons can inform improvement.

DESCRIPTION OF PROGRAM/INTERVENTION: We retrieved all discharges flagged as ‘AMA’ from an urban, academic, tertiary care site between 2016 and 2021 and a random sampling of 10% was evaluated further. A data entry form was created with definitions and concepts clarified through an iterative process. Four hospitalist reviewers independently reviewed charts with periodic group meetings to resolve discrepancies. The review focused on the reasons for leaving as described by the patient and documented in the electronic medical record. The protocol was reviewed and approved by the local IRB.

MEASURES OF SUCCESS: NA

FINDINGS TO DATE: 2,886 patients were discharged AMA and 280 (10%) were randomly selected for further review. We present the preliminary results gleaned from the 219 charts reviewed. Among 219 patients, the mean age was 44.1 years and 98 (44.7%) were female. The average length of stay was 3.5 days and 65 (29.6%) were either readmitted or presented to the ED within 30 days following AMA discharge. For 60 (27.4%) patients there was no reason documented for requesting an AMA discharge. Among the 155 documented reasons for leaving, external obligations (e.g., childcare, elder care) were the most common (n=58, 37%). The next most common documented reason centered around patients articulating that they felt better and did not feel the need to stay (n=20, 13%). This was followed by cravings related to addiction (n=18, 11.6%). Dissatisfaction with hospital policies and procedures (e.g., restricted visitation policies, mobility restrictions, food choices and sleep interruptions) followed closely with 17 discharges (10.9%) related to such issues.

KEY LESSONS FOR DISSEMINATION: Understanding what drives patients to leave AMA may help us create systems to decrease the risks of AMA discharge. Our analysis points to the need for improving documentation as for many patients a reason for leaving AMA was not apparent.

The most common reason noted was patients’ external obligations. While these may not always be modifiable, there may be a role for interventions at the system level such as social work involvement (e.g., for legal matters, bill payments). Our results also highlight issues that may be addressed systematically by improving communication of goals and expectations of care that may address patients leaving because they feel better (yet still have ongoing medical issues). A careful examination of policies and procedures and how they may negatively impact care and how we pre-empt cravings in patients with addiction is also warranted.

LION MOBILE CLINIC: PILOTING AN INITIATIVE TO EXPAND PREVENTIVE HEALTH CARE ACCESS IN RURAL PENNSYLVANIA

Michael McShane¹; Kristina P. Brant²; Jennifer Kowalkowski²; Joel Segel²; Danielle Rhubart²; Mark Stephens³

¹Internal Medicine, Penn State College of Medicine, Hershey, PA; ²The Pennsylvania State University, University Park, PA; ³Family and Community Medicine, Penn State College of Medicine, Hershey, PA. (Control ID #3876890)

STATEMENT OF PROBLEM/QUESTION: How can the student-led, preventive health care mobile clinic model be adapted to the needs and opportunities present in rural communities?

DESCRIPTION OF PROGRAM/INTERVENTION: Snow Shoe, Pennsylvania, a rural community in Central Pennsylvania, has faced significant declines in infrastructure that pose a risk to the health of local residents at risk. Almost simultaneously, the town’s grocery store, bank, pharmacy, and Federally Qualified Health Center were closed down operations. Residents were left scrambling for reliable access food, medicine, health care, financial services, and other basic needs. In response, the Penn State College of Medicine launched the LION Mobile Clinic (MC) to bolster access to health care resources in in the surrounding area. The MC is a student-led free clinic, leveraging medical student time and talents to provide free care. Since May 2022, the MC has been providing preventive services such as COVID influenza vaccinations, blood pressure screening, social determinants of health screens, and health literacy education. We sought to document the challenges and successes of implementing our MC to inform similar initiatives elsewhere.

MEASURES OF SUCCESS: From the outset of implementation, the research team conducted both observations at clinic days and interviews with patients and community members who visited the clinic where the clinic operated. Observations focused on interactions between the MC implementation team and community members who visited the clinic; interviews focused on respondents’ perspectives of their communities’ needs, their access to health care, and their experience seeking care at the MC. Both observation and interview data were analyzed through rounds of primary and secondary coding.

FINDINGS TO DATE: Our findings highlight four major challenges faced by the MC in its early operations, which led to four specific adaptations to better meet community needs. These four areas included: (1) Resource Sharing, (2) Service Integration, (3) Building Communication and Trust, and (4) Responding to Acute Needs. In terms of resource sharing, MC start-up costs can be steep. Sharing resources across health systems helps reduce upfront costs. In terms of service integration, the MC partnered with existing social services such as food distribution networks to facilitate access to populations in need. To build communication and trust, the MC created opportunities for community members to regularly meet students and staff outside the traditional brick-and-mortar site of practice to engage in conversation and shared

planning. Finally, these conversations allowed the MC to specifically tailor services offered to meet community needs (e.g. COVID and influenza vaccinations) as they arose.

KEY LESSONS FOR DISSEMINATION: When implementing a rural MC initiative, providers should identify local partnerships to share resources, integrate within ongoing social services in the community, build trust through activities outside of clinical care, and stay in tune to local needs and respond as they arise.

MAJOR MIDATLANTIC METROPOLITAN AREA HEALTH CARE ACCESS PROGRAM FOR UNDOCUMENTED IMMIGRANTS

Jonathan Jimenez²; Nina Lauro¹; Allison Hartmann¹; Theodore G. Long¹

¹New York City Health and Hospitals Corporation, New York, NY; ²Office of Ambulatory Care & Population Health, New York City Health and Hospitals Corporation, New York, NY. (Control ID #3873687)

STATEMENT OF PROBLEM/QUESTION: Fragmented, uncoordinated saftey nets for the uninsured limit access to affordable, quality health care for undocumented Americans ineligible for health insurance.

DESCRIPTION OF PROGRAM/INTERVENTION: A municipal health care access program for city residents who are ineligible for or cannot afford health insurance, especially undocumented immigrants, was launched. The program streamlined access to low-cost primary and specialty care, hospitalization, radiology, ancillary services, and prescription medicines through the public health care system. Program members are offered a primary care provider and primary care appointment upon enrollment. Health care is coordinated across the safety net using electronic referrals and an electronic medical record system. Program members benefit from a primary care home, a membership card, and a 24-hour customer service telephone line. A multi-lingual public awareness campaign including earned media, advertising, and partnership with community based organizations ensured public knowledge and uptake of the program.

MEASURES OF SUCCESS: The principle measure of success is the number of active program members. Subsequently, measures that indicate engagement in primary and prevenative care and chronic disease control and management are key measures. Specifically, our measures of success include primary care and specialty care utilization in addition to chronic disease control and improvement after enrollment in the program.

FINDINGS TO DATE: The program has close to 110,000 active members, and members have completed over 340,000 primary care visits and 300,000 specialty visits. 70% of members had a primary care visit in the past year, and 50% had two or more primary care visits in the past year. 68% of patients with diabetes had a well-controlled hemoglobin a1c, while 66% of patients with hypertension were well-controlled. In addition, 51% of enrollees with diabetes had improved hemoglobin a1c, and 68% of enrollees with hypertension had improved blood pressure after six months of enrollment.

KEY LESSONS FOR DISSEMINATION: A centralized application process and a comprehensive public awareness campaign have been crucial to program uptake. This health care access program demonstrates that municipalities can improve population health by connecting patients to primary care homes, increasing care coordination, and improving the patient experience.

MAKING FIBROMYALGIA MANAGEABLE: CREATION OF A RHEUMATOLOGY REFERRAL- BASED FIBROMYALGIA CLINIC

Catherine Pressimone²; Jillian Kyle^1,2; Katherine Lane¹; Rachel Vanderberg^1,2

¹Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ²University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #3874059)

STATEMENT OF PROBLEM/QUESTION: The American College of Rheumatology recommends patients with fibromyalgia receive fibromyalgia care from their primary care physicians (PCPs); however, PCPs frequently report low levels of knowledge and confidence regarding fibromyalgia management.

DESCRIPTION OF PROGRAM/INTERVENTION: We created a rheumatology referral-based fibromyalgia clinic within our general internal medicine clinic to shift the care of patients with fibromyalgia from rheumatologists to general internists comfortable with fibromyalgia management. The clinic aims to improve access to rheumatology for patients with autoimmune conditions and provide evidence-based, patient centered care for patients with fibromyalgia. The fibromyalgia clinic is a focused short-term program that includes visits with pharmacists and physicians. The pharmacy visit is comprised of a thorough medication reconciliation, review of past medication trials and responses, and assessment of possible medications for future trial. Physician visits include a 60-minute intake visit and 3 20-minute follow-up visits (every six weeks). During the visits we aim to 1) confirm the diagnosis of fibromyalgia and provide education, 2) identify and treat other contributing pain factors such as musculoskeletal or mental health conditions, and 3) initiate both pharmacologic and nonpharmacologic therapy for fibromyalgia using a shared decision-making approach.

MEASURES OF SUCCESS: We asked patients to complete The Revised Fibromyalgia Impact Questionnaire (FIQR) during the first and last visit. The FIQR is a validated patient questionnaire that assesses the severity and functional impact of fibromyalgia symptoms. A 14% change or an absolute change of 8.1 is accepted as representing a clinically meaningful change.

FINDINGS TO DATE: From February 2021 to June 2022, we evaluated 157 new patients. Patients were predominantly white (81%) women (89%). Twenty-nine (18%) patients filled out both a pre and post FIQRs. All 29 patients (100%) demonstrated a clinically meaningful change on the FIQR by absolute or percent change. Twenty-seven (93%) demonstrated a clinically meaningful change on the FIQR by both absolute and percent change. We are planning to collect missing FIQR data for patients who completed two or more visits and then were lost to follow-up or who completed the program but did not return the post FIQR.

KEY LESSONS FOR DISSEMINATION: Collaborating with rheumatology ensures appropriate patients are referred to our program (i.e., concern for autoimmune conditions has been appropriately assessed).

Comprehensive fibromyalgia care may be difficult to deliver within a traditional primary care framework given competing demands and time constraints. Creating a short-term, focused clinical program may be an effective model for delivering fibromyalgia care in the primary care setting.

MINDING THE GAP: A DEDICATED POPULATION HEALTH PROGRAM FOR PATIENTS CARED FOR BY RESIDENT PHYSICIANS

Meybel Lopez-Flores¹; Mary Merriam²; Katherine Rose²; Bonnie Southworth¹; Hannah Senftleber²; Lisa Rotenstein¹

¹Primary Care Central, Brigham and Women's Hospital, Boston, MA; ²Primary Care, Brigham and Women's Hospital, Needham, MA. (Control ID #3874340)

STATEMENT OF PROBLEM/QUESTION: Patients with resident primary care physicians (PCPs) have worse outcomes on population health (chronic disease management and screening) metrics versus those cared for by attendings. Additionally, at Brigham and Women’s Hospital (BWH), resident panels contain a higher proportion of non-White patients (50% for residents vs. 30% for attendings) and patients with chronic conditions (60% for residents vs. 44% for attendings). Leveraging our existing Central Population Health Team, we developed a systematic intervention to improve population health outcomes for patients cared for by resident PCPs

DESCRIPTION OF PROGRAM/INTERVENTION: Starting in 01/2020, the BWH Central Population Health Team devoted a full FTE population health coordinator (PHC) to address the population health of resident patients. This PHC identified a ~16% performance gap between resident and attendings for diabetes and hypertension control across BWH’s 11 teaching practices. Given this performance gap, the resident PHC started to work with the largest teaching clinic to create quarterly population health didactic sessions, population health immersion sessions and collaborated with a newly implemented physician assistant-co- management model for resident patients. Quarterly population health didactic materials were disseminated to all primary care preceptors and residents. Additionally, the resident PHC met individually with residents from each clinic on a quarterly rotation to conduct population health introduction sessions and conduct panel reviews.

MEASURES OF SUCCESS:

- Process measures:

Number of population health introductions completed

Didactic sessions prepared since program inception

- Outcome measures:

Changes in A1c and hypertension (HTN) control

Changes in the performance gap between resident and attending patients since program initiation.

FINDINGS TO DATE: As of 12/2022, the resident PHC has completed 121 introductions to population health and developed 6 population health didactic sessions. From 01/2020 to 12/2022, A1c control for patients of resident physicians increased from 61.1% to 69.9%. This represented a 14% decrease in the gap between A1c outcomes for resident vs. attending patients (19.4% to 5.4%).

Hypertension control increased from 74% in 01/2020 to 78% on 12/2022, decreasing resident vs. attending patient outcome gap by 2% (6.6% to 4.6%).

KEY LESSONS FOR DISSEMINATION: A multi-level intervention led by the resident PHC significantly decreased disparities in population health outcomes between resident and attending patients. The program has been well received by clinicians, practices, and education leadership alike. A strong partnership between population health, residency education, and practice leaders was crucial for program success.

MPOX PREVENTION AND MITIGATION AT A PRIMARY CARE CLINIC IN METROPOLITAN NEW YORK - A HIGHLY EFFECTIVE HEALTHCARE DELIVERY

Rachel Gnanaprakasam¹; Marina Keller¹; Rebecca Glassman²

¹Medicine, Westchester Medical Center, Valhalla, NY; ²medicine, Westchester Medical Center, Valhalla, NY. (Control ID #3876217)

STATEMENT OF PROBLEM/QUESTION: Primary care doctors who are familiar with their population and individual risk factors, are positioned to effectively address infectious outbreaks in the outpatient setting.

DESCRIPTION OF PROGRAM/INTERVENTION: Starting in May 2022, a global outbreak of Mpox was reported, with high caseloads in the New York metropolitan area. The majority of cases occurred in cisgender men with reported male-to-male sexual contact within 21 days preceding symptom onset. The Ally Care Center (ACC) associated with a medical center in the New York Metropolitan area is a comprehensive primary care clinic, with a focus on caring for patients living with HIV (PLWH) and those at risk for HIV and other sexually transmitted infections (STIs).

Since our HIV care and prevention clinic is fully resourced with case management, psychological support, nursing care, primary care, and Infectious Diseases expertise, we were able to swing into action as soon as we heard about Mpox. We trained our staff to recognize the symptoms of Mpox, isolate the patient and swab the skin lesions. We opened a specialized isolation unit. We diagnosed the first case of Mpox in our county in mid-June and started vaccination by the end of July.

In order to prioritize vaccination efforts, we identified patients at high risk for Mpox based on exposure risk including men who have sex with men, individuals with multiple sexual partners or people treated for a STI in the previous year. All patients were individually contacted by their case managers who were given a script to educate patients about Mpox and vaccination benefits. They arranged transportation to vaccination and helped with any follow up questions or appointments. Initially vaccinations were administered in our clinic. Later as volume grew, to include the general community at risk, our institution pivoted to drive-through vaccination.

MEASURES OF SUCCESS: 1. Percentage of at-risk patients among the clinic panel who were vaccinated 2. Percentage of clinic patients who acquired Mpox after the start of our vaccination drive 3. Vaccination uptake specifically with regards to the vaccine drive by care team.

FINDINGS TO DATE: We started vaccinating for Mpox relatively early in the outbreak and, as such, our patient population had remarkably few cases of Mpox. We only saw five cases of Mpox in our clinic patients who were seen in the first two weeks of our vaccine drive.

KEY LESSONS FOR DISSEMINATION: Primary care HIV prevention and treatment clinics are uniquely posed to address infectious outbreaks due to the all-inclusive medical care they provide. Our patients are assigened case managers who facilitate care coordination and cared for by providers attuned to Infectious Diseases. Such a health care delivery model can be harnessed to rapidly recognize high risk patients, coordinate prevention and treatment outreach, and complete the circle of care by offering easy access to follow up and specialized care.

ONCOLOGY PATIENT PERSPECTIVES FROM TWO DISPARATE HEALTH SYSTEMS ON MANAGING ACUTE CARE NEEDS

Beverly Kyalwazi¹; Simon C. Lee⁴; Ethan Halm²; D Mark Courtney⁵; John Sweetenham^1,6; Navid Sadeghi^6,7; John V. Cox^6,7; Arthur Hong³

¹Internal Medicine, The University of Texas Southwestern Medical Center Department of Internal Medicine, Dallas, TX; ²Consortium of Population Health, Rutgers- RWJ Barnabas Health, New Brunswick, NJ; ³Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; ⁴Population Health, University of Kansas School of Medicine, Kansas City, KS; ⁵Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; ⁶Harold C. Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, TX; ⁷Parkland Health, Dallas, TX. (Control ID #3872269)

STATEMENT OF PROBLEM/QUESTION: Though patients with cancer are a relatively small portion of all patients, they are over-represented in the ED, and because they hospitalized over 60% of the time, represent a substantial proportion of hospitalized patients overall. Oncology urgent care clinics (OUCCs) offer prolonged patient monitoring, lab testing, basic imaging, and intravenous therapies for adults with cancer. OUCC appointments are accessible through patient calls to the nurse triage line. Although OUCCs show promise at reducing emergency department (ED) visits, they are underused by patients. Patient perspectives from different health systems that have established OUCCs may provide insight on how to maximize their impact.

DESCRIPTION OF PROGRAM/INTERVENTION: The University of Texas Southwestern (UTSW) and Parkland Health and Hospital System, the Dallas County Safety-net (SN) hospitals have run OUCCs since 2015. UTSW is an urban academic referral center serving nearly 8 million people with a cancer patient population that is 35% nonwhite and 7% Medicaid or uninsured. The SN hospital serves a cancer patient population that is 77% non-white and 80% with Medicaid or county charity care. The SN patients use the ED twice as often as UTSW patients in the first 6 months after cancer diagnosis. Utilizing semi-structured interviews, we investigated oncology patient perspectives on acute care needs and ED decision-making across the UTSW and SN health systems.

MEASURES OF SUCCESS: We evaluated decision-making, attitudes, beliefs, and barriers to access that influenced decisions to present to the ED across a diverse patient population.

FINDINGS TO DATE: We interviewed 24 UTSW and 16 Parkland patients (5 English-preferring, 11 Spanish-preferring). Interview transcripts were translated, then analyzed using iterative thematic analysis and the constant comparative method. UTSW patients more often described direct access (e.g. personal cell phone numbers) to their oncologist, while SN patients relied on non-clinician family to triage symptoms. SN patients reported barriers to accessing outpatient care (e.g. lack of insurance and limited access to an outpatient doctor). Patients in both health systems reported inadequate counseling on expected side effects from cancer treatment prior to their ED visit. When patients contacted their cancer team for triage advice, they were often referred to the ED. Overall, patients were unaware of OUCCs and a separate 24/7 telephone triage line for oncology, but were interested in using the OUCC to avoid prolonged wait times and exposure to infectious pathogens in the ED.

KEY LESSONS FOR DISSEMINATION: There are notable disparities in rapid access to clinicians prior to ED presentation. Improving visibility of OUCCs and improving counseling on treatment side-effects might mitigate this disparity in access to providers, increase utilization of the OUCC, and reduce low-acuity ED visits in both health systems. Patient perspectives suggest ways to better integrate the OUCC into care as an ED alternative for timely, specialized care for this high-risk population.

OPTIMIZING HOSPITALIST STAFFING MODELS WITH EVIDENCE-BASED PRACTICES FOR IMPROVED PATIENT, CLINICIAN, AND INSTITUTIONAL OUTCOMES

Marisha Burden¹; Lauren McBeth³; Angela Keniston²

¹Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ²Division of Hospital Medicine, University of Colorado, Aurora, CO; ³Medicine/Hospital Medicine, University of Colorado, Aurora, CO. (Control ID #3874116)

STATEMENT OF PROBLEM/QUESTION: The current clinician staffing model in hospitals and healthcare facilities is primarily based on financial considerations rather than evidence-based practices or patient outcomes which leads to inadequate staffing levels and sub-optimal patient care.

DESCRIPTION OF PROGRAM/INTERVENTION: High workloads in hospitals can lead to longer stays, higher costs, and delays in discharging patients. These high workloads also negatively affect quality improvement efforts and can cause clinician burnout. Currently, there is no standard way to measure hospitalist workload, or determine an optimal workload level. We aim to develop an evidence-based approach to building hospitalist staffing models that incorporates clinician data (objective and subjective measures) and electronic clinical data (operational and patient outcomes) to develop a workforce application and safety management platform that drives improved hospitalist, patient, and institutional outcomes.

MEASURES OF SUCCESS: -Identify and establish methods to measure total work -Develop a mobile application to capture clinician perception of work

-Develop a safety management platform and decision support tool that integrates clinician data and electronic clinical data to monitor for worker and patient harms

FINDINGS TO DATE: We are taking a multiple methods approach to (1) identify and establish methods to measure total work and (2) develop an intuitive, accessible mobile application and platform with decision support to capture, in real-time, measures of hospitalist workload and pair this with electronic clinical data. To date, we have conducted a Delphi panel consisting of 17 experts from around the country including frontline hospitalists, hospital leaders, administrators, and experts from fields such as human factors engineering and quality improvement. We are conducting a scoping review to identify how workload has historically been defined and measured. Utilizing preliminary findings from the Delphi panel and ongoing scoping review, we have developed the GrittyWork mobile application (GW app) to measure total hospitalist work. The GW app collects hospitalist perception of work through targeted surveys as well as physical activity data. To guide the design of the tool, we applied the Chokshi and Mann Process Model for User- Centered Digital Development, iteratively modifying the GW app collecting user experience data. Next steps will be to further optimize the tool in preparation for a larger scale multi-site study and to develop a safety management platform that integrates data inputs from clinicians and electronic clinical data to provide decision support to hospital and hospitalist leaders to drive optimal staffing and optimal outcomes.

KEY LESSONS FOR DISSEMINATION: GrittyWork represents a novel approach to building evidence- based staffing practices to transform hospitalist work and improved hospitalist, patient, and institutional outcomes.

POPULATION HEALTH OUTREACH UTILIZING AN ELECTRONIC HEALTH REGISTRY TO IDENTIFY PATIENTS ELIGIBLE FOR COVID-19 PROPHYLAXIS WITH TIXAGEVIMAB/CILGAVIMAB IN A MULTI-SITE ACADEMIC PRIMARY CARE PRACTICE

Jodi M. Grandominico-Bradford¹; Neeraj H. Tayal²; katie delille²; Daniel E. Jonas¹

¹Internal Medicine, The Ohio State University, Columbus, OH; ²Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #3874382)

STATEMENT OF PROBLEM/QUESTION: Many patients in the primary care population qualify for the monoclonal antibody tixagevimab/cilgavimab for prevention of COVID-19 infection, however unnecessary delays and omissions may occur if identification of these patients is not systematic and relies on primary care office visits alone.

DESCRIPTION OF PROGRAM/INTERVENTION: An administration program for tixagevimab/cilgavimab was started in January 2022 at our academic medical center. Concurrently, solid organ transplant patients and those on oncologic therapies were identified and referred for therapy through an existing program developed by the transplant and oncology divisions, respectively. However, many patients receiving immunomodulating medications remained at risk, lacking a prospective and systematic program for identification and referral. In March of 2022, we developed an electronic patient registry identifying potential recipients on qualifying immunosuppressant medications. Medications included TNF alpha blockers, antimetabolites, calcineurin inhibitors, Monoclonal antibodies, Jak Kinase Inhibitors, and other immunosuppressant or antineoplastic agents. A project coordinator nurse was educated on tixagevimab/cilgavimab and performed outreach to identified patients. A templated message was sent via an electronic patient portal in a tiered fashion prioritizing those most at risk for severe complications of COVID-19. Information on tixagevimab/cilgavimab including details of its Emergency Use Authorization (EUA) were included and patients were invited to receive therapy by replying to the project nurse. An electronic consult order was pended by the project nurse for interested patients. Orders were routed to primary care physicians for review and signature, at which point patients followed the existing institutional workflow for tixagevimab/cilgavimab administration.

MEASURES OF SUCCESS: patients identified for referral, patients given tixagevimab/cilgavimab.

FINDINGS TO DATE: Between March 2022 and October 2022, 407 patient outreach messages were sent notifying patients of their eligibility, 79 patients were referred to the program and subsequently administered tixagevimab/cilgavimab. Of those 79, 67% were female, 81.3% were White, 12.5% were Black, and 5% were insured by Medicaid or managed Medicaid health plans. The majority of general internal medicine faculty members (44 out of 65+) from our 8 clinical practices had patients referred to the program through this workflow.

KEY LESSONS FOR DISSEMINATION: A population health workflow focused on identification of immunosuppressed patients through employment of a dedicated, knowledgeable team member can efficiently improve outreach to patients who qualify for potentially life-saving COVID-19 therapeutics. The approach successfully facilitated primary care physicians in identifying eligible patients, provided standardized education, and unburdened the primary care physicians while avoiding delays in care.

RELIEF FOR RURAL CLINICS: A VIRTUAL OPEN ACCESS CLINIC TO IMPROVE PRIMARY CARE ACCESS IN RURAL AREAS

Archana Sridhar^1,2; William B. Smith³; Ashlyn Young⁴; Diana Huynh⁴; Tanvir Hussain^1,2

¹General Internal Medicine, San Francisco VA Health Care System, San Francisco, CA; ²General Internal Medicine, University of California San Francisco, San Francisco, CA; ³Assistant Clinical Prof, Dept. Medicine, University of California, San Francisco, San Francisco, CA; ⁴San Francisco VA Health Care System, San Francisco, CA. (Control ID #3875618)

STATEMENT OF PROBLEM/QUESTION: Ambulatory clinics in rural communities frequently face staffing shortages that adversely affect patients’ access to primary care services and contribute to well- documented disparities in healthcare outcomes for rural patients.

DESCRIPTION OF PROGRAM/INTERVENTION: In early 2020, the San Francisco-based Clinical Resource Hub (CRH), a regional VA telehealth program, created a virtual primary care access clinic serving northern and central California, Nevada, and the Pacific Islands called the Daily Open Access Resource, or DOAR. The clinic is staffed by primary care providers (PCPs) employed by an urban medical center (the “hub”) and uses telehealth to improve access for Veterans within the CRH’s geographic catchment area (“spoke” clinics). There are two referral sources for DOAR: (1) an RN/PCP at a spoke VA clinic refers patients who have pressing primary care needs and there is no timely local access available, and (2) the centralized VA nurse triage line refers patients. CRH PCPs evaluate patients via synchronous video and audio telehealth and use spoke-clinic resources and personnel to coordinate care.

MEASURES OF SUCCESS: The following metrics are used to evaluate DOAR: (1) total number of patients utilizing DOAR (2) percentage of patients from rural/island communities, (3) percentage of video visits compared to audio visits, (4) referral source, and (5) referral reason.

FINDINGS TO DATE: The volume of patients seen in DOAR has increased over time: 1,282 in 2020, 2,148 in 2021, and 2,629 in 2022. The proportion of Veterans seen from rural and island communities compared to urban areas grew: 44% in 2020 to 60% in 2022. The proportion of video visits compared to audio visits declined: 72% in 2020 to 30% in 2022. An audit of 416 DOAR patients scheduled between Oct-Dec 2022 showed 85% of referrals were from spoke clinic RNs/PCPs and 11% from the centralized nurse triage line. The majority of these visits (26%) were for post-hospitalization follow-up. Other common referral reasons were post-ER follow-up care (14%), musculoskeletal concerns (10%), Veterans wanting to discuss test results (8%), Veterans requesting subspecialty referral (7%), and cold symptoms (7%).

KEY LESSONS FOR DISSEMINATION: An increasing volume of Veterans, particularly from rural and island areas, has improved access to primary care services through DOAR. Access to post-hospitalization follow-up care appears to be a particular area of need by many rural patients served by DOAR. An integrated VA healthcare system, allowing easy communication between hub PCPs and spoke clinic staff distributed across a large geographic area, has enabled this care delivery model to succeed. Building trust with rural stakeholders has contributed to the growth in referral volume. Notably, the percentage of video visits has decreased over time. Barriers to video telehealth usage in rural and island communities require further investigation.

REMOVING BARRIERS TO TECOVIRIMAT FOR MPOX-INFECTED INDIVIDUALS

Michael E. McCarthy¹; Joseph Glowacki^1,2; Rostislav Livinsky^1,2; Daniel Taupin^1,2; Dagan Coppock^1,2

¹Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA; ²Department of Medicine, Division of Infectious Diseases, Thomas Jefferson University, Philadelphia, PA. (Control ID #3860511)

STATEMENT OF PROBLEM/QUESTION: During the 2022 mpox outbreak in the United States, the Centers for Disease Control (CDC) recommended consideration of treatment with tecovirimat for select individuals. However, the CDC’s expanded access Investigational New Drug (IND) protocol was a practical barrier to the outpatient provision of tecovirimat.

DESCRIPTION OF PROGRAM/INTERVENTION: We rapidly implemented a tecovirimat prescription program for individuals infected with mpox at an academic medical center in the Mid-Atlantic region. A tecovirimat referral line was created and staffed by a physician assistant (PA) trained in the CDC mpox IND protocol. Overseen by Infectious Diseases faculty, the PA assessed the referred individuals via telemedicine appointments. For select referees, the PA managed all IND paperwork, then prescribed and arranged for home delivery of tecovirimat.

MEASURES OF SUCCESS: The primary measures of program success were the time interval from referral to the mpox clinic to the initial visit with the mpox clinic PA and the time between that initial visit and the receipt of tecovirimat. Time intervals between symptom onset to referring provider visit and referring provider visit to actual referral were also assessed. The secondary measure of success was completion of the tecovirimat course.

FINDINGS TO DATE: The mean time in days from symptom onset to tecovirimat receipt was 10.17 with a standard deviation (SD) of 4.33. Within this overall timeframe, intervals before referral to the mpox clinic were longer: symptom onset to first being seen by a referring provider (mean 4.51, SD 3.86); being seen by a referring provider to the date of referral to the mpox clinic (mean 4.86, SD 3.55). Once subjects were referred to the mpox clinic, care was delivered with minimal delay: days from referral to first mpox provider visit (mean 1.03, SD 1.90) and from first mpox provider visit to receiving tecovirimat (mean 0.22, SD 0.43). Of the 29 patients who met treatment criteria, 17 were prescribed tecovirimat, of which 16 completed treatment. One patient did not complete their course due to an adverse drug event.

KEY LESSONS FOR DISSEMINATION: In the setting of infection outbreaks, providing access to expanded access and emergency use therapeutics can be a challenge. Rapidly implementing models of care that assist with these therapeutics is critical. The goal of such models is to offer general providers both expertise in these therapeutics as well as support in overcoming barriers to their access. Core, reproducible aspects of this program include the creation of a centralized referral hotline, the harnessing of telemedicine visits for rapid patient contact, and the training of an advanced practice provider in the management of an emerging infectious disease and the navigation of the complex steps of investigational drug procurement. An outbreak referral clinic streamlines care and alleviates administrative burdens for general providers.

STREET MEDICINE: INNOVATING HEALTHCARE DELIVERY THROUGH STATE POLICY CHANGE

Neda Ashtari¹; Mary Marfisee²; Brett Feldman⁴; Sydney Kamlager-Dove^3,5

¹Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Family Medicine, University of California Los Angeles, Los Angeles, CA; ³California State Senate, Sacramento, CA; ⁴Family Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA; ⁵University of Southern California, Los Angeles, CA. (Control ID #3840228)

STATEMENT OF PROBLEM/QUESTION: People experiencing homelessness (PEH) experience a higher burden of physical and behavioral health conditions compared to their housed peers but face greater barriers to accessing medical and social services within traditional healthcare systems.

DESCRIPTION OF PROGRAM/INTERVENTION: Street medicine, mobile clinics, and shelter-based care have attempted to bridge the gap between eligibility and access to care for PEH, but state policy has not supported these alternative delivery models. The presenters, a medical student working as a legislative aide, a state senator, and street medicine experts, used process mapping to describe the mechanism by which PEH currently navigate the healthcare system, from the point of Medi-Cal enrollment to the point-of-care. We met with key stakeholders, including health plans, community clinics, hospital systems, and the Department of Health Care Services (DHCS) to identify salient barriers to care; namely: (1) Lack of insurance; (2) Logistical challenges (e.g., transportation, identification, mailing address for beneficiary card, empanelment to unknown/inaccessible provider); and (3) Lack of data on unhoused Medi-Cal beneficiaries. Guided by stakeholder input, we identified potential points of intervention and proposed several policy changes to improve healthcare for PEH. We also conducted a fiscal analysis to demonstrate projected cost-savings, which was presented to the state’s appropriations committees.

MEASURES OF SUCCESS: The adoption of departmental policies or legislation that increase Medi-Cal enrollment among PEH, eliminate logistical challenges to accessing care, allocate additional resources to street medicine programs, incentivize health plans to engage in homeless outreach, and create a mechanism to collect data on unhoused Medi-Cal beneficiaries.

FINDINGS TO DATE: Our policy recommendations were successfully adopted through departmental guidance, making California the first state to: (1) Reimburse street medicine and shelter-based providers for services rendered outside traditional clinical settings; (2) Expand Hospital Presumptive Eligibility to PEH; (3) Categorize street medicine providers as Direct Access Providers, allowing direct access to primary care and referrals from all licensed providers regardless of empanelment; (4) Streamline the process of PCP reassignment for PEH; (5) Provide financial incentives to health plans for homeless outreach; and (6) Add housing status to Medi-Cal applications to facilitate data collection on unhoused Medi-Cal beneficiaries.

KEY LESSONS FOR DISSEMINATION: Traditional healthcare models have failed to meet the needs of complex populations, but provider-legislator partnerships can facilitate the adoption of innovative patient- centered healthcare delivery models. Successful policy change requires engaging a broad range of stakeholders, demonstrating projected cost-savings, and considering legislative and departmental approaches. Other states may utilize the framework shared here to advocate for innovative policies that improve care for their most vulnerable populations.

SUCCESSFUL TREATMENT OF HEPATITIS C IN A TINY SHELTER ENCAMPMENT ON VETERANS AFFAIRS GROUNDS

Kimberly Lynch^2,3; Cassandra C. Lautredou¹; Peter Capone-Newton²; Katherine Strickler¹; Matthew McCoy²; Jenna Kawamoto²; Arpan Patel^2,3; Debika Bhattacharya^2,1; Michele Seckington²

¹University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²VA Greater Los Angeles Healthcare System, Los Angeles, CA; ³University of California Los Angeles, Los Angeles, CA. (Control ID #3868823)

STATEMENT OF PROBLEM/QUESTION: Hepatitis C (HCV) is a curable disease with a high prevalence in people experiencing homelessness (PEH) due to multiple risk factors. However, treatment for HCV in this population is often not offered nor completed due to barriers with receiving care in traditional healthcare settings.

DESCRIPTION OF PROGRAM/INTERVENTION: We hypothesized that providing low barrier HCV care coordination and treatment within a sanctioned tiny shelter encampment on Veterans Affairs (VA) grounds would result in cure of HCV for the majority of Veterans offered treatment. Fall 2021, an on-site “encampment medicine” team began to engage with and care for Veterans at the encampment on the grounds of the West Los Angeles (LA) VA. Despite the encampment’s close proximity (1/2 mile) to the VA hospital and homeless specific primary care clinic, Veterans routinely missed appointments for laboratory testing, liver ultrasound, and HCV treatment initiation and counseling. This showed that the traditional treatment workflow was inaccessible for this population. Acknowledging this unique opportunity to engage this vulnerable population, the on-site team worked with the Greater LA VA Healthcare System Viral Hepatitis Program to simplify the HCV treatment workflow for Veterans in the encampment. Baseline data via chart review identified 11 of 103 Veterans in the encampment with active treatment naïve HCV (age range: 28-68; average years since diagnosis: 8, range 1-15). Veterans reported that despite knowing about their diagnosis for years and having an interest in treatment, prior healthcare settings had precluded them from treatment due to their housing instability.

MEASURES OF SUCCESS: Rate of engagement in care, treatment completion and HCV cure with Sustained Virologic Response (SVR12).

FINDINGS TO DATE: In the initial six months of the on-site outreach program:

9 patients started HCV treatment

- 4 completed treatment with on-site team (1 with SVR12 cure, 3 awaiting SVR12 laboratory testing)

- 3 completed partial treatment (~2-4 weeks of medications) with on-site team (2 with SVR12 cure, 1 not cured)

- 2 completed treatment with clinic providers (both with SVR12 cure)

2 patients left for transitional / supportive housing and were not started on treatment (1 received medications but did not start)

Anecdotally, patients reported HCV treatment as a reason for renewed interest and as a possible catalyst for engagement in medical/substance use treatment. A second cohort of patients with HCV (n=6) was engaged in Fall 2022 with results to follow.

KEY LESSONS FOR DISSEMINATION: HCV treatment is feasible in a tiny shelter encampment for PEH. Success is attributed to 1) a simplified workflow for treatment initiation through partnership with the viral hepatitis program group and 2) building trust and solidarity with PEH by delivering care at a convenient time and place via a consistent on-site team. This workflow and team-based care should be easily reproducible for other health systems and communities although feasibility may be limited by insurance authorizations for those with non-VA insurance.

SUPPORTING CHANGE MANAGEMENT AND OPTIMIZING SKILLED NURSING FACILITY UTILIZATION AT A LARGE ACCOUNTABLE CARE ORGANIZATION

Kathryn Corelli^1,6; Katie Carr¹; Jenna Morrissey¹; Julia Meehan¹; Annmarie Chase²; Carolyn Yuse³; Elizabeth Cronin⁴; Maureen L. Palla⁵; Brook Calton⁶; Sandra Butler^1,6; Kristian Olson^1,6; Amy Baughman^1,6

¹Population Health, Mass General Brigham Inc, Boston, MA; ²Mass General Brigham Salem Hospital, Salem, MA; ³Brigham and Women's Hospital, Boston, MA; ⁴Emerson Hospital, Concord, MA; ⁵Pentucket Medical Associates, Newburyport, MA; ⁶Massachusetts General Hospital, Boston, MA. (Control ID #3873443)

STATEMENT OF PROBLEM/QUESTION: Skilled nursing facility (SNF) use is suboptimal for low risk and end of life patients who are better served in the home or palliative setting.

DESCRIPTION OF PROGRAM/INTERVENTION: Hospitals rely on SNFs to manage capacity issues, which has promoted SNF overutilization. Value-based care – improving quality and reducing costs— is where reducing inappropriate SNF utilization can shine. SNF utilization is high-cost, accounting for 6% of total 2019 expenditures in our Medicare Shared Savings Program accountable care organization (MSSP ACO). Reducing inappropriate exposure to institutional care settings can improve quality of care and reduce rates of readmissions for elderly, frail patients.

Our population health management team’s goal was to use multiple levers to support novel programs that optimize SNF use across our healthcare system, a large nonprofit multicenter including two academic medical centers, community hospitals, physician organizations, and a post-acute care (PAC) organization.

While all 12 sites have transitional care managers that focus on utilization management, few were engaged in formal innovative strategies to reduce SNF use.

In late 2021, we created financial incentives to reduce inappropriate SNF use at hospitals. In 2022, we created a learning collaborative and toolkit to provide evidence and examples for seven intervention areas: expanded home services, education, mobility, care management, PAC needs assessment, end of life, and clinical pathways. We partnered with an innovation team, Springboard Studio, and established a grant competition for six proposals, up to $50,000 each, to decrease inappropriate SNF use across the system.

MEASURES OF SUCCESS: We track average rates of SNF use across our system using SNF referral data and engagement in SNF utilization work as evidenced by participation in the learning collaboratives and launching of a pilot program. We will evaluate discharge disposition, readmission rates and SNF/hospital length of stay across all pilots, in addition to pilot specific outcomes.

FINDINGS TO DATE: MSSP ACO SNF referral data showed an average rate of 1305 and 1318 days/1000 total stays in 2021 and the first half of 2022, approximately 10% above national average. We supported 6 innovative pilots at 5 sites to date; a SNF-at-home model with expanded home services, two palliative care pilots aimed at avoiding the “rehabbed to death” cycle, a ‘6-clicks’ PAC needs assessment tool and remote monitoring effort, and two focused on increasing inpatient mobility.

The ongoing pilots have been shared across our learning collaborative which all 12 sites have participated. This has resulted in positive change and new efforts to decrease inappropriate SNF use. Two additional programs are being implemented at a non-pilot site: a mobility program and hospice referral pilot.

KEY LESSONS FOR DISSEMINATION: Change management requires multiple levers. By providing education, quality improvement coaching, financial incentives, and robust support, we have promoted several replicable efforts to optimize SNF use at the local level.

TELE-SPECIALIST PROGRAMS SERVING RURAL AMERICAN INDIANS AND ALASKA NATIVES: CURRENT IMPLEMENTATION STATUS

Yun Li²; Brooke Wilson³; Matthew Tobey¹

¹Medicine, Massachusetts General Hospital, Boston, MA; ²Medicine, Massachusetts General Hospital, Boston, MA; ³Massachusetts General Hospital, Boston, MA. (Control ID #3873974)

STATEMENT OF PROBLEM/QUESTION: To understand implementation status of selective tele- specialist programs serving rural AIAN population, including barriers to implementation and threats to sustainability

DESCRIPTION OF PROGRAM/INTERVENTION: There is a significant lack of access to specialist care for the 8.75 million people in the US who identify as American Indians and Alaska Natives (AI/AN). Such disparity is more alarming for AI/ANs residing in rural areas. The Indian Health Service (IHS) and Tribal health facilities are tasked by the US Congress and Tribal governments to provide quality medical care to AI/AN population. These organizations have been piloting tele-specialist programs in outpatient setting to improve access.

Our academic teaching hospital physician team has been staffing a rural IHS facility through a partnership with IHS. Our team has been active using telemedicine to improve care delivery, such as delivering Hepatitis C and HIV care and providing clinical service to jail facilities. Our team has also been referring patients to a tele-specialist service, vended by a third-party health care organization. Little is known about the current status of this program. Data acquisition for quality improvement is limited due to program's inter-agency nature and privacy issues. We instead surveyed selective existing tele-specialist programs to understand their current status, with hope that such learnings would shed light on our own practice.

MEASURES OF SUCCESS: We queried each tele-specialist program implementation specifics by interviewing its program leadership. A semi-structure interview guide was used to frame the interviews. Key specifics included program starting year, lines of specialty available, volume of the service, delivery modality, measures of cultural adaptation. Interviewees were prompted to identify factors that were barriers to implementation and threats to program sustainability.

FINDINGS TO DATE: We conducted 11 interviews representing 7 tele-specialist programs. These programs varied significantly in initiation years, patient volume and number of specialty service lines. All used video as media and had patients travelled to a centralized location. All programs had medical staff assisting patients interacting with the specialist during the clinical encounter. Yet the training of the staff varied significantly. Interviewees usually took additional time to identify cultural adaption measures, with some programs having more organized approaches than others. All programs commented the presence of administrative support and sustainable financial reimbursement as key factors for program sustainability.

KEY LESSONS FOR DISSEMINATION: There is emergence of tele-specialist programs serving rural AI/AN populations at IHS and Tribal health care facilities. These programs aim to improve specialist care assess. Most programs are still early-stage and small in scale. Strong administrative support, correct provider incentives, clear reimbursement policy, and timely communication are identified as important factors for program sustainability.

THE EHR, THE PHYSICIAN AND THE SYSTEM: A MORE HOLISTIC APPROACH TO OPTIMIZATION

Stewart Babbott, Janet Lewis

Medicine, University of Virginia, Charlottesville, VA. (Control ID #3875734)

STATEMENT OF PROBLEM/QUESTION: The Chief of an Ambulatory Academic Subspecialty practice noticed some of her faculty were having challenges with the EHR as measured by the volume and nature of unresolved in basket items. In the EPIC EHR, the inbasket contains activities such as telephone calls, patient portal messages and prescription refills. Using a standard approach, an institutional EPIC trainer reviewed EHR related performance data (Signal) and met with the faculty to assess their knowledge about EPIC and use of tools designed to enhance efficiency.

Recognizing that the clinical and clerical systems influence physician performance, our broader approach included interview with (1) Chief to assess work demands and work flow including referrals and consultative care (2) nursing to assess for internal messaging and work flows, (3) pharmacy to assess prior authorization and related work for non-biologic and biologic medications, (4) EPIC trainer/analyst for training and acquisition/analysis of Signal assessment as well as (5) wellbeing assessment by our Wellbeing team (outside of the department).

DESCRIPTION OF PROGRAM/INTERVENTION: Review of Signal data, especially for time in chart and documentation

EPIC trainer for 1:1 direct observation, development and implementation of training plan, assessment of sources of items sent to inbasket

Interview with pharmacists for prior authorization management Interview with nurses by trainer and by Chief to assess workflow.

MEASURES OF SUCCESS: Measures of Success

Chief –Support for physicians

Physician – Workflow review and engagement in training

Nursing – Adjustments for internal work flows

Pharmacy – Prior authorization process

FINDINGS TO DATE: In basket – improvement in task completion timeliness

Signal – Less time on chart review and documentation

Pharmacy – unanticipated loss of personnel resulted in shifting of work back to nurses and physicians Nursing – identification of workflows that were inefficient; implementation of changes in monthly meetings with nurses and physicians

Physician – offered support with additional personnel to help clear out backlog of in basket items (declined by physician)

Physician –additional time to accomplish tasks; given a reduced clinical schedule over several months to allow time to catch up; has been able to resume a full time schedule.

KEY LESSONS FOR DISSEMINATION: Optimization of physician’s individual use of the EHR through tools and skills is a relatively small part of addressing workload and sustainability

Recognition that tasks such as “inbasket” activities outside of clinic sessions add a significant amount of time to physician daily workload.

Physician struggles with EMR documentation and workload should not be attributed solely to individual deficiencies, but often reflect a systemic failure that requires a holistic, team-based approach. Engagement of key stakeholders including leadership, nursing, pharmacy

Engagement of trainer to assess and support physician

Engagement of analyst (Signal) to assess data that highlights key practice issues

THE PLOT THICKENS: A VIDEO MASTER CLASS ON GROWING FOOD AT HOME FOR PATIENTS WITH MENTAL HEALTH (MH) DISORDERS

Sally Namboodiri^1,2

¹Medicine, VA Northeast Ohio Healthcare System, Cleveland, OH; ²Case Western Reserve University School of Medicine, Cleveland, OH. (Control ID #3860412)

STATEMENT OF PROBLEM/QUESTION: Studies show that MH patients have lower levels of stress hormones when engaged in gardening activities and that patients who grow their own food have more nutritious diets and increased physical activity; we wanted to explore if a video class led by a Master Gardener would enhance patients' confidence in growing their own food and promote positive changes in their moods and physical activity.

DESCRIPTION OF PROGRAM/INTERVENTION: A weekly one-hour group video session is held with a cohort of 2 to 4 MH patients across four weeks. Patients are recruited to the program through MH provider consults. Using a Likert scale, patients rate their confidence levels in food growing prior to and after the 4-week program. A Master Gardener volunteer reviews a power point each session; topics include planting mediums, steps in seed starting, growing herbs and microgreens, and a gardening topic of the patients' choice. Sessions are highly interactive. Patients complete short answer questions at the end of the series about effects of the program on their moods and physical activity levels. They also complete a program evaluation.

MEASURES OF SUCCESS: Qualitative metrics include patients' confidence levels in choosing soil amendments, seed starting, growing herbs and microgreens, and class quality rating. Short answer questions request input for class improvements and any self-perceived effects of the class on mood and physical activity.

FINDINGS TO DATE: Over 8 months, 16 patients were enrolled and 10 completed all 4 sessions. Average age was 57, with 6 males and 10 females, 56% White and 43% Black, and 100% of patients having a MH diagnosis, such as post-traumatic stress disorder. Baseline confidence levels varied widely from 1 (not confident) to 5 (very confident) in areas of growing herbs and microgreens, growing food from seeds, choosing soil amendments, and knowing how and when to water plants. Post series confidence levels in these areas increased for 80% of participants by an average of 25%-50%. Patients with higher baseline confidence levels expressed the greatest enthusiasm and were most likely to complete all 4 classes; they cited convenience and safety of virtual sessions and knowledge sharing as program highlights. Ninety percent of participants felt the classes improved their mood and determination to be more active in the garden.

KEY LESSONS FOR DISSEMINATION: Medical center gardens are ideal sites for MH patients to gain hands-on experience in all aspects of food growing, but due to COVID-19 mandated social distancing and the fact that many interested participants lived far from our medical center, we created a virtual class format. Volunteer Master Gardeners provide patients with a wealth of education, trouble-shooting, and free local resources tailored to various interests. Virtual classes can improve mood and physical activity by promoting connectedness and community building. Such classes may especially benefit seasoned gardeners with MH disorders through the exchange of advanced horticultural knowledge in the safety and convenience of their own homes.

TRANSFORMING THE COMPENSATION MODEL OF A NETWORK OF PRIMARY CARE PRACTICES AFFILIATED WITH AN ACADEMIC MEDICAL CENTER (AMC): A VALUE- BASED APPROACH THROUGH RISK-ADJUSTED PANELS

Salina Bakshi¹; Richard S. Gitomer²; Lipika Samal³

¹Medicine, Brigham and Women's Hospital, Brookline, MA; ²Internal Medicine, Brigham Health, Boston, MA; ³Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #3874622)

STATEMENT OF PROBLEM/QUESTION: By shifting from a fee-for-service (FFS) to a value-based compensation model, we aimed to align provider incentives and increase revenue by growing primary care covered lives.

DESCRIPTION OF PROGRAM/INTERVENTION: Primary care functions optimally when a multidisciplinary team of individuals care for a complex patient population through medical, nursing, and psychosocial resources. Value-based care models can provide support for population health resources while also recognizing and incorporating physician work effort. Our AMC is part of a large integrated delivery system and has sixteen primary care practices. In this setting, we designed a novel compensation plan in which physician salary centered upon a per-member-per-year rate based on panel size. We accounted for physician work effort by adjusting panel size based on patient clinical complexity (risk score), social complexity (Medicaid status), and proportion of panel that was female. Primary care revenue continued to be generated through RVUs; however, physician salary was determined by panel size. Our model included an RVU floor, which ensured that there would not be a large decrease in revenue generated through FFS encounters. An increase in covered lives and associated downstream revenue thus enabled us to pay our physicians through a panel-based system.

MEASURES OF SUCCESS: Our quantitative measures of success included panel growth and associated downstream revenue generated for our AMC as a result of panel expansion through patient acquisition for our health system, and burnout rate measured by the Stanford Doctor Survey^TM tool administered every other year. We have compared pre and post intervention periods (10/2017 vs 10/1021 dates). We are also planning to measure physician well-being and satisfaction using surveys.

FINDINGS TO DATE: The 16 primary care practices included 200 primary care physicians who participated in the new compensation model. Primary care revenue through FFS encounters remained consistent. Primary care covered lives grew from approximately 122,000 lives in fiscal year 2017 to approximately 142,000 lives in fiscal year 2021, and resulted in an incremental downstream margin that grew from 2.5% in 2017 to 7.2% in 2021. Burnout rate decreased from 49% (2017) to 43% (2021).

KEY LESSONS FOR DISSEMINATION: The increase in covered lives through our panel based model generated downstream revenue that enabled us to support a multidisciplinary primary care team with medical, nursing, and psychosocial resources. Our panel based model supports physician wellbeing through incorporating physician work effort as well as providing additional practice resources. Initial findings suggest a decrease in primary care physician burnout.

USING ARTIFICIAL INTELLIGENCE TO UNDERSTAND THE FREQUENCY AND VOLUME OF HIGH-RISK PATIENT MESSAGES IN THE PRIMARY CARE SETTING

Kaustav Shah¹; Clifford Pang³; Scott Teplin⁴; Kamran Kowsari⁵; Jeffrey Fujimoto²

¹Medicine, University of California Los Angeles, Los Angeles, CA; ²Internal Medicine, UCLA, Los Angeles, CA; ³Family Medicine, University of California Los Angeles, Los Angeles, CA; ⁴Nursing, University of California Los Angeles, Los Angeles, CA; ⁵Office of Health Information and Analytics, University of California Los Angeles, Los Angeles, CA. (Control ID #3874795)

STATEMENT OF PROBLEM/QUESTION: Can an artificial intelligence tool help identify high-risk patient portal messages that may require faster triage?

DESCRIPTION OF PROGRAM/INTERVENTION: In basket messaging has grown in popularity as a mechanism for patients to directly communicate with their medical providers. However, there is lack of standardization around what content is appropriate for patient portal communication and expectations around response times. As message volumes increase, there are also patient safety issues that arise when patients utilize the messaging portal inappropriately. To understand the urgency and volume of high-risk patient messages, an academic center in the California-Hawaii region developed an artificial intelligence (AI) tool leveraging natural language processing (NLP) to assign a risk score to all patient portal messages in the primary care setting. The model was validated against 17,000 messages using an internally developed high- risk symptom checklist used to triage patient phone calls. The model interfaces with the electronic health record and can flag high-risk messages for the user. One early intervention that was launched moves high-risk messages to the top of a user’s work queue automatically with the intention of promoting earlier action on the message.

MEASURES OF SUCCESS: We analyzed the distribution of high-risk messages during weekends and non-

business hours to determine whether the volume of high-risk messages at times when clinics may not be staffed. We also will measure median turnaround times, essentially the time it takes for a message to be routed to nurse triage or physicians by staff who are the first to see any message. A difference in differences study will be used to compare median turnaround times for pilot clinics in which message reprioritization was implemented against control clinics.

FINDINGS TO DATE: The NLP tool was successfully developed and deployed by the health system. Over 140,000 patient portal messages have been scored. 30% of all messages are received by clinics outside of typical business hours (9AM to 5PM). Notably, 36% of all high-risk messages are received during non- business hours. The weekend days had fewer portal messages than the weekdays, but had a higher percentage of high-risk messages. Next steps include analyzing median turnaround times for all messages, stratified by day of week and time of day. Operationally, evaluating the feasibility of automatic triage of high-risk messages during off-hours and further study of disposition decisions from high-risk messages will help guide resource allocation to address these messages in the future.

KEY LESSONS FOR DISSEMINATION: Artificial intelligence tools may be helpful for identifying patient portal messages that require expedited response. Preliminary analysis shows the there may be a significant volume of messages with high-risk features occurring at times (weekends and nights) when inboxes may not be actively reviewed. Health systems should continue to develop solutions to tackle this challenge to ensure patient safety.

USING HUMAN-CENTERED DESIGN TO INNOVATE END-OF-LIFE CARE FOR OLDER ADULTS WITH DEMENTIA

Lorraine M. Pereira¹; Lara Z. Chehab³; Amanda Sammann³; Daniel Dohan²; Elizabeth W. Dzeng^1,2

¹Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA; ²Philip R. Lee Institute of Health Policy Studies, University of California San Francisco, San Francisco, CA; ³Department of Surgery, University of California San Francisco, San Francisco, CA. (Control ID #3874030)

STATEMENT OF PROBLEM/QUESTION: In the United States, 75% of acute care hospitalizations in older adults with advanced dementia are medically unnecessary or inconsistent with patient preferences and are associated with worse outcomes. Prior interventions to reduce the prevalence of potentially non-beneficial life-sustaining treatments (“burdensome care”) for this population have focused on modifying individual clinicians’ behaviors and have been ineffective, suggesting the need for innovative approaches to produce systems-level solutions that are both impactful and desirable.

DESCRIPTION OF PROGRAM/INTERVENTION: This study utilized human-centered design (HCD) to create and test provider-facing, systems-level interventions for reducing burdensome care near the end of life (EOL) for older adults with dementia. HCD includes 3 phases: Inspiration (understanding stakeholder needs), Ideation (brainstorming solutions) and Implementation (testing and refining solutions.) In the Inspiration phase, we conducted and analyzed interviews with clinicians who care for older adults with dementia near the EOL to identify potential drivers of burdensome care. In the Ideation phase, we assembled teams of clinicians, designers and researchers to brainstorm solutions to address these drivers. In the Implementation phase, we iteratively tested and refined solution concepts (“prototypes”) through testing with clinician stakeholders.

MEASURES OF SUCCESS: In the Implementation phase, participants were asked to both rate each prototype on a 1-5 scale based on desirability, feasibility and impact and rank the prototypes within each thematic category. The median and mode of these quantities were calculated for each prototype for each testing cycle. Qualitative feedback on prototypes was garnered from interview transcripts. Both quantitative and qualitative feedback were discussed within the study team and decisions were made to refine, consolidate, improve or eliminate prototypes.

FINDINGS TO DATE: The study team interviewed 22 clinicians from 3 academic medical centers. 5 insights arose from thematic analysis, and were presented to 11 stakeholders across 3 brainstorming sessions. Out of a total of 132 ideas generated across 46 different themes, the top 9 solution areas were selected and representative prototypes were developed. These novel prototypes to reduce burdensome care were iterated and refined across 3 cycles of testing with clinician stakeholders from 3 different hospitals in California.

KEY LESSONS FOR DISSEMINATION: HCD is an innovative and rigorous approach that yields high- quality interventions through engaging stakeholders at every stage of intervention development. This methodology may be particularly impactful for developing solutions to systems-level challenges in healthcare. Our team will continue to closely engage clinicians who care for older adults with dementia near the EOL as we refine and pilot provider-facing, systems-level interventions to mitigate burdensome care.

UTILIZING A DATA VISUALIZATION TOOL AND AUTOMATED DISTRIBUTION PLATFORM WITH EMBEDDED LINKS TO EDUCATION TO IMPROVE ACCESS TO PRIMARY CARE PHYSICIAN BILLING, PANEL SIZE, AND QUALITY METRIC DATA: FACULTY PERCEPTIONS AFTER ONE YEAR.

Jodi M. Grandominico-Bradford¹; Neeraj H. Tayal²; Thomas Brancazio¹; Daniel E. Jonas¹

¹Internal Medicine, The Ohio State University, Columbus, OH; ²Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #3874396)

STATEMENT OF PROBLEM/QUESTION: Physicians experience inadequate access to data related to professional billing patterns, clinical quality metrics, and panel size despite these being key drivers of group financial performance and physician compensation, leading to limited participation in practice management initiatives.

DESCRIPTION OF PROGRAM/INTERVENTION: Utilizing the business intelligence platform Qlik Sense®, we designed intuitive visualizations of key financial drivers for faculty in an academic division of general internal medicine. In November 2021, a monthly email program was created to deliver personalized metrics allowing for regular feedback on and self-assessment of performance. Visualizations are emailed as PowerPoint files. Extracting, packing, and emailing occurs automatically utilizing nPrinting, an add-on module to Qlik Sense®. Each slide contains an individual faculty member’s data with descriptions of panel size calculations, a trend line depicting monthly panel trends, and target panel size. Suggestions for template adjustments are included based on % target panel achieved. Faculty receive their clinical quality metrics and professional billing patterns as well as those of all colleagues. Professional billing slides contain educational materials embedded as hyperlinks to videos covering 15 common primary care services. Faculty were surveyed prior to distributing emails on perceptions of access to this information. The survey included twelve 5-item Likert scale questions and was re-administered one year later to reassess.

MEASURES OF SUCCESS: Faculty knowledge, satisfaction, perception of behavior change, and use of educational videos

FINDINGS TO DATE: Pre-intervention survey response rate was 42% (28/67); post-intervention response rate was 53% (38/72). After 12 months of the intervention, there were increases in proportion of faculty reporting understanding of how patient panel size is calculated (64% [18/28] pre-intervention vs. 87% [33/38] post-intervention, p=0.01), having regular access to patient panel data (75% [21/28] pre vs. 90% post [33/37], p=0.047), to quality data (72% [20/28] pre vs. 89% [34/38] post, p=0.058), to professional billing patterns (36% [10/28] pre vs. 90% [34/38] post, p<0.01), and to educational material on coding/billing (33% [9/28] pre vs. 74% [28/38] post, p<0.01). Pre- and post-intervention, the majority agreed that the information would be helpful to have (82% vs. 82%). Post-intervention, the majority (89%) agreed that access to the information provided increased awareness of QI initiatives. A third (34%) indicated that it changed their billing practices. Some respondents (38%) indicated that the intervention increased stress. Educational videos on coding/billing were viewed a total of 217 times.

KEY LESSONS FOR DISSEMINATION: Personalized, regular feedback on key finacial drivers and quality metrics improved faculty knowledge of metrics, and increased awareness of quality initiatives. Linkage with educational tools for improved knowledge on billing and coding may result in behavior change for a substantial percentage of faculty.

“SURPRISINGLY HELPFUL”: THE INTRODUCTION OF “PORTAL PRACTICE SLOTS” TO ADDRESS THE INBASKET EXPLOSION

Jennifer Lukela¹; Audrey Fan¹; Julia Chen¹; Floyd J. Brinley¹; James Henderson¹; Eve Kerr^1,2

¹Internal Medicine, University of Michigan, Ann Arbor, MI; ²Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI. (Control ID #3872599)

STATEMENT OF PROBLEM/QUESTION: Despite the dramatic increase in the volume of electronic health record (EHR) in basket work over the past 3 years, including portal-based medical advice requests, organizations rarely provide dedicated time to address “portal practice” which has resulted in significantly more work for physicians outside of usual work hours and has negatively impacted physician well-being. DESCRIPTION OF PROGRAM/INTERVENTION: We implemented 20 minute “portal practice slots” (PPS) in our schedule templates (equivalent of one urgent visit per half-day of clinic) to allow physicians structured time to address inbasket workload and delivery of asynchronous patient care during the day. MEASURES OF SUCCESS: A survey was distributed 5 months after the intervention to assess physician agreement (5-point scale) regarding the impact of PPS on workload and worklife balance; a regression analysis assessed change in ‘pajama time’ using EPIC signal data, which measures monthly hours spent in the EHR on evenings and weekends.

FINDINGS TO DATE: 57 of 88 (65%) of general medicine faculty physicians responded to our post- intervention survey. 84% of respondents agreed or strongly agreed (referred to as agreed) that PPS decreased the amount of time spent on patient care outside of regular working hours, while 4% disagreed (no one strongly disagreed). 86% of faculty agreed that PPS improved their ability to address urgent inbasket messages during work hours (no one disagreed). 77% of faculty agreed that PPS have made inbasket work feel less overwhelming (5% disagreed). A common theme from qualitative survey comments included that PPS have been “surprisingly helpful,” with one physician stating, "One slot might not seem like much[,] but it has been incredibly helpful to have that time in clinic” and another noting, “My response times to messages have certainly been faster and patients have commented on improved satisfaction to me.” Another theme that emerged from comments was that PPS have “helped with feelings of desperation,” with one physician noting that “It has really improved my quality of life and satisfaction with practice.” Negative impact of PPS included decreased appointment access for synchronous patient care activities. The impact of PPS on pajama time was minimal and not significant [rate ratio: 0.983, 95% CI: 0.923-1.048]. During the post-intervention period the cFTE-weighted mean (sd) monthly pajama time was 18.4 (14.4) hours compared to 18.9 (14.6) hours pre-intervention.

KEY LESSONS FOR DISSEMINATION: The introduction of dedicated time for inbasket management in schedule templates is well received by physicians and led to perceptions of increased wellness and decreased work outside of regular work hours, despite limited evidence of impact on quantitative measures of pajama time.

Innovation in Healthcare Delivery (IHD) - Health Policy

DEVELOPMENT OF A MODEL TO END THE UNIVERSAL SHACKLING OF INCARCERATED PATIENTS

Nisha Mathur^2,1; Judy Wang^3,1; Neil Singh Bedi^2,1

¹Internal Medicine, Boston Medical Center, Boston, MA; ²Boston University School of Medicine, Boston, MA; ³School of Medicine, Boston University, Boston, MA. (Control ID #3872413)

STATEMENT OF PROBLEM/QUESTION: Despite their moral obligation to provide equitable, ethical, and humane care, healthcare institutions nationwide universally shackle incarcerated patients, regardless of circumstance and adverse effects to patient health.

DESCRIPTION OF PROGRAM/INTERVENTION: Shackling patients leads to ineffective patient care. The practice limits complete physical exams, negatively biases clinicians, and precipitates risk of falls,

delirium and severe vascular injury. Though international human rights and legal groups have voiced opposition, the shackling of incarcerated patients persists regardless of patient age, illness severity, consciousness, or mobility.

Led by medical students, clinicians, and public health faculty, the Stop Shackling Patients (SSP) Coalition is a task force and learning collaborative of clinicians, public health practitioners, human rights advocates, and community members with the goal of revising inpatient treatment of incarcerated patients. This Coalition collaborated with hospital leadership to reform their hospital’s Care of Prisoners policy. The revised policy innovates a process to provide individualized and dignified care for incarcerated patients by routinely screening the patient's medical status and altering the patient's shackles accordingly. The protocol outlines a schema for communication among carceral facilities, hospital security, and the healthcare team.

MEASURES OF SUCCESS: The initial aim was to form a diverse and informed task force to revise policy at the pilot hospital. The established Coalition and subsequent policy revisions successfully accomplished this goal. The implementation of the policy at the pilot hospital will be evaluated by completing periodic chart review audits and soliciting provider and patient feedback. The Coalition’s success will be measured by its establishment of educational programs, working groups, and changes to policy nationwide.

FINDINGS TO DATE: The Coalition summarized research on shackling policies and its repercussions in a nationally-recognized petition which garnered 780 signatures spanning 129 institutions. This capital was used to engage hospital leadership in policy reform. SSP also presented a resolution to the Massachusetts Medical Society, which was subsequently endorsed by their Committee on Public Health and the Medical Students, Residents, and Fellows section. As awareness spread, the Coalition extended to several additional hospitals, non-profit organizations, and health policymakers. SSP has also been invited to present at hospital rounds and forums of allied health professionals.

KEY LESSONS FOR DISSEMINATION: Entrenched hospital policies can seem impossible to modify. SSP overcame these seemingly immovable barriers in a stepwise process that can be modeled for a multitude of agendas. The Coalition systematically synthesized data, developed social and political capital, solicited stakeholders, and identified shared values to broaden support for policy change. With systematic processes and an amenable hospital administration, policy change and healthcare innovation is possible.

Innovation in Healthcare Delivery (IHD) - Medical Education and Scholarship

PARTNERSHIPS TO ACCELERATE THE ADOPTION OF RESEARCH INTO CLINICAL PRACTICE

Mia A. Papas¹; LeRoi S. Hicks^2,1

¹Institute for Research on Equity and Community Health, Christiana Care Health Services Inc, Wilmington, DE; ²Christiana Care Health Services Inc, Wilmington, DE. (Control ID #3876745)

STATEMENT OF PROBLEM/QUESTION: On average it takes 17 years for research evidence to reach clinical practice and even then, the application is uneven across diverse clinical environments and patient populations resulting in a critical need to narrow the research to practice gap.

DESCRIPTION OF PROGRAM/INTERVENTION: Most clinical research is conducted in large academic medical centers and is disconnected from health systems operations. Community based health care systems (CBHS) have a unique, valuable contribution to advance research agendas as they serve diverse patient populations and may have more simplified clinical operational structures. Developing research capacity embedded in CBHS may narrow the research to practice gap allowing a continued focus on improving patient outcomes while addressing health disparities, aiding in the recruitment and retention of clinical staff, and diversifying revenue streams. Through participation in the Cerner Learning Health Network (CLHN), a collaborative of >90 US health systems, our CBHS research group assessed healthcare systems’ readiness for conducting research, and ability to apply learnings from clinical research toward improving health outcomes.

MEASURES OF SUCCESS: We measured the number of research studies and the type of research (clinical trial or observational study) started post collaboration with the CLHN, the speed of adoption of research findings into clinical practice (< 1-year classified as immediate adoption and >= 1-year slow adoption), and the frequency of subsequent sponsored research studies.

FINDINGS TO DATE: Our non-profit, community-based healthcare system joined the CLHN at the beginning of the COVID-19 pandemic in June 2020. In the subsequent 2-year time frame, seven research investigations were launched, six observational studies and one clinical trial, involving physicians from six clinical disciplines including nephrology, hematology/oncology, family medicine, internal medicine, critical care medicine, and cardiology. Three of the seven investigations (42%) led to immediate adoption of findings in the delivery of care. Two of the investigations (28%) led to subsequent sponsored research studies, providing an additional source of revenue for the healthcare system. And each of the 7 investigations examined race/ethnic disparities in outcomes.

KEY LESSONS FOR DISSEMINATION: Clinical researchers embedded within healthcare systems can conduct and disseminate high quality research that provides guidance for clinical practice with the high potential of narrowing the 17-year research to practice gap and improving outcomes for diverse populations. Collaborations with National Networks, such as the Cerner Learning Health Network, can bring much needed resources to community-based healthcare systems to allow them to participate in research initiatives, reduce the time required to conduct site specific research, allow for the participation of diverse populations in research, and more rapidly apply evidence-based practice guidelines.

Innovation in Healthcare Delivery (IHD) - Medical Ethics and Humanities

THE PAUSE: AN INITIATIVE TO HONOR PATIENTS AND FACILITATE TRANSITION AFTER DEATH

Collin Hanson¹; Catherine Waymel¹; Maya Faison¹; Natalie K. Munger^2,1; Monica Malec¹

¹Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ²Palliative Care, Northwestern Memorial HealthCare Corp, Chicago, IL. (Control ID #3876231)

STATEMENT OF PROBLEM/QUESTION: The death of a patient can lead to a wide range of emotions experienced by healthcare providers (HCPs) involved in the patient’s care. HCPs are often required to transition from a patient’s death to the next patient encounter without adequate time to reflect.

DESCRIPTION OF PROGRAM/INTERVENTION: Here, we describe the process of instituting and evaluating a method, The Pause, to honor the loss of life while acknowledging the care provided by the care team.

The Pause is a voluntary moment of silence performed after a patient’s death. A group of Internal Medicine- Pediatrics residents at a Midwestern academic medical center initiated the roll-out of The Pause with institutional project support. Our team promoted the practice by facilitating focus groups to elicit feedback and tailor the approach to education and roll-out, coordinating meetings with multidisciplinary stakeholders (including nurses, physicians, respiratory therapists, pharmacists, and chaplains), and engaging instructors of resident code simulations to include The Pause.

MEASURES OF SUCCESS: To track our efforts to increase uptake and to evaluate provider experiences with and attitudes towards The Pause, we created a space within the electronic medical record to track when it is performed. A multidisciplinary focus group was surveyed to assess positive effects and any unintentional negative consequences of this practice.

FINDINGS TO DATE: After the focus group with 17 participants, there were 11 survey respondents. 7 respondents had previously engaged in a Pause, and of these, 6 had a very favorable attitude and 1 had a favorable attitude toward the practice. Of these 7, when asked if The Pause helped them process and transition to the next clinical encounter, 5 strongly agreed, 1 agreed, and 1 was neutral. Pause participants were asked if they felt this practice recognized the dignity of the deceased patient. 5 strongly agreed and 2 agreed with this statement. When asked to explain why, common themes emerged. 2 participants noted that The Pause provided respect for the deceased, 2 felt the practice honored the life of the deceased, and 1 participant felt The Pause encouraged reflection on “the sacredness of life.” Of the remaining 4 respondents who had not taken part in a Pause, attitudes toward the practice were much more variable with 2 favorable or very favorable, 1 neutral, and 1 unfavorable.

KEY LESSONS FOR DISSEMINATION: Within the focus group, 100% of those who participated in a Pause felt favorably about the practice and its ability to acknowledge the dignity of deceased patients. 86% felt it helped them transition to their next clinical encounter. There is greater variability in attitudes among non-participants. It may be that those who feel unfavorable or neutral towards The Pause are less likely to participate in this practice, or that participating in The Pause elevates favorability through its lived experience. With additional survey data, we hope to assess if this trend remains and to investigate why non- participants have a less favorable attitude toward The Pause.

Innovation in Healthcare Delivery (IHD) - Mental/Behavioral Health and Substance Use Disorders

A 5-YEAR EVALUATION OF MULTI-LEVEL INTERVENTION TO IMPROVE PRIMARY CARE- BEHAVIORAL HEALTH INTEGRATION

Neda Laiteerapong¹; Sandra A. Ham²; Lisa Vinci³; Fabiana Araujo¹; Mim Ari¹; Daniel Yohanna¹; Erin Staab⁴

¹University of Chicago Division of the Biological Sciences, Chicago, IL; ²Sandra Ham Consulting, Buffalo, NY; ³University of Chicago Division of the Biological Sciences, Chicago, IL; ⁴Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #3876901)

STATEMENT OF PROBLEM/QUESTION: Although primary care is the de facto mental health (MH) provider in the U.S., the majority of primary care clinicians and practices have limited MH training and services.

DESCRIPTION OF PROGRAM/INTERVENTION: A multi-level intervention (patient, clinician, health system) at a single urban, academic general internal medicine practice (18 full-time equivalents: 40 attending physicians and advance practice nurses, 100 resident physicians; ~30,000 patients: 58% Black, 28% White, 5% Asian, 5% Hispanic, 4% Other/Unknown) from 2015-2019. The intervention used data-driven continuous quality improvement and focused on clinical decision support tools for common mental health problems, depression screening, a co-located health psychology practice, and reducing stigma.

MEASURES OF SUCCESS: Success of the intervention was measured by an increase in 1) primary care visits with MH diagnosis, 2) follow-up visits in primary care after a MH diagnosis; and 3) follow-up visits after starting psychiatric medication. Additionally, success was judged by narrowing of age, sex, and race/ethnicity disparities in follow-up visits in primary care after a MH diagnosis.

FINDINGS TO DATE: We used interrupted time series to account for secular trends by comparing the pre- (2010-2014) to post-intervention period (2015-2019). Pre-intervention, 17% of the population had a visit with a MH diagnosis and the annual rate did not change (-0.1% (-0.6 to 0.4), p=0.80). Post-intervention, in 2015, the rate was 23% and increased by 1.8% (1.3 to 2.3%, p<0.001) per year. Pre-intervention, the rate of follow- up primary care visits for MH diagnoses was 163 per 1000 persons. The rate of follow-up primary care visits increased by 56.7 (11.6 to 101.7) per 1000 persons (p=0.05) in 2015 and remained steady in subsequent years (slope= 6.3 (-4.6 to 17.2), p=0.30). For patients on a psychiatric medication, pre-intervention, there was a declining rate of follow-up visits to primary care, psychiatry or behavioral medicine (-14.2 (-27.5 to -0.8) per 1000 persons, p=0.08). Post-intervention, this trend reversed and the rate of visits for those prescribed a psychiatric medication increased (25.9 (7.0-44.8) per 1000 persons, p=0.04). In stratified analyses, follow-up visits in in primary care for a MH diagnosis increased in the post-intervention period for all age and sex subcategories. Post-intervention, racial/ethnic differences in follow-up visits in PCG for a MH diagnosis were smaller.

KEY LESSONS FOR DISSEMINATION: Improving primary care-behavioral health integration is important but challenging. A multi-level, interdisciplinary approach can lead to substantial improvements in clinical diagnosis and visits for behavioral health in primary care.

AVOIDING THE “ASSESSMENT TRAP”: A QUALITY IMPROVEMENT INITIATIVE TO IMPROVE ACCESS AND ENGAGEMENT IN AN OUTPATIENT VA SPECIALTY ADDICTION TREATMENT PROGRAM

David Lawrence^1,2; Jesse Barglow¹; Pushpa V. Raja¹; Michael F. Mayo-Smith³

¹VA Greater Los Angeles Healthcare System, Los Angeles, CA; ²University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ³Medicine, White River Junction VA Medical Center, White River Junction, VT. (Control ID #3876014)

STATEMENT OF PROBLEM/QUESTION: Barriers to accessing substance use disorder (SUD) care remain a widely recognized contributor to the escalating US drug overdose crisis. In outpatient specialty addiction treatment programs (SATPs) limited provider resources often contribute to long wait times for the intake visit necessary to enroll in care. Furthermore, intake visits often become lengthy information gathering sessions that—while serving the needs of programs, payors, and regulators—often put patients in a passive and disempowered role that undermines collaboration and engagement. For patients struggling with fluctuating motivation, these obstacles stymie successful treatment entry and increase risk for SUD complications like overdose.

With a rationale that simplifying intake visits could improve appointment availability, treatment participation, and alignment with key principles of motivational interviewing, we implemented a rapid access model to facilitate low-barrier SATP admissions and studied its association with treatment entry outcomes.

DESCRIPTION OF PROGRAM/INTERVENTION: The key component of the rapid access model was a shortened intake visit focused on 6 critical domains, with 15 other previously required assessment elements (e.g. childhood & developmental history, nutritional assessment) shifted to a subsequent visit, allowing for a 2.5-fold greater number of shorter (from 60 to 30 minutes) and more collaborative intake appointments, without changes to clinic staffing. The model also eliminated a referral review step (all referrals were automatically accepted) and added pathways for virtual hand-offs, next-day visits, and patient self-referrals.

MEASURES OF SUCCESS: We measured number of referrals, time from referral to initial SUD visit completion, and rates of treatment enrollment (additional visit within 14 days) and engagement (>= 4 total visits within 60 days) for the 564 veterans referred to an outpatient SATP in the California-Hawaii region between May 2021 and August 2022, a time period encompassing eight months each of pre- and post- intervention data.

FINDINGS TO DATE: Between the pre- and post-intervention periods the mean time from referral to initial visit completion decreased from 27 to 11 days despite an increase in mean referrals from 27 to 44 patients per month. Additionally, the mean rates of enrollment and engagement increased from 39% to 55% and 34% to 48% of total referrals, respectively, between the pre- and post-intervention periods.

KEY LESSONS FOR DISSEMINATION: Despite increased referrals, the intervention was associated with faster entry into SUD services and increased rates of treatment enrollment and engagement. Key facilitators include more focused intake visits, proactive collaboration with referring providers, and options for self- referral. Broader redesign of SATP intakes along these lines could contribute to better use of existing resources in addressing the drug overdose crisis.

CO-OCCURRING INITIATIVES: THE EFFECTS OF ACADEMIC DETAILING ON THE ADVANCING PHARMACOLOGICAL TREATMENT FOR OPIOID USE DISORDER (ADAPT- OUD) STUDY

Wendy A. Miller¹; Adam J. Gordon^2,3; Barbara Clothier¹; Princess E. Ackland^1,4; Mark Bounthavong^5,6; Carla C. Garcia⁵; Marie E. Kenny¹; Siamak Noorbaloochi¹; Hildi Hagedorn^1,7

¹VA Center for Care Delivery and Outcomes Research, Minneapolis, MN; ²Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT; ³Department of Internal Medicine, The University of Utah School of Medicine, Salt Lake City, UT; ⁴University of Minnesota Department of Medicine, Minneapolis, MN; ⁵Health Economics Resource Center, Palo Alto Veterans Affairs HealthCare System, Palo Alto, CA; ⁶Skaggs School of Pharmacy Pharmaceutical Sciences, University of California San Diego, San Diego, CA; ⁷Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, MN. (Control ID #3868228)

STATEMENT OF PROBLEM/QUESTION: Did the co-occurring and independent initiatives of the Pharmacy Benefits Management (PBM) Academic Detailing Services Opioid Agonist Treatment of OUD Campaign and Advancing Pharmacological Treatment of Opioid Use Disorder (ADaPT-OUD) study have a positive synergistic effect on medication for opioid use disorder (MOUD) prescribing when used in combination?

DESCRIPTION OF PROGRAM/INTERVENTION: The ADaPT-OUD study implemented a 12-month individualized external facilitation strategy at eight Veterans Health Administration (VHA) facilities with the goal to improve MOUD access by addressing facility-level barriers. The external facilitation was guided by pre-implementation site interviews and included developing local implementation teams, educational didactics, as-needed consultation, and feedback on the national performance metric (ratio of patients with OUD diagnoses receiving MOUD of all patients with OUD diagnoses, the MOUD/OUD ratio). During the ADaPT-OUD intervention, the VHA PBM Academic Detailing Services Opioid Agonist Treatment of OUD Campaign was co-occurring. Academic Detailing (AD) aims to increase evidence-based practice at the clinician level. Within VHA, Academic Detailers engage clinicians by delivering targeted outreach using education materials and help identify barrier resolution strategies to improve evidence-based practice. While both interventions aimed to increase MOUD, they addressed different barriers and did not intentionally collaborate, thus, understanding their interaction will further inform implementation efforts of MOUD.

MEASURES OF SUCCESS: This was a secondary analysis of the ADaPT-OUD study that included 35 VHA facilities (8 intervention sites and 27 matched controls). The number of AD visits was used as a proxy for the intensity of AD activity, and the interaction between ADaPT-OUD and AD was evaluated by comparing the change in facility-level MOUD/OUD ratio at the beginning and end of the ADaPT-OUD intervention.

FINDINGS TO DATE: There was a general increase in the number of AD visits over the course of the ADaPT-OUD intervention period in both the intervention and control sites. Furthermore, there was a positively sloped linear relationship observed between the average number of AD visits per quarter during the intervention period and change in MOUD/OUD in the intervention sites that was not observed in the control sites; however, this was not significant.

KEY LESSONS FOR DISSEMINATION: Combination interventions aimed at facility- and clinician-level barriers have the potential to further increase access to MOUD, but research into the timing, quality, and synergistic effect is warranted.

EXPANDING OUTPATIENT ACCESS TO OPIOID USE DISORDER (OUD) TREATMENT IN AN ACADEMIC INTERNAL MEDICINE CLINIC

Helen C. West¹; Jasmine Williams⁵; Shayla Mitchell Bigelow⁵; Vickie Wheeley⁵; Jennifer Elston Lafata^3,2; Jacob Amburn⁴; Shana Ratner^1,3; Matthew Huemmer³; Kelly Reilly³; Holly Moore⁵

¹Division of General Internal Medicine, UNC Chapel Hill, Chapel Hill, NC; ²Health Policy and Management, The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC; ³Institute for Healthcare Quality Improvement, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; ⁴Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; ⁵UNC Health Care System, Chapel Hill, NC. (Control ID #3859654)

STATEMENT OF PROBLEM/QUESTION: In 2019, the University of North Carolina (UNC) internal medicine residency and faculty clinic had no buprenorphine providers and no OUD training program at a time when 80% of North Carolinians with OUD did not have easy access to treatment.

DESCRIPTION OF PROGRAM/INTERVENTION: To bridge the large gap between the number of patients with OUD and the number of addiction specialists, delivery of OUD care must shift to primary care. With the support of North Carolina MAHEC (Mountain Area Health Education Center) and the UNC institute for Healthcare Quality Improvement the UNC Internal medicine Clinic (IMC) assembled a multidisciplinary team to develop a primary care-based OUD treatment and training program.

MEASURES OF SUCCESS: We aimed to develop an OUD treatment clinic that would double its growth from 13 to 26 patients from September 2021 to August 2022 and after, maintain capacity to accept at least 2 patients per month. Process measures included a turnaround time of 21 days, social determinants of health screening (SDOH) and number of clinic providers able to prescribe buprenorphine. Goals for our training program included all medicine residents completing their waiver training and receiving ambulatory exposure to OUD treatment.

FINDINGS TO DATE: The UNC IMC grew its OUD clinic from 13 to 39 patients between September 2021 and October 2022 (300% growth, >2 patients per month). We implemented a residency OUD training program and have thus far provided waiver training to 100 residents. We grew our faculty prescriber pool from a baseline of 4 to 19. The current average turnaround time from referral to visit is 11 days, exceeding our initial target of 21 days. The UNC Health System's current goal for SDOH screening is to screen at least 55% of patients in any domain with the priority domains being food, transportation, housing, and financial resource insecurity. The IMC OUD clinic has screened 80%, 76%, 68% and 52% of its patients, respectively.

KEY LESSONS FOR DISSEMINATION: We encountered multilevel barriers in building a successful primary care-based opioid treatment and training program. Our project would not have been successful without strong support from leadership. By starting with small PDSAs to improve our clinic processes and riding the momentum of early success, we fueled further growth and engagement. We involved end-users in continual qualitative interviews and surveys and, by communicating our work persistently, we engaged our work force to change. We worked with our institution to build out data and analytic support tools embedded in our EMR (Electronic Medical Record), external registry tracking and a population health demographics dashboard. Sharing patient stories replaced stigma with joy and pride in collective successes.

IS EVERYONE REALLY ANXIOUS AND DEPRESSED?: A CLOSER LOOK AT MANAGING MENTAL HEALTH

Varun Choudhary. Clinical Care and Provider Services, Talkspace Network LLC, New York, NY. (Control ID #3874092)

STATEMENT OF PROBLEM/QUESTION: The mental health crisis is demanding physicians to provide services that they lack proper staffing, comprehensive training, and resources to appropriately and effectively address, leading to increased overdiagnosis and overprescribing.

DESCRIPTION OF PROGRAM/INTERVENTION: Mental illness is one of the most common worldwide causes of disability and poor health. Consequently the current global mental health crisis is one we are all fighting, making it essential for physicians to take on a more substantial role in addressing mental health conditions, yet the majority are unprepared to do so. Lacking the time and training to diagnose and manage the follow up necessary, the complexities of clinical mental health are often overdiagnosed and overtreated or misdiagnosed and mistreated.

The best possible solution offers treatment utilizing an omni-channel, multidisciplinary approach to care. Telemental healthcare delivery offers a truly innovative, comprehensive, and proven approach to care that has led to industry outcomes for the past decade. When providers align with interventions with telemental health, they offer three levels of support that improve mental health access, convenience, and a continuum of care. Digital mental healthcare technologies can supplement and extend clinical, operational, scientific, and technological resources.

MEASURES OF SUCCESS: As the foremost provider in modern-day telemental health, Talkspace therapy leads the industry in behavioral health research and has proven to be an effective, convenient, and affordable method for those facing mental health challenges. This presentation will primarily focus on two Talkspace research studies and expand on the following metrics:

As of 2021, 63% of a surveyed population utilizing telemental health services experienced a reduction in anxiety symptoms, and 67% experienced a reduction in symptoms of depression over the course of 54 days on average. 89% of members signed up for telemental health are still actively engaged with their provider.

Another study suggests that among individuals willing to initiate care through a DMHI, older adults had similar engagement as younger adults and showed similar improvement in symptoms of depression and anxiety.

FINDINGS TO DATE: According to a large randomized clinical trial (RCT), 84% of participants with clinically elevated depression and 64% of participants with clinically elevated anxiety experienced clinically significant symptom reduction when utilizing text therapy. 89% of members who signed up for telemental health are still actively engaged with their provider.

Another study suggests the use of specific linguistic indicators via telemental health can pinpoint how depressed, suicidal, or anxious an individual is feeling, thus assisting in automated diagnosis and assessment of depression, timely crisis intervention, and preparation for future care.

KEY LESSONS FOR DISSEMINATION: Providers will be able to manage mental health disorders incorporating omni-level patient treatment to determine a needed level of care to which individuals should be referred.

MENTAL HEALTH INTEGRATION INTO PRIMARY CARE: ONE CLINIC’S APPROACH FOR INCREASING ACCESS AND ADDRESSING PATIENTS’ MENTAL HEALTH NEEDS

David M. Callender, Brenda Doremus-Daniel, Brian Ludwin

UVA Health, Charlottesville, VA. (Control ID #3870673)

STATEMENT OF PROBLEM/QUESTION: Within a large primary care clinic at an academic medical center serving a diverse and often economically vulnerable population, only a small portion of people with a mental health diagnosis received mental healthcare.

DESCRIPTION OF PROGRAM/INTERVENTION: Our program aimed to improve mental health outcomes and access to services for patients within a large primary care clinic. Utilizing input from stakeholders, empirically-based care models, and community care goals, we designed and implemented a program of integrated mental health care offering screening, diagnostic evaluation, psychotherapy, and psychiatric chart review during the pandemic through in-person and remote access options.

MEASURES OF SUCCESS: The primary clinical outcomes were severity of depression and anxiety measured via PHQ-9 and GAD-7. Secondary outcomes were number of emergency department visits and

hospitalizations. To understand improvement in access to care, we tallied number of mental health screenings, therapy sessions, and medication optimization notes. Primary care physicians’ impressions were measured using pre/post surveys.

FINDINGS TO DATE: From July 2020-June 2022, 898 patients were referred, and 538 patients enrolled in the program. Among those enrolled, average depression scores (PHQ9), improved from 14.1 to 11.3. Average anxiety scores (GAD7) improved from 12.8 to 9.7. African-Americans experienced improved scores relative to Whites, and Spanish speakers experienced greater improvements in depression and anxiety relative to English speakers. Those enrolled subsequently had more healthcare visits (+4.32 PCP visits/year, +0.70 non- PCP visits/year) compared to those referred and not enrolled (+0.03 PCP visits/year; +0.27 non-PCP visits/year). We did not find a substantial change in emergency department visits or hospital admissions. The surveyed physicians (n=106) noted an improved ability to obtain a timely referral to a psychiatrist or psychotherapy and an improved perception of having enough resources to manage their patients’ mental health.

KEY LESSONS FOR DISSEMINATION: Our program improved access to mental health care in a vulnerable population and improved mental health outcomes for enrolled patients, including for those who identify as minorities. Given successful implementation of integrated mental health services in a large primary care clinic, improved timely access for mental health care that is often unattainable for our patients elsewhere, and improved depression and anxiety outcomes, it would be beneficial to expand integrated mental health care into additional primary care clinics.

OPIOID OVERDOSE ACTION PLAN FOR MEDICAL TEAMS EMBEDDED IN EMERGENCY SHELTER

Russell D. Berg¹; Sarah Leyde²; Mary Davies³

¹General Internal Medicine, Harborview Medical Center, Seattle, WA; ²General Internal Medicine, Harborview Medical Center, Seattle, WA; ³Yakima Valley Farm Workers Clinic, Toppenish, WA. (Control ID #3870240)

STATEMENT OF PROBLEM/QUESTION: How can embedded medical teams increase access to overdose-prevention medications in emergency homeless shelters?

DESCRIPTION OF PROGRAM/INTERVENTION: Many major cities in the United States are seeing rising rates of homelessness and opioid overdose. People experiencing homelessness (PEH) are particularly vulnerable; one recent study showed 1 in 4 deaths in PEH were due to overdose.

This project addresses the high rates of overdose among residents of a low barrier emergency shelter located in a former hotel, which serves approximately 100 residents. The shelter clinic is staffed by a provider and nurse.

Medications are a cornerstone of overdose prevention, including naloxone to reverse overdose and buprenorphine (bup) to treat opioid use disorder (OUD). IM naltrexone is used to treat OUD but case reports also describe prescribing naltrexone off-label to decrease the risk of opioid overdose in patients who do not have OUD but who overdose after unknowingly ingesting opioids (I.e., contaminated drugs.)

This project increases access and engagement through proactive identification, outreach, and naloxone distribution. The team identifies people at risk for overdose then conducts outreach via common spaces, phone calls, room visits, and coordination with case managers.

At first contact, intranasal naloxone is offered in-hand. Patients with OUD are offered bup for treatment of OUD or PRN opioid withdrawal. For patients without OUD but at high risk of unintentional opioid overdose, naltrexone is offered.

The team outreaches recipients of bup within 2 weeks to assess the need for dose changes and offer refills. Urine toxicology is not routinely collected.

MEASURES OF SUCCESS: # of patients at risk of overdose, # successfully outreached

# of patients prescribed bup (new, returned for refill)

# of patients given naloxone (Rx, in-hand)

# of patients prescribed naltrexone

FINDINGS TO DATE: From 3/7/21 through 12/3/22 , 29 residents were outreached. Of these, 12 (41%) were newly prescribed bup, 14 (48%) received refills of bup, and a total of 16 (55%) received a prescription for bup. 20 (69%) received a prescription for intranasal naloxone and 13 (45%) received intranasal naloxone in-hand at time of outreach. 4 (14%) were prescribed PO naltrexone.

KEY LESSONS FOR DISSEMINATION: For patients living in emergency shelter, proactive identification and outreach increases access to overdose-prevention medications.

Not all patients will pick up naloxone from a pharmacy; dispensing in-hand at first contact improves access. Offering bup as a harm reduction tool and PRN opioid withdrawal, instead of explicit goal of abstinence, may increase engagement.

PRIMARY CARE BEHAVIORAL HEALTH INTEGRATION FOR MEDICALLY AND SOCIALLY COMPLEX MEDICARE PATIENTS WAS ASSOCIATED WITH DECREASED PRIMARY CARE VISITS FOR THOSE HIGHLY ENGAGED IN PRIMARY CARE BUT WITH INCREASED PRIMARY CARE VISITS AMONG THOSE WITH LOW ENGAGEMENT IN PRIMARY CARE. Venkatesan R. Krishnamoorthi^1,2; Nicole M. Gier⁴; Tony Liu²; Anna Zonderman¹; Yuki Chong¹; Andrea Flores¹; David O. Meltzer³

¹Medicine, University of Chicago, Chicago, IL; ²University of Chicago Pritzker School of Medicine, Chicago, IL; ³Medicine, The University of Chicago, Chicago, IL; ⁴Hospital Medicine, The University of Chicago, Chicago, IL. (Control ID #3877410)

STATEMENT OF PROBLEM/QUESTION: Behavioral health (BH) problems are prevalent among patients with high health care utilization, and yet access to BH care remains challenging for this population, especially those in Medicare and Medicaid. Primary care-behavioral health integration (PCBHI) models have attempted to improve BH access and outcomes. One focus of existing literature on PCBHI models has been on decreased overall health care utilization. However, for some patients, increasing primary care engagement may be desirable and PCBHI may play a role. Also, few studies have focused on medically complex Medicare beneficiaries, a population with unique utilization patterns and BH needs.

DESCRIPTION OF PROGRAM/INTERVENTION: Starting in June 2019, at an urban academic center in the Midwest region, we implemented a PCBHI program in our program for Medicare beneficiaries with complex medical and social needs and at least one hospitalization in the prior 12 months. Enrollment in PCBHI involved patients consenting for their BH problems to be discussed among a multi-disciplinary team of internists, nurses, social workers, and psychiatrist consultants. Patients were listed in a BH management registry, and BH-related encounters were tracked, including brief BH interventions by team members, discussions during collaborative care rounds, and appointment-scheduling for community-based BH care providers.

MEASURES OF SUCCESS: We evaluated the impact of PCBHI on utilization of primary care visits, stratifying patients based on their rate of engagement at baseline. The mean number of completed primary care appointments and mean completion rate (show rate) was calculated and compared between one year prior to date of enrollment and for the one year afterward. Patients were stratified by their baseline (pre- PCBHI) number of appointments and completion rates. Paired t-tests were conducted using STATA.

FINDINGS TO DATE: Since June 2018, 142 patients were enrolled in PCBHI; the majority were women, and average age was 64. The mean number of completed appointments for all patients enrolled in PCBHI (n=133) decreased from 8.2 to 5.1 visits (p<0.001) in the year before to the year after enrollment. For patients in the top 25^th percentile of visits prior to PCBHI enrollment (n=35), visit number dropped from 10.2 to 5.7 (p<0.001). For patients in the bottom 25^th percentile of visits and show rate (n=32), visit number increased from 2.0 to 3.4 (p=0.002) and completion rate from 38% to 54% (p =0.012). Number of completed primary care appointments did not change significantly for the bottom 50^th percentile (n=64) while completed visits dropped for the top 50^th percentile (n=69) from 12.8 to 6.5 after PCBHI (p<0.001).

KEY LESSONS FOR DISSEMINATION: Consistent with current literature, our PCBHI program for a medically and socially complex Medicare population was associated with decreased health care utilization, specifically primary care visits. However, among patients with lower engagement in primary care, enrolling in PCBHI was associated with a possibly a beneficial effect of increased primary care utilization.

SUICIDALITY AMONG PATIENTS WHO HAVE OPIOID USE DISORDER AND CO- OCCURRING DEPRESSION AND/OR PTSD

Miriam Komaromy^1,6; Kirsten Becker²; Lisa S. Meredith²; Jasen Christensen⁴; Seth Williams³; John Bettler³; Michael Schoenbaum⁷; Colleen M. McCullough²; Christina Crowley⁵; Murad Laradji²; Katherine E. Watkins²

¹Grayken Center for Addiction, Boston Medical Center, Boston, MA; ²RAND Corporation, Santa Monica, CA; ³University of New Mexico Health Sciences Center, Albuquerque, NM; ⁴University of New Mexico School of Medicine, Albuquerque, NM; ⁵Pardee RAND Graduate School, Santa Monica, CA; ⁶Internal Medicine, Boston University, Boston, MA; ⁷National Institute of Mental Health, Bethesda, MD. (Control ID #3870675)

STATEMENT OF PROBLEM/QUESTION: Suicide and overdose are prevalent in people with opioid use disorder (OUD), and are of particular concern among those with co-occurring mental illness. We evaluated how common suicidality and overdose are in patients who have opioid use disorder plus co-occurring depression and/or PTSD.

DESCRIPTION OF PROGRAM/INTERVENTION: As part of a study of the use of the collaborative care model for patients who present to primary care with co-occurring opioid and mental health disorders (NIMH U01MH121954), we enrolled patients who report OUD and have probable depression and/or PTSD detected on baseline screening. We evaluated how often these disorders co-occur and studied participants’ patterns of self-reported suicidality and overdose.

MEASURES OF SUCCESS: We used data from eligibility screening to identify participants with probable OUD plus probable co-occurring depression and/or PTSD. Baseline surveys provided data on the frequency of self-reported suicidal ideation (past 30 days), history of suicide attempts (lifetime), and rates of overdose (past 90 days). We used chi-squared tests to compare these frequencies among the participants who had OUD, plus depression or PTSD exclusively, or both, at baseline.

FINDINGS TO DATE: The study enrolled 589 participants with probable OUD plus depression and/or PTSD. Among enrollees, 107 (18 %) reported depression alone and 137 (23 %) reported PTSD alone. 345 (59 %) reported co-occurring depression and PTSD. Baseline survey data revealed that 184 (31%) endorsed suicidal ideation during the 30 days prior to enrollment; participants with depression and PTSD reported suicidal ideation at a higher frequency (130; 38%) than did those with either depression (25; 23%) or PTSD (29; 21%) exclusively (X²=16.223; p<0.001). 194 (33%) participants reported ever making a suicide attempt; participants with co-occurring depression and PTSD (129; 37%) were more likely to report a previous attempt than those with depression (27; 25%) or PTSD (38; 28%) alone (X²=7.651, p=0.022). Reported overdoses in the past 90 days were rare (28; 5%), and did not differ significantly among groups (X²=3.587, p=0.166).

KEY LESSONS FOR DISSEMINATION: Among primary care patients with probable OUD, PTSD was more common than depression, and the co-occurrence of all three was the most prevalent condition. Patients with all three disorders had nearly twice the rates of current suicidal thoughts, compared with patients who had OUD plus depression or PTSD exclusively, and occurred in more than one third of patients. We conclude that very high rates of suicidality occur among patients with OUD and co-occurring depression, PTSD, and especially both depression plus PTSD together. Screening and intervention for depression, PTSD and suicidality are essential for care and safety of patients with opioid use disorder.

Innovation in Healthcare Delivery (IHD) - Quality Improvement and Patient Safety

ACHIEVING BONY GROWTH: IMPROVING OSTEOPOROSIS SCREENING IN A RESIDENT- RUN CLINIC

Devorah Edelman, Rebecca Pietro, Elizabeth Zipf

Internal Medicine, Mount Sinai School of Medicine, New Rochelle, NY. (Control ID #3848582)

STATEMENT OF PROBLEM/QUESTION: How do we improve osteoporosis screening rates in a resident-run primary care clinic?

DESCRIPTION OF PROGRAM/INTERVENTION: Osteoporosis and osteopenia are crucial public health issues, affecting over 53 million Americans and predisposing them to fractures. Fractures of the hip and vertebra are particularly associated with significant morbidity, mortality, and economic burden. Many expert groups have established guidelines to utilize BMD screening (DEXA scans) to identify individuals at risk of fracture, diagnose osteoporosis, and guide anti-fracture therapy. At the federally qualified Ryan Health Centers (in Manhattan, New York), only 16 percent of DEXA scans ordered by resident physicians were completed between 6/2019 to 11/2020. Our clinic serves a predominantly underinsured/uninsured population, many of whom are not English-speaking. At our specific site, the WFR Ryan Center, only 2.3 percent of orders were completed during this time. Our quality improvement project aimed to increase the DEXA scan completion rate by 10 percent.

Intervention: A root cause analysis was completed to identify barriers to the completion of DEXA scans, which included language, patient understanding of DEXA scans, patient-physician communication, and scheduling site issues. An information sheet with DEXA site information and a brief description of osteoporosis and DEXA screening was compiled. Copies in English and Spanish were placed in preceptor rooms and provided to resident physicians. Residents were notified through email, and the topic was discussed during pre-clinic huddle sessions. Residents provided handouts to all patients who met the criteria for BMD screening based on the National Osteoporosis Foundation Guidelines. Patients were encouraged to schedule their own appointments.

MEASURES OF SUCCESS: DEXA scans ordered and resulted between 3/2021 - 12/2021 were obtained from the EMR (ECW) for WFR and other Ryan Center sites (Thelma, Nena, Chelsea). Statistical analysis was performed using the chi-square test. We were looking for an increase in the proportion of scans completed after being ordered by residents after the intervention.

FINDINGS TO DATE: The DEXA completion rate at the WFR Ryan Center after intervention improved by 26% (p<0.0001). The DEXA scan completion rate decreased at the Thelma site, but the difference was not significant (p=0.31). At the Nena and Chelsea sites, the DEXA completion rate improved but not significantly (p=0.30 and p=0.96, respectively).

KEY LESSONS FOR DISSEMINATION: Resident-led initiatives targeting process measures can be effective. Implementing this intervention added virtually no time to a patient visit. A tool harnessing simple and culturally informed patient education significantly increased osteoporosis screening in our clinic.

ADDRESSING TRANSPORTATION BARRIERS IMPROVES NO-SHOW RATES IN A PRIMARY CARE CLINIC

Elizabeth M. Jean-Marie^1,2; Mihir Patel²; Tyler Luonuansuu^1,2; Andrew T. Harris³; Megan McNamara⁴; Timica Campbell^5,2; Melissa D. Klein⁶

¹Medicine, University Hospitals, Cleveland, OH; ²Medicine, VA Northeast Ohio Healthcare System, Cleveland, OH; ³Medicine, Louis Stokes Cleveland VA Medical Center, University Heights, OH; ⁴Internal Medicine, Louis Stokes Cleveland VAMC, Cleveland, OH; ⁵Internal Medicine, Louis Stokes VA Medical Center, Cleveland, OH; ⁶Medicine, Cleveland VA Medical Center, Shaker Hts, OH. (Control ID #3857162)

STATEMENT OF PROBLEM/QUESTION: At our Northeast Ohio VA Primary Care Clinic, a significant portion of missed clinic appointments is due to a lack of transportation to the visit.

DESCRIPTION OF PROGRAM/INTERVENTION: Our team developed a new process to identify Veterans who had transportation barriers contributing to appointment no-shows. Licensed practical nurses (LPN) or Clerks in four MD or NP resident-led Patient Aligned Care Teams (PACT) called each Veteran who missed an in-person appointment within one week of the missed appointment. Utilizing a Qualtrics survey patients were asked if lack of transportation was a reason they missed their appointment. Veterans who endorsed transportation concerns were given a number for the Veteran’s transportation service (VTS) van as well as referred to a Social Worker to help with long-term transportation options.

MEASURES OF SUCCESS: We aimed to identify the rate of no-shows for in-person primary care visits secondary to transportation barriers and to decrease patient no-shows for in-person appointments secondary to transport barriers by 50% by July 2022.

FINDINGS TO DATE: A total of 66 patients were contacted after they did not attend their primary care in- person visit. Forty-six (69.7%) of those patients had the survey completed and were asked if lack of transportation was a reason they did not make their appointment. A total of 10 (21.7%) patients answered yes, they had transportation issues. A total of 10 patients were provided the contact for the VTS. Of the patients with transportation issues, a follow-up EMR review in August, approximately three to four months after the initial missed visit, revealed that four patients were set up with Social Work, of which one had a video visit appointment completed and two had follow-up in-person appointments completed. An additional patient successfully completed an in-person follow-up visit but without the aid of social work. Currently, our no- show rate is down by 40% for our intervention group (from 100% to 60%).

KEY LESSONS FOR DISSEMINATION: Our team found a rate of 21% no-shows secondary to transportation barriers. Our QI project successfully streamlined our patient survey into the workflow of PACTs allowing us to identify Veterans with transportation barriers and connect them with transportation options. Our team aims to support the implementation of this workflow across all PACTs in our Primary Care Clinic. We identified virtual visits as a useful method for delivering essential primary care for patients with transportation issues while long-term transportation options are explored. Future efforts should focus on understanding the best strategies to connect Veterans with transportation options and ongoing monitoring of the impact on no-show rates.

ADOPTING SGLT2 INHIBITORS WITHIN A RESIDENT-RUN URBAN MEDICINE CLINIC: AN INTERDISCIPLINARY APPROACH

Melissa Neumann¹; Alexander T. Smith¹; Noreen Syed¹; Jason Ehrlich²

¹Internal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; ²Medicine, Northwell Health, New Hyde Park, NY. (Control ID #3872200)

STATEMENT OF PROBLEM/QUESTION: Despite their proven efficacy, sodium-glucose cotransporter 2 (SGLT-2) inhibitors are prescribed at particularly low rates to those at a socioeconomic disadvantage.

Our resident-run, urban, internal medicine clinic almost exclusively treats patients who are publicly insured or uninsured, and many of our patients have diabetes, cardiovascular disease, and/or renal disease. Given the relatively limited implementation of SGLT-2 inhibitors, our practice sought to increase the rate of prescription of this medication to qualifying patients.

DESCRIPTION OF PROGRAM/INTERVENTION: In July 2021, we compiled a list of patients at our urban, resident-run, internal medicine clinic who suffered from nephropathy and qualified for prescription of an SGLT-2 inhibitor by the DAPA-CKD or CREDENCE trial. We identified those patients who had a glomerular filtration rate between 25 and 90 milliliters per minute per 1.73 meters squared as estimated by the chronic kidney disease epidemiology group equation, and who either suffered from T2DM or had a urine albumin-to-creatinine ratio between 200 and 5000 mg/g. Prior to our study, only 23 of 118 patients identified received the medication.

We sought to prescribe this medication to at least 10% of these patients over the subsequent academic year. Providers involved in the care of each qualifying patient were sent a message that these patients were candidates for an SGLT-2 inhibitor, and those providers prescribed the medication at their own discretion.

MEASURES OF SUCCESS: Between July of 2021 and May of 2022, we continuosuly reviewed the charts of those patients that we had noted to qualify for prescription of SGLT-2 inhibitors but who had not yet received the medication. We noted which patients had newly been prescribed an SGLT-2 inhibitor.

FINDINGS TO DATE: Of the remaining 95 patients, 21 (22%) were prescribed an SGLT-2 inhibitor by May 11, 2022. On average, about two eligible patients newly were prescribed an SGLT-2 inhibitor each month.

KEY LESSONS FOR DISSEMINATION: Our study demonstrates a successful quality improvement effort to transition qualifying patients to therapy with SGLT-2 inhibitors—as we exceeded our goal of 10% of patients. Further research should seek to replicate our work at larger clinical sites and for additional therapeutic indications.

A HOUSESTAFF-LED QUALITY IMPROVEMENT INITIATIVE TO INCREASE HEPATITIS C SCREENING AMONGST PATIENTS ADMITTED TO AN ACADEMIC, SAFETY-NET HOSPITAL Catherine Crawford¹; Sarah Burbank¹; Kevin Guzman²; Julia Chambers¹; Nicole Dalal¹; Emily Harris¹; Tessa M. Kaplan¹; Samuel Lee¹; April S. Liang¹; Emily Lydon¹; Sheyla Medina¹; Nicholas R. Murphy³; Anne Luetkemeyer⁴

¹Internal Medicine, University of California San Francisco, San Francisco, CA; ²Pulmonary Critical Care, Columbia University, New York, NY; ³Internal Medicine, UCSF Medical Center, San Francisco, CA; ⁴Department of Infectious Disease, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA. (Control ID #3876405)

STATEMENT OF PROBLEM/QUESTION: Despite the high prevalence of risk factors for Hepatitis C Virus (HCV) infection among patients admitted to San Francisco General Hospital (SFGH), more than 40% of patients admitted to the Resident Internal Medicine Service (RIS) have not received lifetime HCV screening as recommended by CDC and USPTF.

DESCRIPTION OF PROGRAM/INTERVENTION: HCV is the most common chronic blood-borne pathogen in the United States and a leading cause of chronic liver disease and liver failure. Rates of HCV continue to increase despite the availability of curative, well-tolerated oral treatment. SFGH serves many patients who are at higher risk for HCV infection. Pre-implementation analysis found that 5.5% of patients admitted to SFGH had a positive HCV antibody test, over double the rate within San Francisco (2.5%) and well above the national rate (1.7%). We developed an incentive-based quality improvement initiative at SFGH to promote improved HCV screening of patients. Beginning August 1st, 2021, education materials and EMR-based tools (smart phrases and tracking tools) were distributed through monthly hospital orientations, team emails, and information at workstations. An EMR-based admission order set for HCV testing was later developed and launched on March 1st, 2022.

MEASURES OF SUCCESS: Our goal was to increase lifetime HCV screening rates among patients admitted to RIS and Cardiology teams to greater than 65%, approximately a 10% absolute increase from baseline. Using a binomial logistic regression model we analyzed lifetime screening rates at baseline (May 1st, 2021 - July 31st, 2021) and during our intervention (August 1st, 2021 - April 30th, 2022) adjusting for demographic differences between groups. Additional stratified analysis of age, sex, race, language, and housing status were performed using separate binomial logistic regression model at baseline and during our intervention.

FINDINGS TO DATE: Overall, there were 986 patients admitted during the baseline period and 2726 patients during our intervention. Patients were more likely to be screened during our intervention (78.7%), compared to baseline (56.7%) (p <.001, OR 3.24, 95% CI 2.74 - 3.83). At baseline, patients who identified as homeless were screened at a higher rate than those who were housed and patients older than 70 were screened less than other age groups. These differences persisted during our intervention. During our interventions, additional disparities emerged: cis-gender women and patients who spoke a Chinese-based language were screened at lower rates. Patients who identified as Hispanic/Latino(a) were also more likely to be screened than other races.

KEY LESSONS FOR DISSEMINATION: 1. Incentive-based quality improvement initiatives that incorporate electronic medical record interventions & educational outreach can be effective in increasing Hepatitis C screening in an urban safety net hospital setting.

2. Future work is needed to address disparities in screening, especially among women, patients who speak a Chinese language, and patients that are older than 70 years old.

AN INNOVATIVE APPROACH TO REDUCE DISPARITIES IN LUNG CANCER SCREENINGS Jasmin Hundal¹; Autumn Leavitt³; Christopher Steele²

¹Internal Medicine , University of Connecticut, Hartford, CT; ²general medicine, University of Connecticut, Storrs, CT; ³University of Connecticut, Storrs, CT. (Control ID #3874720)

STATEMENT OF PROBLEM/QUESTION: The 2022 “State of Lung Cancer” report found that only 5.8% of eligible Americans were screened for lung cancer (CA), and screening is key to early diagnosis and reducing cancer-related deaths.

DESCRIPTION OF PROGRAM/INTERVENTION: The lack of screening uptake include limited access to screening, incomplete smoking history documentation, patient acceptance, and lack of physician knowledge and recommendation. Additionally, patients of lower socioeconomic and racial/ethnic minority status have additional barriers to completion.

A quality improvement program was implemented at an academic, outpatient internal medicine resident primary care clinic and aimed to decrease the gap in lung cancer screening to identify those eligible for lung cancer screening better and address any barriers to care that may arise preventing them from completing their treatment. The team consists of internal medicine physicians, residents, and fellow pre-medical and medical

students. Patients eligible for LDCT were identified via remote chart review, and patients who did not receive were contacted by our volunteers. For eligible patients with no active LDCT orders, volunteers contact the primary care resident physician and attending physicians. This project aims to decrease the barriers and increase the uptake of lung cancer screening according to the national guidelines.

MEASURES OF SUCCESS: We identified patients with active low-dose CT orders that were not completed in the past year. We then called patients to a) identify the reason that patient did not previously complete the low-dose CT scan and b) if they would like our volunteers to call radiology with the patient to schedule the scan. We provided patients with appropriate resources if they were identified as facing social determinants of health barriers.

FINDINGS TO DATE: While our findings are preliminary, our findings demonstrate significant higher uptake compared to the national average. Within five weeks, 171 patient charts were reviewed for potential eligibility, 117 patients were contacted, and 43 patients responded. Our volunteers have scheduled 11 low- dose CT scans. Two scheduled scans have been completed, while the others are pending. Patients have expressed barriers to previously receiving low-dose CT scans, including lack of knowledge about the scan, transportation issues, fear of potential covid exposure, and financial concerns.

KEY LESSONS FOR DISSEMINATION: An equity-focused quality improvement program may offer an opportunity to improve lung cancer screening. It leads to a decrease in provider-level barriers, healthcare system-level barriers, improvement in eligible patients, and education of our patients. This integrated care delivery model closes the gap in healthcare delivery and inequities and is replicable.

AN INNOVATIVE PROGRAM TO ENHANCE ACCESS TO PRIMARY CARE AFTER HOSPITALIZATION

Neeraj Agrawal¹; Allison Heinen¹; Joseph Sayegh¹; Anuradha Sudharakan¹; Daniel R. Murphy²

¹Section of General Internal Medicine, Baylor College of Medicine, Houston, TX; ²Department of Medicine, Baylor College of Medicine, Houston, TX. (Control ID #3875871)

STATEMENT OF PROBLEM/QUESTION: Inadequate coordination with primary care after hospital discharge can lead to poor patient outcomes and high readmission rates.

DESCRIPTION OF PROGRAM/INTERVENTION: Despite known benefits of effective transitions to primary care after hospital discharge, patients frequently do not receive timely appointments with primary care providers. To help improve transitions at our Texas-based academic hospital and clinic systems, our institutions developed a novel closed loop referral system in June 2019. This system has successfully communicated over 17,000 referrals to multiple subspecialties since implementation. However, analysis of referrals in February 2022 showed a scheduling rate of only 49% and a completion rate of only 26%.

Despite 750 hospital medicine discharges per month, only an average of 13 patients were being referred to the affiliate primary care clinic each month. We therefore implemented a pilot project to increase rates of both referrals to primary care and completion of these visits. We began this pilot in August 2022. We created a position for a dedicated scheduler for all Internal Medicine (IM) referrals who would follow a specific scheduling script. Patients were called within 2 days after discharge with the goal of scheduling patients within 2 weeks of their discharge date. Primary care provider feedback on the process was used to iteratively revise the process and ensure appropriate patients were scheduled. Hospitalists were educated on referral processes and provided contact information of the scheduler. Hospitalists were encouraged to refer all eligible patients and allow the scheduling algorithm to guide appropriate visit options.

MEASURES OF SUCCESS: Measures tracked included number of referrals placed, percent of patients scheduled, and percent of patient visits completed. We also reviewed the average time between referral entry and patient scheduled visit date.

FINDINGS TO DATE: Since development of the pilot, referral orders to primary care have experienced a large increase from 13 to 86 referrals a month. Primary care visit completion rate decreased but not significantly (20% pre-intervention, 14% post-intervention). However, completed appointments increased from 2.6/month to 12/month. Average time from referral to clinic appointment remained stable at 20.7 days despite increased volumes of referrals.

KEY LESSONS FOR DISSEMINATION: Scheduling early post discharge primary care visits remains a challenge in large academic medical centers. An electronic order set, dedicated schedulers, and focused education for hospitalists can positively impact the number of referrals to primary care and consequently the number of patients accessing primary care after hospital discharge. Increased revenue from higher patient loads in primary care clinics may justify a dedicated scheduler; however, more data is needed to fully evaluate the program. Ongoing quality improvement initiatives (PDSA cycles) are planned to enhance further retention in primary care clinics and better understand the direct impact on readmission rates.

A QUALITATIVE ASSESSMENT OF PROACTIVE PHYSICIAN-NURSE ROUNDS ON NIGHT SHIFTS IN AN INTERNAL MEDICINE RESIDENCY PROGRAM

Robert Morris, Keir MacKay, Niranjan Thothala

Internal Medicine, Indiana University School of Medicine, Indianapolis, IN. (Control ID #3864206)

STATEMENT OF PROBLEM/QUESTION: Our objective was to qualitatively assess nursing experiences and perceptions of proactive physician-nurse night rounding with residents and hospitalists.

DESCRIPTION OF PROGRAM/INTERVENTION: Proactive physician-nurse night rounding is a process when the physicians (resident physician and supervising physician) visit each patient’s nurse to review the patient’s status, care plan, care priorities, and daily goals.

MEASURES OF SUCCESS: Fifty-one shift nurses were recruited to complete a survey towards their perceptions of physician-nurse rounding on night shift. In-person interviews were undertaken on August- October 2022. The survey included 5 questions and opportunity for feedback after each question. Responses were transcribed and analyzed in a qualitative inductive analysis. The setting included a single-center, GME rural hospital in Southwest Indiana.

FINDINGS TO DATE: Seventy-eight percent of night nurses ‘strongly agreed’ that physician-nurse rounding improved provider communication, with the other twenty-two percent ‘agreeing’. Sixty-three percent of night nurses ‘strongly agreed’ that physician-nurse rounding improved patient outcomes communication, with the other thirty three percent ‘agreeing’. Sixty-five percent of night nurses ‘strongly agreed’ that physician-nurse rounding improved the team dynamic, with the other thirty-five percent ‘agreeing’. Forty-three percent of night nurses ‘strongly agreed’ that physician-nurse rounding reduced the times needing to page the physician, with the other thirty three percent ‘agreeing’. fourteen percent were neutral, six percent disagreed, and two percent strongly disagreed. Thirty-seven percent of nurses "strongly disagreed" that physician-nurse rounds was counterproductive, with fifty-seven disagreeing, and six percent being neutral. The opportunity for feedback during the survey resulted in 87 total responses describing the effect of physician-nurse rounding.

KEY LESSONS FOR DISSEMINATION: According to our survey, proactive physician-nurse rounding on night shifts dramatically improved the subjective experience of provider communication, team dynamics, patient outcomes, and reduced frequency of nursing pages. Further research into the efficacy of this collaborative and patient-centered model of care is needed

A QUALITY IMPROVEMENT PROJECT TO INCREASE SCREENING FOR B12 DEFICIENCY IN PATIENTS ON CHRONIC METFORMIN

Farhana Begum¹; Maham Ghani¹; Nida Khan¹; Lauren Block²; Jason Ehrlich³

¹Internal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; ²medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY; ³Medicine, Northwell Health, New Hyde Park, NY. (Control ID #3847444)

STATEMENT OF PROBLEM/QUESTION: Screening patients who take metformin for B12 deficiency is not universally practiced.

DESCRIPTION OF PROGRAM/INTERVENTION: The objective of our quality improvement project was to increase serum B12 level screening for patients in the outpatient resident clinic who were on metformin for greater than 6 months. Our intervention was to educate residents on B12 screening and repletion via live presentations and information sheets sent via email and displayed in workspaces. Using a multidisciplinary approach, the pharmacy team screened patients scheduled for the day and would remind providers which patients were eligible for B12 screening. Provider education and reminders were provided over an eight-month period.

MEASURES OF SUCCESS: The goal of the QI project was to increase the percentage of applicable patients screened for B12 deficiency. Data collected by project members included the percentage of patients on chronic metformin who had a serum B12 level collected before and after the educational intervention. Additional variables studied included dose of metformin, type of diabetes, if a diagnosis of diabetic neuropathy was present, whether patient was already on B12/multivitamin supplements, and if a methylmalonic acid (MMA) or homocysteine level was checked. Patients who were on metformin for less than 6 months were excluded. Serum B12 deficiency was defined as serum B12 < 300 pg/mL.

FINDINGS TO DATE: A total of 293 patients, ranging from ages 20-100, were seen with the practice during the study period who met the inclusion criteria. Approximately 280 (93 %) of patients had type II diabetes, the remainder had prediabetes. About 42 (15 %) patients had a diagnosis of diabetic neuropathy. Of the 293 patients, 42 (15%) had serum B12 levels screened prior to intervention. This screening rate increased to 86 patients (29 %) after provider education. 16 patients, which was 19 % of the patients who were screened, were found to have B12 deficiency and were repleted with oral B12. Of the 16 patients with B12 deficiency, 3 had homocysteine levels checked, of which 2 patients had elevated levels. Five patients with low serum B12 levels had their MMA levels checked, of which 1 patient had an elevated MMA level. Of the 16 patients with B12 deficiency, 4 had a diagnosis of diabetic neuropathy and two patients were already taking multivitamins. There was no association found between doses of metformin and level of B12 deficiency in our patients.

KEY LESSONS FOR DISSEMINATION: Provider education on guideline-based practice is an important method to improve healthcare delivery to patients. Metformin is commonly used to treat diabetes, and screening patients who take metformin for B12 deficiency is important. A multidisciplinary approach can help increase resident awareness and improve clinical practices concerning this issue.

A SIMPLE SCHEDULING INTERVENTION TO IMPROVE BREAST CANCER SCREENING Shing Chao¹; Mohamad Beidoun²; Austin J. Parsons³; Anupama Nair¹; Danielle Heidemann¹; Megan Dekker¹

¹Internal Medicine, Henry Ford Health System, Detroit, MI; ²Internal Medicine, Henry Ford Hospital, Detroit, MI; ³Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #3875286)

STATEMENT OF PROBLEM/QUESTION: Structural barriers such as obstacles in scheduling appointments can prevent patients from receiving appropriate cancer screenings.

DESCRIPTION OF PROGRAM/INTERVENTION: This study is a quality improvement (QI) project designed to increase completion rates of breast cancer screening. We use a multidisciplinary team-based care approach in our outpatient, academic clinic. Our annual clinic volume is about 40,000 visits and 74% of our patients are African Americans. In our practice, a workflow is in place to allow medical assistants to pend certain orders pertaining to health maintenance including mammograms which are then signed by providers if deemed appropriate. Prior to our intervention, when a mammogram was ordered for a patient, the medical assistant provided the phone number to the patient to schedule their appointment after leaving the clinic. Our intervention was to use our secretaries to schedule the mammogram during check-out, prior to the patient leaving the clinic.

MEASURES OF SUCCESS: To determine the effectiveness of our intervention, we analyzed the overall mammogram completion rates eight months prior and eight months after the intervention. Statistical analysis was completed by comparing the difference in the slopes prior and after intervention.

FINDINGS TO DATE: Over the sixteen-month period of this study, an average of 4,843 patients were due for their mammogram. The average completion rate of mammograms prior to the intervention was 68.4% compared to 74.1% after the intervention. Prior to the intervention, the completion rate slope was 0.44 and the standard error (SE) of the regression slope was 0.02. After the intervention, the slope was 0.74 and the SE of the regression slope was 0.12. The t-statistic was 2.6 and the p-value was 0.02.

KEY LESSONS FOR DISSEMINATION: Mammogram allows for effective identification of pre- cancerous lesions and early identification of malignancy. The goal of this QI project was to reduce structural barriers by creating a simplified process for scheduling mammograms. Our intervention to reduce barriers to mammography scheduling showed a statistically significant improvement in mammography completion. This study demonstrates that simple organizational changes can have a significant impact on patient outcomes.

BARRIERS TO RESIDENT SAFETY EVENT REPORTING

Christine Gallati, Beenish Ahmed

Internal Medicine , Christiana Care Health System, Wilmington, DE. (Control ID #3875602)

STATEMENT OF PROBLEM/QUESTION: What factors affect a resident’s decision to report a safety event?

DESCRIPTION OF PROGRAM/INTERVENTION: Safety event reporting is an important means by which healthcare systems identify existing and potential threats to patient well-being and quality of care. As leaders in healthcare settings, physicians have a critical responsibility to report safety events. Unfortunately, it has been well documented in the literature that physicians under-utilize voluntary event reporting systems. During training, resident physicians are introduced to these systems and are encouraged to participate in safety event reporting. Little is known about resident attitudes and utilization of these systems, however.

A web-based survey was administered to internal medicine and med-peds residents during a regularly scheduled didactic session. The survey sought to detail resident attitudes toward the safety event reporting system and to identify potential barriers to its use. Residents were assured that their responses would remain anonymous.

MEASURES OF SUCCESS: The survey asked residents to select from a list of potential factors that could deter them from reporting a safety event. The respondents were able to select multiple factors and were also able to respond that they had “Never felt deterred”.

FINDINGS TO DATE: In total, 32 of the 56 residents present at the session completed the survey. The most frequently cited deterrents to reporting were: “Nervous about getting in trouble and/or nervous about getting peers or coworkers in trouble” 50% (16/32), “Not enough time” 47% (15/32), and “Not sure if it will make a difference” 41% (9/32). Less cited factors included: “Not sure if event was appropriate to log” 28% (9/32)

and “Unsure of how to log an event” 13% (4/32). Only 16% (5/32) of respondents reported that they “Never felt deterred”.

KEY LESSONS FOR DISSEMINATION: Physicians under-utilize safety event reporting systems. Negative attitudes towards safety event reporting systems may develop early in a physician’s career. The responses to our survey revealed that many of the residents at our institution are concerned about the possible negative consequences of reporting for themselves and their peers/coworkers. Additionally, many residents question the value and efficacy of safety event reporting. Further work needs to be done to understand why these negative attitudes exist and if they are unique to our institution.

BRIDGING THE DIVIDE: CREATING AN AMBULATORY CARE LEADERSHIP FORUM TO UNITE LOCAL AND REGIONAL LEADERS IN ADVANCING QUALITY IMPROVEMENT Jeffrey Fujimoto, Cory Hedwall, Anna Dermenchyan, Nathan Samras, Maria Han

University of California Los Angeles Health System, Los Angeles, CA. (Control ID #3871892)

STATEMENT OF PROBLEM/QUESTION: Previously, there was a lack of clear leadership and governance for standardizing operations and workflows to communicate health system goals in the primary care setting.

DESCRIPTION OF PROGRAM/INTERVENTION: Implementing a strategic vision across a large health system poses many challenges. Strong local leadership and effective communication channels are needed to provide high-quality care. The Ambulatory Care Leadership Forum (ACLF) was launched in 2019 to bring together 34 clinics with the goal of optimizing quality in the primary care setting. Formalized clinic and regional physician lead roles were created to carry out this vision. Clinic physician leaders were paired with clinic managers to form “leadership dyads” responsible for monitoring and improving day-to-day operations. Regional physician leads were created to oversee clinic operations with an eye toward regional needs and priorities. Physician leaders were given protected time for their responsibilities. To facilitate communication and leadership training, the Department of Medicine Quality team established rotating monthly touchpoints consisting of workshops, leadership huddles, and strategy meetings. During workshops, leaders were introduced to institutional priorities for the quarter and educational content on how to achieve quality improvement goals. Leadership huddles were then held to provide protected time for leadership dyads to implement clinic-level interventions. Strategy meetings were later convened to review and refine best practices. The five foundational domains that serve as forum focus areas include clinical quality, team-based care and operations, shared leadership, finance and aligned incentives, and organizational well-being.

MEASURES OF SUCCESS: ACLF impact is measured qualitatively through quarterly feedback surveys. More recently, we have started formally tracking impact on quantitative performance measures.

FINDINGS TO DATE: In recent quarterly surveys, 100% of surveyed participants agreed that the ACLF has practical value and rated overall impressions as “good” or “excellent.” Confidence in improving performance increased across all five foundational domains. The most noted benefit in free-text responses is heightened communication with other physicians and staff vertically and horizontally. Quantitative data collection on quality performance is ongoing.

KEY LESSONS FOR DISSEMINATION: Enhancing quality in the primary care setting requires established leaders with protected non-clinical time to drive strategic vision and operations. Local leaders can drive change on a day-to-day basis, while regional leaders oversee the allocation of resources and system- wide goals. Close collaboration with administrative leadership is foundational for implementing effective workflows. Providing regular touchpoints allows local leaders to feel engaged in implementing institutional priorities and enables open feedback and collaboration. Regular communication from a centralized Quality team helps to deliver a consistent strategic vision.

BUILDING RESEARCH CAPACITY AT A FEDERALLY QUALIFIED HEALTH CENTER (FQHC) TO ADVANCE HEALTH EQUITY.

Radhika Gore^1,2; Isaac Dapkins^1,2; Valy Fontil^1,2

¹Family Health Centers at NYU Langone, NYU Langone Health, Brooklyn, NY; ²NYU Langone Health, New York, NY. (Control ID #3875206)

STATEMENT OF PROBLEM/QUESTION: FQHCs have little guidance to ensure that FQHC-academic partnerships for research meet the safety-net mission, which is to deliver high-quality primary care to vulnerable individuals and families and use quality improvement (QI) practices to reduce health disparities.

DESCRIPTION OF PROGRAM/INTERVENTION: We conducted a qualitative baseline assessment in Nov 2022 for a 3-year initiative to enhance research capacity at an FQHC in a Mid-Atlantic state. Our FQHC offers outpatient medical, dental, and behavioral health care to 100,000 patients annually. Since 2017, partnership with an academic medical center has led to increasing research involving our patients and services. Strategies for research capacity-building include strengthening internal review of proposed research and leveraging research grants to build research assistance and health care delivery infrastructure. MEASURES OF SUCCESS:

Assess y early 2023-25

Quantitative

Number of peer-reviewed publications authored by FQHC staff. Proportion of QI initiatives with robust evaluation plans.

Proportion of QI projects that integrate community-based services in health care delivery. Number and proportion of research projects that include implementation science to inform QI. Number and proportion of FQHC QI leaders or clinicians who are aware of or use FQHC research infrastructure.

Qualitative

Extent to which research findings inform and inspire health care innovation and vice versa. Knowledge among clinicians of how to engage in research.

Baseline 2022

To examine barriers/facilitators to transform the FQHC to a learning health system, we drew upon minutes of research review and FQHC-academic partner meetings over the past 18 months. We conducted 14 key informant interviews with clinical, QI, residency, and community program leaders. We used the Consolidated Framework for Implementation Research to organize our findings.

FINDINGS TO DATE:

Inner setting (FQHC organizational readiness). Executive leaders value research. Clinical and QI duties leave little time for research-related activity.

Outer setting (academic institution strategic readiness). Academic partners are not always cognizant of FQHC constraints (how research presents logistical and data-extraction burdens) or FQHC priorities (interventions should be culturally concordant and address quality-of-care gaps).

Intervention characteristics (adaptability of research participation). Research operates on longer timelines than QI. QI initiatives need evaluation support but researchers may be unavailable to supply it. Stakeholders perceive research as unwieldy on these counts.

Individuals’ characteristics. Clinicians value research for professional advancement for self and team but individual expertise in research varies.

Process to iterate research involvement. Frequent dialogue with academic partner exists but does not center FQHC QI priorities.

KEY LESSONS FOR DISSEMINATION: For an FQHC, building a learning health system will entail creating processes to deliberate research proposals and findings in actionable ways and communicate QI priorities to academic partners.

CLOSING THE GAP IN INFECTIOUS DISEASE SCREENING IN CHEMOTHERAPY PATIENTS Taylor N. Francoeur²; Katherine A. Reifler³; Mark Sloan¹

¹Hematology/Oncology, Boston Medical Center, Boston, MA; ²Internal Medicine, Boston Medical Center, Boston, MA; ³Infectious Disease, Boston Medical Center, Boston, MA. (Control ID #3875767)

STATEMENT OF PROBLEM/QUESTION: There are currently no society-based guidelines for screening of strongyloidiasis and latent tuberculosis in oncology patients prior to chemotherapy initiation, both of which are infections that have the highest prevalence among migrants from low and middle-income countries and if unidentified and untreated can develop into severe, disseminated infections with significant consequences.

DESCRIPTION OF PROGRAM/INTERVENTION: To help address this problem and clear gap in health equity we implemented a focused screening protocol for these infectious diseases at Boston Medical Center (BMC). With screening, we aim to improve treatment rates for this vulnerable population and create the best future screening practices at BMC and other institutions. Screening includes all patients with hematologic malignancies in the outpatient hematology/oncology clinic prior to initiating chemotherapy and receiving steroids. We decided to screen all patients in this group, rather than only migrants, to estimate overall infection rates, for provider ease, and because of the large regions where these infections are endemic. The screening takes place through laboratory order prompts in the electronic medical record that is already in use for all treatment plans in the clinic.

If a patient is positive for the strongyloides, they will receive treatment with ivermectin in subsequent visits. If a patient is positive for the QuantiFERON gold assay, the oncologist will order imaging and refer to the BMC TB clinic. We are also in the process of conducting educational sessions for the outpatient hematology providers about our study. This project is a joint collaboration between clinicians in the hematology/oncology and infectious disease departments and is conducted under an IRB approved protocol.

MEASURES OF SUCCESS: After the initial screening period, we will collect retrospective data from the medical record of all patients who fit the inclusion criteria described above. This data will allow us to understand the prevalence in our population, screening rates and key risk factors. The success of our intervention is multifaceted and based on demonstrating an increase in screening and treatment rates alongside using our data to inform future screening protocols with better definitions of risk factors associated with seropositivity.

FINDINGS TO DATE: Initial data from the BMC medical record shows that only 182 out of 7878 (2.3%) patients who received chemotherapy since 2014 were tested for strongyloidiasis. These patients are at increased risk with 18 out of the 182 patients testing (9.8%) positive.

For TB, 1316 out of 7878 (16.7%) were screened with the quantiferon gold assay with 250 out of 1316 (19.0%) testing positive. This data is the baseline for comparison once our initial screening protocol has been implemented for a period of time.

KEY LESSONS FOR DISSEMINATION: A systematic, data-driven approach to prevent future cases of disseminated strongyloidiasis and re-activated TB has the potential to close an important health equity gap, particularly among migrants from endemic areas.

DECREASING THE NUMBER OF OVERNIGHT CALLS BY ROUNDING AT NIGHT: A MULTIDISCIPLINARY, QUALITY IMPROVEMENT PROJECT

Neil Gerts, Trevor Owens, Preetivi Ellis, Jasprit Takher

Internal Medicine, Los Robles Regional Medical Center, Thousand Oaks, CA. (Control ID #3867912)

STATEMENT OF PROBLEM/QUESTION: Overnight calls can be frequent and interuptive, but an implementaton of a new rounding protocol can decrease the amount of calls experienced. DESCRIPTION OF PROGRAM/INTERVENTION: Overnight calls from nurses can range from advancing a diet to emergencies requiring urgent intervention. At times when only one resident is covering all the patients admitted to an in patient service, overnight calls can take up a majority of the night. During periods when residents are admitting patients, overnight calls can either interrupt a patient encounter or increase the time spent admitting the patient. By proactively addressing questions early during the night shift, residents may be able to decrease the number of overnight calls, which may allow for a quieter night for both nurses and residents on call.

MEASURES OF SUCCESS: This quality improvement initiative is a collaboration of a multidisciplinary team composed of resident physicians, attendings, nurses, nurse managers, and quality improvement specialists. Data during a three month period data will be collected regarding the amount of overnight calls which will be measured to create an average baseline. Following this time period, both residents and faculty members composing of the multidisciplinary team will be educated on the new process of nightly rounds. A nightly rounding protocol will be initiated, and the multidisciplinary team will recieve education on implementation and continued compliance. The compliance of the new rounding protocol will be monitored. Following the implementation of the rounding protocol, the number of overnight calls will be measured.

FINDINGS TO DATE: Before any interventions, a baseline of overnight calls was established over a three- month period. The amount of overnight calls averaged to be 44.20 calls per an average of 81.20 patients per night, which is 54.43% of phone calls received to patients covered. Following the implementation of the interventions, over a three-month period, residents received an average of 32.80 calls per an average of 80.80 patients per night, which is a 40.59% of phone calls received to patients covered. As a result, after implementation, the residents experienced a decrease of 13.84% of the number of overnight calls.

KEY LESSONS FOR DISSEMINATION: Our intervention had a significant impact in reducing the amount of overnight calls by proactively addressing questions at the beginning of the night. Residents that take the time to proactively round at night may experience fewer phone calls, suggesting that the time spent proactively addressing anticipated questions in the beginning of the night can limit unexpected acute medical issues that may result at night for the patients. Updating the night shift nurses on what events are to be expected during the night, pertinent labs that may result, and asking questions such as if as needed medications are available, all seem to lead to a substantial decrease in calls. In summary, proactively addressing these questions by rounding at night will decrease the number of overnight calls that residents will receive.

DON'T GO BREAKING MY HEART: A SIMPLIFIED PRIMARY CARE PATHWAY FOR THE EVALUATION OF STABLE CHEST PAIN

Benjamin Titus¹; Eric W. Rudofker⁴; Michael Weinreich⁴; Kelly White³; Laura Macke²

¹Medicine, University of Colorado, Denver, CO; ²General Internal Medicine, University of Colorado, Denver, CO; ³GIM, University of Colorado SOM, Aurora, CO; ⁴Cardiology, University of Colorado, Denver, CO. (Control ID #3872154)

STATEMENT OF PROBLEM/QUESTION: Society guidelines for the evidence-based evaluation of stable chest pain in the outpatient setting are complex and difficult to access at the point of care.

DESCRIPTION OF PROGRAM/INTERVENTION: Stable chest pain is a common patient presentation resulting in nearly four million annual outpatient visits. During these visits, primary care providers (PCPs) must risk stratify patients by history and comorbidity to guide further evaluation and management. Although non-invasive tests are commonly ordered, choosing the most appropriate test can be challenging. Ideally, PCPs would apply up to date society guidelines to assist them in their choices, but they are often complex, difficult to access at the point of care, and vary based on available resources. Our goal was to create a clinical care pathway for PCPs that simplified the selection of appropriate non-invasive testing for stable chest pain in accordance with recent chest pain guidelines. To accomplish this, we formed a group of PCPs and cardiologists and developed an electronic health record (EHR)-integrated algorithm that could be accessed at the point of care. The pathway included a tool for risk stratification, guide for non-invasive test selection, and suggestions for timely referral.

MEASURES OF SUCCESS: Distinct pathway users, total pathway uses, non-invasive tests ordered (sub- divided into coronary CTAs, treadmill ECGs, nuclear perfusion studies, stress echocardiogram studies) FINDINGS TO DATE: Since release on 9/26/22, there have been 22 unique pathway users (4% of all PCPs) and 47 instances of pathway usage. Review of post-intervention ordering practices is ongoing, but does show a trend towards increased ordering of coronary CTAs and decreased ordering of stress electrocardiograms.

KEY LESSONS FOR DISSEMINATION: Clinical pathways are one tool to guide non-invasive evaluation of patients with stable chest pain in the outpatient setting. It is possible to streamline complex guidelines into actionable algorithms that are integrated into the EHR and available at the point of care.

DON’T MAKE HYPERTENSIVE URGENCY AN EMERGENCY: GUIDING PRACTICE TO REDUCE HARM ASSOCIATED WITH PRN ANTIHYPERTENSIVES

Richard Lowell T. Barr, Jess Dreicer

Internal Medicine, University of Virginia, Charlottesville, VA. (Control ID #3874912)

STATEMENT OF PROBLEM/QUESTION: As needed antihypertensive medications (PRN AHTs) are commonly used in the hospital but their use has been correlated with increased risk of acute kidney injury (AKI), stroke, mortality, and longer length of stay (LOS) in the hospital.

DESCRIPTION OF PROGRAM/INTERVENTION: Antihypertensives (AHTs) are commonly used in the inpatient setting on an as needed basis to treat hypertensive urgency (i.e., systolic blood pressure >180 or diastolic blood pressure >120). This is contrary to the American Heart Association/American College of Cardiology (AHA/ACC) guideline on management of hypertensive urgency which emphasizes treating patients based on the presence or absence of end-organ damage, rather than for specific blood pressure values. PRN AHTs delivered in the acute care setting lower BP unpredictably and have been associated with increased mortality, AKI, stroke, and increased LOS. Given the risk of patient harm, a quality improvement project started in August 2022 aimed to bring inpatient practice in line with AHA/ACC guidelines. An order- set, currently under review by an interprofessional team, is being created with the aim of prompting clinicians to help guide management of inpatient hypertension as recommend by the AHA/ACC guidelines. Data will be collected through chart review comparing several months before and after introduction of the order set.

MEASURES OF SUCCESS: Outcome measures will be comparative incidence of AKI, acute ischemic stroke, LOS, and mortality on target units. Process measures will be the comparative percentage of patients administered PRN AHTs (e.g., IV labetalol PRN, IV hydralazine PRN) and order set usage. Balancing measures will be the comparative incidence of hypertensive emergency and aortic dissection.

FINDINGS TO DATE: Data from the three acute care units over the year previous to August 2022 show that 56% of patients receiving IV labetalol had a non-ED in-hospital diagnosis of AKI compared to 29% of those not receiving this medicine. The same pattern held for IV labetalol and acute ischemic stroke (26% vs 7%, respectively). These findings are intriguing and consistent with published data linking administration of PRN AHT medications and end-organ damage and mortality.

KEY LESSONS FOR DISSEMINATION: - Treating hypertensive crises requires careful assessment of patients for target-organ damage and appropriate treatment based on its presence or absence, rather than treating by numbers alone.

- Administration of PRN AHTs in an acute care setting is not consistent with AHA/ACC guidelines for hypertensive urgency.

- There is compelling evidence that administration of PRN AHTs is associated with increased risk of AKI, stroke, LOS, and mortality.

EMPHASIZING INDIVIDUALIZED ANTICIPATORY GUIDANCE AND SELF-MANAGEMENT IN DISCHARGE INSTRUCTIONS

Jenna Carson²; Jessica Donato¹

¹Hospital Medicine, Cleveland Clinic, Cleveland, OH; ²Internal Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #3867882)

STATEMENT OF PROBLEM/QUESTION: Written discharge instructions frequently lack guidance on how patients should address problems and questions that arise at home, and this represents an opportunity to enhance discharge safety and prevent readmissions.

DESCRIPTION OF PROGRAM/INTERVENTION: This study aimed to increase the number of discharge instructions that included anticipatory guidance and self-management among patients discharged from internal medicine teaching services at a large academic medical center. Baseline data was collected through manual chart review of a sample of medical patients starting in May of 2022. Discharge instructions were evaluated for 3 primary components of anticipatory guidance and patient self-management: how to manage symptoms at home, who to call with questions, and when to return to the emergency department. A new discharge instruction SmartPhrase (SP) was created and made available to residents which has prompts for the inclusion of the 3 components outlined above. Five iterations of this SP were completed through PDSA cycling based on data analysis and resident feedback, which was obtained via survey.

MEASURES OF SUCCESS: The key performance indicator was defined as the percent of patients with discharge instructions including all 3 aforementioned components of anticipatory guidance and patient self- management. Measurement of inclusion of each individual component and utilization rates of the SP template were also tracked as process measures.

FINDINGS TO DATE: Discharge instructions with all 3 aspects of anticipatory guidance increased from 0% in the pre-intervention period (n=23) to 18% in the post-intervention period (n=90). The specific components of anticipatory guidance each increased: symptom management instructions from 9% to 48%, information on who to call from 13% to 36%, and emergency room return precautions from 26% to 53%. The SP was utilized for 31% of patients in the post-intervention period. Only 6% of patients received the 3 aspects of anticipatory guidance when their instructions were created from a standard template, as opposed to 43% of patients whose instructions were created with the SP. Of residents who used the SP, 81% thought it added value to their instructions and 44% agreed it added new information which they otherwise would not have included.

KEY LESSONS FOR DISSEMINATION: Anticipatory guidance and patient self-management are vital components to incorporate into discharge instructions for home-going patients. We focused on 3 primary components that were rarely incorporated into discharge instructions prior to our intervention, and never were all 3 incorporated. Through the development of our novel SP, which has prompts for each element, we significantly increased inclusion of these important concepts, both individually and collectively for all 3. Despite residents reporting added value from using the SP, it was utilized in less than half of discharges in the post-intervention period. Future efforts will focus on standard integration of the SP into clinical workflows to further increase utilization rates.

EQUITABLE IMPLEMENTATION OF AN INTENSIVE TELEPHONE-BASED SMOKING CESSATION PROGRAM IN A SAFETY NET SYSTEM

Nirupama Ancha¹; Patrick Chang²; Nicole Kluz³; Amaris Martinez¹; LaTasha Vanin⁴; Eda Baykal-Caglar⁵; Michael Pignone⁶

¹Department of Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; ²Population Health, The University of Texas at Austin Dell Medical School, Austin, TX; ³Internal Medicine, University of Texas at Austin, Austin, TX; ⁴CommUnityCare Health Centers, Austin, TX; ⁵Education and Research, CommUnityCare, Austin, TX; ⁶Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #3873432)

STATEMENT OF PROBLEM/QUESTION: Smoking cessation services can reduce lung cancer incidence and mortality, and while these services are recommended, they disproportionately reach fewer patients within Federally Qualified Health Centers (FQHCs) due to constrained resources.

DESCRIPTION OF PROGRAM/INTERVENTION: We implemented and examined the effectiveness of intensive smoking cessation services from 1/1/2020 to 9/30/22 for high risk patients ages 50 and older in a safety net system. Eligible patients were identified through internal referrals and mailed outreach to patients previously documented as current tobacco users. Patients were offered 1 telephone-based counseling session a week for 8 weeks with trained, bilingual social workers, and pharmacotherapy was also offered. MEASURES OF SUCCESS: We measured end-of-counseling smoking quit rate based on self-reported abstinence.

FINDINGS TO DATE: We extended mailed outreach to 1020 age-eligible patients, of whom 77 responded and identified themselves as current smokers interested in smoking cessation. We also received 405 internal referrals from other providers. Of these 482 patients, we successfully engaged 294 in our telephone-based counseling program.

Of the 294 patients who participated in at least 1 appointment, the mean age was 58 and 52% were female. The population was diverse: 35% identified as Latino and 28% as African-American; 18% preferred receiving services in Spanish; 9% had private insurance, 22% Medicare or Medicaid, 47% were covered through the county medical assistance program (MAP), and 7% were uninsured. The median pack years was 30.

Out of the 294 patients who engaged in counseling, 19 (7%) completed only 1 session, 109 (37%) completed 2-4 sessions, and 166 (56%) completed 5 or more sessions. Of those who participated in smoking cessation, 56 (19%) used pharmacotherapy in addition to counseling; 21 (7%) received nicotine replacement therapy (NRT) only, 30 (10%) received non-NRT, and 5 (2%) used both.

Of the 294 patients who participated, 69 (22%) successfully quit smoking. The end-of-counseling quit rate was 0% (0/19) for patients who participated in only 1 session, 6% (6/109) for patients who participated in 2-4 sessions, and 38% (63/166) for patients who participated in 5 or more sessions.

Of the patients who used pharmacotherapy, 30% successfully quit smoking, compared with 22% in those who did not use pharmacotherapy (OR 1.6; 95% CI 0.8-2.9). Those with Medicaid (17%) and MAP (21%) were less likely to successfully quit than those with commercial insurance: OR 0.3, 95% CI (0.1-1.0) and OR 0.4, 95% CI (0.2-0.9), respectively.

KEY LESSONS FOR DISSEMINATION: Intensive telephone-based smoking cessation services in an FQHC resulted in a 22% quit rate, and participation in more sessions and use of pharmacotherapy led to higher quit rates. Increased accessibility to smoking cessation services will help FQHCs address and reduce cancer risk among vulnerable populations.

EVALUATION OF MULTIDISCIPLINARY ROUNDS TO REDUCE LENGTH OF STAY FOR DISPERSED PATIENTS: THEY WORK, BUT NEITHER SCALABLE NOR SUSTAINABLE

Joanna S. Cavalier¹; Benjamin A. Goldstein²; Stephen Telloni¹

¹Department of Medicine, Duke University Health System, Durham, NC; ²Department of Biostatistics and Bioinformatics, Duke University, Durham, NC. (Control ID #3873854)

STATEMENT OF PROBLEM/QUESTION: Multidisciplinary rounds (MDRs) are considered a gold standard for effective discharge planning to reduce excess length of stay (LOS), but historically have been difficult to implement on teams that are “nongeographic” with patients dispersed throughout multiple units.

DESCRIPTION OF PROGRAM/INTERVENTION: Nongeographic teams are unavoidable at most hospitals given staffing constraints, patient flow optimization, and space limitations. We aimed to implement and study the impact of nongeographic MDRs at our 1000-bed teaching hospital for general medicine patients. We designed two versions of nongeographic MDRs. The team-based pilot involved a provider, CM, PT or OT coordinator, and an administrative facilitator meeting in-person twice daily. The unit-based pilot involved a nurse manager, charge nurse, PT, OT, nutritionist, pharmacist, and medical director meeting in- person twice daily, with asynchronous communication regarding discharge planning via the electronic health record (EHR) from providers and CMs.

MEASURES OF SUCCESS: We assessed pre- and post-implementation outcome metrics including LOS, excess LOS (eLOS), proportion of discharges with eLOS, and discharge time using X-Bar R control charts, t-tests, Wilcoxon tests, and two-sample tests for proportions. We assessed scalability and sustainability through surveys and manual tracking of asynchronous response rates.

FINDINGS TO DATE: The team-based MDRs were associated with a 1.5-day mean eLOS reduction (p<0.05) and a trend toward a 1.1-day reduction in median eLOS (p>0.05). There was no impact on LOS, discharge time, or proportion with eLOS. Qualitative feedback resulted in our stopping the team-based pilot after 1 month due to lack sustainability and scalability. The unit-based pilot was not associated with a significant impact on mean or median LOS, eLOS, or discharge time nor on proportion of patients with eLOS. Mean response rates for asynchronous communication before MDRs over 6 weeks were 45% for CM, 48% for teaching providers, and 65% for non-teaching providers.

KEY LESSONS FOR DISSEMINATION: The nongeographic MDR pilots yielded several learnings. First, asynchronous communication is inferior to having in-person front-line providers and CMs who can engage the MDR group in active dialogue for effective and timely resolution of discharge barriers. Second, the EHR requires specific optimizations such as a shared note and escalation capabilities to facilitate discharge planning amongst nongeographic care teams. Third, reduction in LOS from MDRs must be considered in conjunction with scalability, sustainability, bias introduced by the Hawthorne effect, and perceived usefulness from frontline providers. Finally, MDRs optimally function with a consistent facilitator accountable to performance metrics, an experienced provider to question discharge delays and identify solutions, and the CM given their crucial role in discharge planning.

EXPANDING NALOXONE CO-PRESCRIBING AT A REGIONAL VA MEDICAL CENTER Jeremy Zhang¹; Kathie Zhang¹; Joseph Phillips¹; Michael Sauer¹; Sarah Van Dorin¹; Patrick Watson¹; Lauren Zabel¹; Emily Peters³; Yvonne De Sloover Koch³; Ethan Kuperman⁴; Matthew D. Soltys²

¹Internal Medicine, The University of Iowa Hospitals and Clinics, Iowa City, IA; ²Internal Medicine, The University of Iowa Hospitals and Clinics Department of Internal Medicine, Iowa City, IA; ³Iowa City VA Medical Center, Iowa City, IA; ⁴Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA. (Control ID #3869901)

STATEMENT OF PROBLEM/QUESTION: Can the interventions that were associated with increased naloxone co-prescriptions within one resident Continuity of Care clinic be applied on a larger scale to all resident primary care patients at this regional VA medical center?

DESCRIPTION OF PROGRAM/INTERVENTION: Veterans are disproportionately affected by chronic pain and are more likely to be prescribed opioids. Unfortunately, risks of chronic opioid use include dependence, overdose, and death. The CDC and Department of Defense recommend naloxone for risk mitigation for patients with risk factors, including: use of more than 50 Morphine Milligram Equivalents (MMEs) daily, concurrent benzodiazepine/sedative use, substance use disorder, sleep apnea, and pulmonary or liver disease. An interprofessional team of 6 residents, 1 pharmacist, and 1 faculty mentor was formed to increase naloxone co-prescriptions. Process mapping and stakeholder interviews identified prescriber unfamiliarity and the prescribing process as contributors to low prescribing rates.

Initial intervention was performed within one resident panel (6 residents) at the VA Continuity of Care (COC) Clinic by identifying eligible patients via the VA Primary Care Almanac’s Opioid Therapy Risk Report (OTTR) and alerting their provider. Naloxone co-prescriptions increased from 29% to 89% over 6 months. These interventions were subsequently expanded to all 40 residents covering approximately 2,800 patients. Data pulls using the OTTR was performed every 2 weeks and resident providers were then notified every 5 weeks via email/VA message regarding eligible patients who lacked naloxone prescription. Finally, education sessions led by a pharmacist and nurse educator were also created to help increase resident familiarity with the prescribing and education process.

MEASURES OF SUCCESS: Our aim was to increase at-risk patients with active naloxone prescriptions from 42% in June 2022 to 75% by June 2023

FINDINGS TO DATE: Naloxone co-prescription rate was gathered every two weeks using the ORTT. In June 2022, 42% (29/69 eligible patients) in all resident clinics had active naloxone co-prescription. By December 2022, 60% of patients (33/55 patients, p= 0.047) had active naloxone co-prescriptions. Intervention with email/VA message to resident providers started in September 2022 and an additional educational intervention started in November 2022. A P chart demonstrates continuous uptrend to current peak of 60% but does not show a special cause signal at this point in time.

KEY LESSONS FOR DISSEMINATION: This project demonstrates that use of notifying providers of high-risk patients can significantly increase naloxone co-prescriptions. Reasons for success include use of a standardized tool with the VA Primary Care Almanac (OTTR) and the formation of a multidisciplinary team with distinct roles; our pharmacists and nurse educator provided essential clinical education that helped providers feel confident in prescribing naloxone.

I DO GOC: IMPROVING DOCUMENTATION OF GOALS OF CARE FOR ADVANCED CANCER PATIENTS

Karen A. Hauser³; Francisco J. Martinez¹; Ashley Aller¹; Raymond Liu¹; Peggy T. Lim²; Hannah Whitehead²; Jed Katzel¹

¹Medical Oncology & Hematology, Kaiser Permanente, San Francisco, CA; ²Kaiser Permanente, San Francisco, CA; ³Hospital Medicine, Kaiser Permanente Northern California, San Francisco, CA. (Control ID #3875355)

STATEMENT OF PROBLEM/QUESTION: Patients with advanced cancer often lack documented goals of care (GOC), highlighting an opportunity for increased oncologist initiation and documentation of these conversations.

DESCRIPTION OF PROGRAM/INTERVENTION: Goals of care (GOC) discussions are a type of advance care planning (ACP) that allow patients, caregivers, and clinicians to align on disease trajectory, treatment goals, and patient values. Accessible ACP information at the point of care is essential for goal- concordant care delivery. A multidisciplinary team recognized an opportunity to improve ACP in cancer patients at our community medical center in the California-Hawaii region. A retrospective review of 82 patients diagnosed with advanced (stage IV or recurrent) cancer found 56% of patients had electronic health record (EHR) documented GOC, of which only 9% were documented by an oncologist. 15% of initial GOC discussions occurred in the acute care setting (ED, hospital, ICU). Advanced directives or POLSTs were absent in 48% of this cohort. To improve ACP, a quality improvement project to promote oncologist-initiated discussion and documentation of GOC began at our medical center in 2022. The intervention consisted of 1) education reframing and normalizing GOC discussion, 2) serious illness communication skills training, and 3) co-development of a templated GOC smartphrase. The GOC smartphrase could be used in any note and consolidated ACP content into a visible, centralized EHR location.

MEASURES OF SUCCESS: The QI pilot aimed to increase rates of oncologist-documented GOC for advanced cancer patients from a baseline of 9% to a goal of 25% within 6 months. The primary outcome was frequency of GOC smartphrase usage in patients with advanced cancer. Secondary outcomes included rates of palliative care and hospice referral, advanced directive/POLST completion, and a qualitative review of patient-expressed goals and values. Pre- and post-intervention surveys assessed impact on workflows, usability of the smartphrase, and physician satisfaction.

FINDINGS TO DATE: Within 5.5 months of implementation, 44% (n=185) of the eligible 418 advanced cancer patients had oncologist documentation using the GOC smartphrase. This represented a 35% absolute increase over baseline, exceeding the goal of 25%. In post-implementation surveys, 89% of respondents rated the GOC smartphrase as “very helpful” in facilitating conversation and enabling documentation.

KEY LESSONS FOR DISSEMINATION: By incorporating GOC training, individualized feedback and a simple EHR GOC template into the standard clinical workflow, we significantly increased oncologist documented GOC discussions above our goal. Normalizing these discussions across specialties and care settings ensures GOC are revisited as a patient’s health needs or preferences change. Ongoing Plan-Do- Study-Act cycles will refine our technology-based interventions and enable the spread of this intervention across the care continuum.

IMPLEMENTATION OF A RAPID MORTALITY REVIEW PROCESS WITH DIVISION-WIDE PARTICIPATION AND ENGAGEMENT IN HOSPITAL MEDICINE

Huixia Wei, Garima Agrawal, Simon Ascher

Hospital Medicine, University of California Davis, Davis, CA. (Control ID #3875517)

STATEMENT OF PROBLEM/QUESTION: Systematic and prompt review of mortality events on hospital medicine services helps guide quality improvement efforts, but these efforts are usually the responsibility of a select few and lack engagement from the entire group.

DESCRIPTION OF PROGRAM/INTERVENTION: We designed and implemented a peer-reviewed rapid mortality review process in an academic hospital medicine division of fifty to sixty hospitalists using an electronic protected-health-information platform. The process was modified ad hoc during its implementation. Each mortality event underwent a primary review by the attending of record, a secondary peer review by an independent hospitalist, and those marked for improvement (either by primary or secondary reviewers) were discussed during division-wide tertiary review at monthly quality improvement meetings and quarterly morbidity and mortality (M&M) conferences. The primary review consisted of questions on causes of death, palliative care resources utilized, and physician well-being. The secondary review identified system-level errors that may have been preventable. The discussions at the tertiary review proposed action items and systemic changes to improve care quality and promote patient safety.

MEASURES OF SUCCESS: This division-wide review process was intended to be timely, user-friendly, quick, informative, and inclusive. For the qualitative metrics, we assessed provider satisfaction with the process, and the perceived impact on a safety culture via an anonymous survey. For the quantitative metrics, we included total cases reviewed, number of preventable deaths, and encounters with difficult goals of care conversations. We also captured the impact of a patient’s death on physician wellness both qualitative and quantitatively.

FINDINGS TO DATE: The process underwent several changes over a thirteen-month period based on timely user feedback. These changes include automating the identification of mortality cases, streamlining notifications to reviewers, changing physician workflow, improving accessibility of the software, and modifying review questions. Among 225 mortality events that underwent primary and secondary review, the top causes of death were cancer (32%) and sepsis (13%). Physicians encountered difficulties in goals of care discussion in 7% of cases, and palliative care was consulted 58% of the time. More patients expired on inpatient hospice (43%) than on comfort care alone (35%). Notably, 11% of the hospitalist expressed feeling emotionally impacted by the patient’s death. 16% of cases were escalated to tertiary review, and fifteen cases were discussed at the M&M conferences.

KEY LESSONS FOR DISSEMINATION: An electronic peer-reviewed rapid mortality review process maximizing physician participation in a large academic division was feasible and widely accepted by the hospitalists. Key components to the success of this sustainable review process are user-friendly and centralized electronic platform, regular user feedback inquiries, administrative and leadership support in improving adaptability to physician workflow.

IMPROVING HYPERTENSION CARE THROUGH SCHEDULED OUTREACH TO INCREASE PATIENT ENGAGEMENT IN PRIMARY CARE

Shengyi Mao^2,1; Angela Yurkovich²

¹Nationwide Children's Hospital, Columbus, OH; ²General Internal Medicine, The Ohio State University, Columbus, OH. (Control ID #3858377)

STATEMENT OF PROBLEM/QUESTION: Does scheduling hypertension outreach improve patient response and engagement compared to standard outreach in primary care?

DESCRIPTION OF PROGRAM/INTERVENTION: Population health outreach is increasingly commonplace as primary care practices move to value-based care models. Unfortunately, outreach often results in poor response rates highlighting the need for improved outreach efficiency processes. We describe a quality improvement project to increase patient engagement with hypertension outreach in a suburban academic primary care clinic with embedded nurses who perform patient outreach. For hypertension, outreach often results in patients not responding or patients unprepared to share home blood pressure (BP) readings. To address this problem, we scheduled hypertension outreach appointments on a nurse outreach template. Scheduling patients on a template activates our institution’s appointment reminder system which includes automated phone calls and electronic portal reminders.

MEASURES OF SUCCESS: We compared scheduled nurse outreach (intervention) with standard outreach (control) from January 2022 through September 2022 with data collection through November 2022. We measured patient engagement from most to least engaged as responded with home BPs, responded without home BPs, or no response. We looked at controlled hypertension as the last documented BP reading <140/90 and used chi-square test to compare BP between groups. The number of attempts per encounter serves as a surrogate for nursing effort required to contact patients per outreach.

FINDINGS TO DATE: A total of 83 outreaches were scheduled for 61 patients and 211 standard outreaches were performed on 178 patients. In the intervention group, 63/83 (76%) responded with home BPs and 6/83 (7%) had no response. In the control group, 74/211 (35%) responded with home BPs and 108/211 (51%) had no response. The rate of controlled hypertension was 51/83 (61%) in the intervention group and 136/211 (64%) in the control group. There was no statistically significant difference between the BPs of the two groups (0.03 difference with 95% confidence interval [-0.16, 0.10], p value=0.73). In the intervention group, 77/83 (93%) of encounters had one attempt to connect, 6/83 (7%) had two or more attempts. For the control group, 173/211 (82%) of encounters had one attempt and 37/211 (17%) had two or more attempts.

KEY LESSONS FOR DISSEMINATION: We showed that scheduling outreach resulted in higher patient engagement with fewer attempts at connection and similar BP control compared to standard outreach. Our outreach time is valuable and limited and reducing attempts to reach patients helps to preserve valuable time to address other disease processes and healthcare needs. Scheduling outreach appointments for hypertension follow-up is a simple and effective way to improve outreach engagement and efficiency. In the future, utilizing scheduled outreach for other conditions/situations like depression, diabetes, weight management, hospital discharge follow-up and even advance care planning could be tested.

IMPROVING PRIMARY CARE LUNG CANCER SCREENING AT AN ACADEMIC MEDICAL CENTER

Cynthia L. Cantu¹; Arlene Reyes²; Dolores Garcia³; Rebecca Jones³; Ramon Cancino²

¹Department of Medicine, University of Texas Health San Antonio, San Antonio, TX; ²Family and Community Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; ³Institute for Health Promotion Research, The University of Texas Health Science Center at San Antonio, San Antonio, TX. (Control ID #3853751)

STATEMENT OF PROBLEM/QUESTION: Lung cancer is the leading cause of cancer death in the US, therefore quality improvement (QI) interventions are needed in primary care to decrease the burden of lung cancer.

DESCRIPTION OF PROGRAM/INTERVENTION: The U.S. Preventive Services Task Force (USPSTF) updated guidelines for lung cancer screening with LDCT in adults 50-80 years old with a 20 pack-year smoking history who currently smoke or have quit within 15 years. From 2014-2018, the age-adjusted incidence for lung and bronchial cancer in the southern region of Texas was 40.4 cases per 100,000 for all populations and 25.7 per 100,000 for Hispanics. This is higher than the rate amongst Hispanics for the state of Texas (25.5 per 100,000). In partnership with a nationwide voluntary health organization, our academic primary care practice is leading a multi-disciplinary QI project to improve lung cancer screening for eligible patients. This project is implemented across 7 primary care locations. The project duration is 01/31/2022- 12/31/2022. The aim is to improve lung cancer screening rates by 10% from 01/31/2022-12/31/2022. Interventions include enhanced tobacco use history collection, staff and provider education, adding lung cancer screening to health maintenance, use of an updated order in the electronic medical record which will capture completion of shared-decision making, providing lung cancer screening information for eligible patients in an after-visit summary, and development of clinic materials to facilitate shared-decision making conversations with patients during office visits.

MEASURES OF SUCCESS: Metrics include percentage of patients with full tobacco history collected, proportion of USPSTF eligible patients with LDCT ordered and, of those, percentage who received a LDCT. FINDINGS TO DATE: Baseline data as of 1/31/22 showed 10,935 patients within the PCC: 49.3% were identified as current tobacco users with pack years on file. At baseline, approximately 3.2% never had tobacco status documented and 16% of ordered lung cancer screenings were completed. Currently, there has been a 14.3% increase in patients with complete tobacco history documentation on file since the start of the project and 20% of ordered screenings have been completed.

KEY LESSONS FOR DISSEMINATION: This QI project is currently ongoing. An upward trend in those patients who identify as tobacco users has been observed since implementing more robust tobacco history documentation. Because USPSTF guidelines are dependent on knowing tobacco use history, this is an important first-step in identifying patients at-risk for lung cancer and improving lung cancer screening rates. Partnerships with multiple departments and organizations was key to successful implementation. Of note, we have been granted funding for a second year of this project which will continue through 2023.

IMPROVING THE RATE OF LUNG CANCER SCREENING IN AN URBAN INTERNAL MEDICINE RESIDENCY CLINIC

Vamsi Matta, John Nawrocki, Frank Duan, Christian Noblett, Genti Shatri, Zehra Hussain

Internal Medicine, Christiana Care Health System, Wilmington, DE. (Control ID #3874499)

STATEMENT OF PROBLEM/QUESTION: Lung cancer is the leading cause of cancer death in the United States; our team aimed to increase the lung cancer screening rate in our residency clinic and to better understand specific barriers to screening.

DESCRIPTION OF PROGRAM/INTERVENTION: The USPSTF recommends screening for lung cancer via annual low dose chest CT (LDCT) in individuals age 50-80 who are currently smoking or have quit within the last 15 years and have at least a 20 pack-year smoking history. Adherence to this screening guideline is estimated to be as low as 5.8% nationally. At our internal medicine residency clinic, the lung cancer screening rate in September 2021 was 20%. Our team of residents reviewed charts of 10% of patients who were overdue for screening (40 charts), with the goal of quantifying specific barriers to screening. We found that provider and patient contributors were similar in magnitude; for our first PDSA cycle we focused on provider factors. We conducted a resident survey to understand baseline resident knowledge and practices around lung health screening and developed a resident-led workshop around rationale for lung cancer screening, latest USPSTF guidelines, ordering LDCT in our EMR, and referral to our Lung Health team (an institution-specific team that orders and follows up on LDCT once a referral is made by the PCP)

MEASURES OF SUCCESS: Our primary measure of success is increasing the overall rate of successful lung cancer screening in our clinic. Our secondary measure is improving resident knowledge of screening guidelines and documentation of pack-years.

FINDINGS TO DATE: Our baseline chart reviews showed that while 97.5% (39/40) of the patients had a tobacco use history documented, only 77.5% (31/40) had specific pack-years documented. 52.5% (21/40) of patients had been referred for LDCT and/or to the lung health program. For patients who had been referred, documented patient barriers included difficulty scheduling appointments and competing health priorities. In addition, results of our resident survey revealed that only 59.4% of residents (19/32) were aware of the USPSTF lung cancer guidelines. 87% of the residents (28/32) were able to correctly calculate pack-years, but only 62.5% (20/32) reported that they were calculating and documenting pack-years consistently. The overall rate of lung cancer screening was 20% (78/381) in April 2021 and improved to 29% (156/535) in December 2022 (p=0.002).

KEY LESSONS FOR DISSEMINATION: Our root cause analysis highlighted that there are multiple layered barriers to successful lung cancer screening in our clinic: residents are only ordering the screening about half of the time, and even after it is ordered, there are patient barriers preventing successful follow- through. Our first PDSA cycle focused on provider education, which did correlate with a significant increase in screening completion. For the next PDSA cycle, we will continue provider education and also focus on targeting patient barriers to screening completion through closer collaboration with the Lung Health team and focused follow up visits.

IMPROVING UTILIZATION OF SGLT-2 INHIBITORS IN VETERANS WITH TYPE 2 DIABETES MELLITUS AND CHRONIC KIDNEY DISEASE IN A VA PRIMARY CARE CLINIC

Rachel Anderson¹; Jonathan Day¹; Solanus de la Serna¹; Mackenzie Hines¹; Sruti Prathivadhi- Bhayankaram¹; Joseph Salomone¹; Naomi Vather¹; Arya Zandvakili¹; Leslie Brettell¹; Krista M. Johnson²; Derek Hupp³

¹Internal Medicine, The University of Iowa Hospitals and Clinics, Iowa City, IA; ²Internal Medicine, University of Iowa, Iowa City, IA; ³Internal Medicine, Iowa City VA Medical Center, Iowa City, IA. (Control ID #3876008)

STATEMENT OF PROBLEM/QUESTION: SGLT-2 inhibitors (SGLT2i) reduce progression to end stage renal disease, doubling of creatinine, and death from renal causes in patients with chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM), but they are underutilized in our VA primary care clinic with only 43% of eligible veterans prescribed an SGLT2i.

DESCRIPTION OF PROGRAM/INTERVENTION: We previously focused on increasing utilization of SGLT2i in veterans with T2DM and cardiovascular disease in an Internal Medicine resident primary care clinic at the Iowa City Veteran Affairs Medical Center. The original intervention resulted in a 53% relative increase in the number of candidate veterans prescribed an SGLT2i over 4 months. Given this success, we broadened the scope of the project to increase SGLT2i use in veterans with T2DM and CKD. We used the Primary Care Almanac (PCA) CKD report to identify SGLT2i candidates. Inclusion criteria were an A1c 6.5-10.0%, use of at least one medication for diabetes, and eGFR 45-90. The exclusion criteria were a history of pancreatitis, urinary tract infections, and amputation. For the intervention, pharmacists placed a standardized note in the electronic medical record (EMR) 1-2 weeks prior to a candidate veteran’s next primary care appointment. The note identified the veteran as an SGLT2i candidate, provided indications, contraindications, side effects of the medication, and recommendations for monitoring.

MEASURES OF SUCCESS: The primary outcome measure was the proportion of candidates prescribed an SGLT2i. The process measure was the proportion of SGLT2i candidates who had a standardized note placed in their EMR.

FINDINGS TO DATE: Baseline data showed 157/365 (43.0%) candidates were already prescribed an SGLT2i. Over a 5-month period, 83 candidates had a standardized note placed in their EMR. Of those, 18 (21%) were started on an SGLT2i.

KEY LESSONS FOR DISSEMINATION: - Using the PCA allowed us to efficiently identify SGLT2i candidates and upcoming appointments with minimal data-processing.

- Clinic pharmacists were key collaborators and without their buy-in and knowledge our intervention would not have been successful.

- Many candidates did not have appointments during the 5-month intervention therefore a longer intervention may be beneficial.

- Many candidates had an A1c within goal, thus were deemed inappropriate for additional therapy. Raising the A1c lower limit may help with selection of candidates.

IMPROVING WEIGHT MANAGEMENT IN THE AMBULATORY CARE SETTING

David A. Goodson, Elora M. Negose

University of California Davis Department of Internal Medicine, Sacramento, CA. (Control ID #3875147)

STATEMENT OF PROBLEM/QUESTION: Obesity is a serious chronic disease that places patients at increased risk of comorbidities and all-cause mortality, yet it remains a topic incompletely addressed by primary care providers with patients.

DESCRIPTION OF PROGRAM/INTERVENTION: Internists cite multiple barriers to addressing obesity in primary care settings, including lack of knowledge about recent advances in weight management, time, and ancillary support.

Clinic data was extracted from the EMR which showed that of patients seen who had a known BMI of 30 kg/m2 or greater (n=7,077; FY20 and FY21), only 15.29% of those clinical encounters had a primary diagnosis code for obesity (n=1,077). Very few referrals were made for bariatric surgery consultation or behavioral modification courses (<1%, n=57). Additionally, internal medicine residents were questioned about their medical knowledge regarding obesity and comfort discussing weight management. Residents felt modest comfort about having weight management discussions with patients (5.7 on 10 pt scale) and 52% did not think medications could help with weight management. Finally, patients were queried, and of those who self-identified as overweight or obese, 47.3% had not discussed weight with their primary care provider.

Educational seminars were held to provide training on weight management. Patients who were interested in further discussions of their weight were contacted to schedule appointments dedicated to weight management. Finally, an electronic order set was created within the EMR to facilitate provider referrals and medication options to help treat obesity

MEASURES OF SUCCESS: Obesity ICD10 codes listed as the primary encounter diagnosis were used as a surrogate marker to estimate prevalence of weight management discussions in the outpatient setting. Resident survey data was collected pre- and post-educational seminar to identify resident comfort with weight management and knowledge about medical and surgical interventions for weight loss. Provider referrals to bariatric surgery, nutrition clinics and weight management classes were tracked through the EMR.

FINDINGS TO DATE: Nearly 40% of internal medicine clinic patients are obese or overweight by BMI measurement, but obesity is often not formally documented in the patient’s problem list or significantly addressed during the clinic visit. Few referrals are placed that could support patients’ weight loss journeys. After educational seminars, residents felt more comfortable with weight management (7.65 on 10 pt scale) and 97% believed medications could help with weight management.

KEY LESSONS FOR DISSEMINATION: Increasing the number of outpatient visits dedicated to weight management will be the first step towards adequate treatment. Protected educational time towards this topic can help internists feel more comfortable addressing obesity in the primary care setting. Finally, creation of the weight management order set can help providers combat time constraints and increase the number of prescriptions, referrals to bariatric surgery, and future visits to address weight management.

INCREASING BUPRENORPHINE ACCESS FOR PATIENTS WITH CHRONIC PAIN: A MULTI- PHASE QUALITY IMPROVEMENT INITIATIVE

Danielle Wesolowicz^1,2; Juliette F. Spelman^3,2; Sara Edmond^1,2; William Becker^1,2

¹Research, VA Pain Research Informatics Multi-morbidities and Education Center, West Haven, CT; ²Yale School of Medicine, New Haven, CT; ³VA Connecticut Healthcare System, West Haven, CT. (Control ID #3868105)

STATEMENT OF PROBLEM/QUESTION: Buprenorphine is effective for chronic pain and safer than full-agonist opioids; however, limited education and support regarding buprenorphine prescribing are potential barriers for primary care (PC) providers (PCPs), resulting in under-prescribing PC and reduced access in pain clinics.The purpose of this quality improvement (QI) initiative was to optimize and evaluate procedures for transferring patients stable on buprenorphine for chronic pain from a specialty pain clinic back to PC at one VA healthcare system in the Northeast.

DESCRIPTION OF PROGRAM/INTERVENTION: We conducted a needs assessment with PC and pain clinic leadership to increase buprenorphine prescribing for pain in PC. We developed a standard operating procedure (SOP) using a “graded responsibility” approach to facilitate PCPs taking back patients stable on buprenorphine. The SOP detailed eligibility for transfer, the transfer process, and ways for PCPs to re-engage with the pain clinic if needed. Prior to implementation, PCPs participated in a 1-hour orientation to the SOP.

MEASURES OF SUCCESS: We tracked success by monitoring the number of patients transferred back to PC, PCPs with newly obtained X-waivers, and consults from PCPs to specialty care providers (including pain and substance use clinics) following transfer of care; we anticipated that these consults would reflect instability in buprenorphine regimens and/or pain management.

FINDINGS TO DATE: Ten months into the initiative, a total of 22 patients were successfully transferred back to 18 PCPs; of those patients, 1 requested re-consultation with the pain clinic for medication management. 12 PCPs with eligible patients were contacted and encouraged to obtain their X-waiver; 2 of those PCPs successfully obtained their X-waiver, and 1 obtained active prescribing privileges within the healthcare system.

Survey results indicated PCPs varied in their degree of readiness and view of prescribing buprenorphine as within the scope of their practice; additionally, once a provider initially began prescribing buprenorphine, they were likely to continue prescribing. Qualitative feedback suggested the need for enhanced organizational support and tailored approaches to improve comfort with initiation of buprenorphine prescribing, including providing opportunities for consultation and education on best practices.

KEY LESSONS FOR DISSEMINATION: Returning pain management care for stable patients back to PC has several advantages, including centralization of care for patients and improving specialty pain care’s access. Addressing system and provider-level barriers to buprenorphine prescribing can improve accessibility to pain management for patients. Future work will assess if increasing comfort with managing stable regimens will increase PCPs’ initiation of buprenorphine regimens for pain management.

INCREASING HEPATITIS C SCREENING IN A VA PRIMARY CARE CLINIC

James F. Burton¹; Tristan Bakerink¹; Tyler Bullis¹; Taylor Cox¹; Katelin Durham¹; Daniel Goering¹; Adam E. Prescott¹; Mackenzie Walhof¹; Robert Windisch¹; Qiujun Yu¹; Yolanda Rodriguez Villalvazo^1,2; Carly Kuehn^1,2

¹Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA; ²Iowa City VA Medical Center, Iowa City, IA. (Control ID #3874774)

STATEMENT OF PROBLEM/QUESTION: Current USPTF guidelines recommend universal screening for chronic hepatitis C virus (HCV) infection in all adults ages 18-79 years, yet barriers to screening still exist within primary care.

DESCRIPTION OF PROGRAM/INTERVENTION: HCV infection is a leading cause of cirrhosis in the United States. With increasing prevalence and effective treatment options, in 2020 the USPSTF recommended universal screening for HCV in all adults ages 18-79 years. With these expanded guidelines, many patients became newly eligible for HCV screening. We implemented a project to increase the rate of HCV screening among patients in a primary care clinic. A total of 2,350 patients at a resident-run primary care clinic located at a Midwestern Veterans Affairs (VA) Medical Center were included. Using the electronic health record, 424 patients lacked a qualitative HCV antibody result. Of these, 52 patients had upcoming lab appointments scheduled within the next 6 months. These patients had an order for hepatitis C antibodies pended and flagged to be reviewed by the patient’s primary care physician. If deemed appropriate, the primary care provider was prompted to order the screening test to be completed at the upcoming lab visit.

Any positive HCV antibody test had automatic reflex quantitative HCV PCR testing, and follow-up was to be done by the ordering provider. Patient data was followed up at 3 months to assess for interval improvement in the number of patients who completed HCV screening, with a 6-month endpoint remaining in the future.

MEASURES OF SUCCESS: Our aim was to reduce unscreened, guideline-eligible patients by 50% within 6 months of implementation. Number of positive screens from the intervention was tracked as well. A process measure was the percentage of pended orders signed by the primary care physician.

FINDINGS TO DATE: Fifty-two patients were identified to still need HCV screening and have pre-existing lab appointments. At the end of 3 months, 21 patients (40%) completed the HCV antibody test. The percentage of unscreened patients decreased by 5%. Twenty-nine (56%) of the total 52 orders that were pended were signed by the primary care physician. None of the qualitative hepatitis C antibody tests obtained as part of this study returned as positive.

KEY LESSONS FOR DISSEMINATION: Pending and flagging qualitative HCV antibody tests increased the rate of hepatitis C screening within a VA resident primary care clinic. This demonstrates a cost and time efficient strategy for increasing screening rates in a primary care setting.

INTEGRATING AUTOMATED OFFICE BLOOD PRESSURE MEASUREMENTS INTO A RESIDENT GENERAL INTERNAL MEDICINE CLINIC

Benjamin J. Seifer¹; Andrew W. Schultz²; Lefan He²; Caroline Lombardo³; Kelly A. Kieffer¹

¹Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH; ²Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH; ³Internal Medicine, Dartmouth Health, Lebanon, NH. (Control ID #3873671)

STATEMENT OF PROBLEM/QUESTION: Guidelines recommend automated office blood pressure measurement (AOBPM) – recording multiple unattended blood pressure (BP) readings at a single appointment - be used in the office as AOBPM is more accurate than routine office BP measurement (OBPM). However, AOBPM requires additional time to perform. Staffing shortages faced by many practices during the COVID-19 pandemic make integration of new processes challenging.

DESCRIPTION OF PROGRAM/INTERVENTION: We seek to incorporate AOBPM into a resident clinic at an academic medical center. Resident visits include “dead time” where the resident is presenting to an attending physician and the patient is left alone. “Dead time” can be used for automated processes that improve patient care, such as AOBPM, without disrupting workflow. We have created a protocol for performing AOBPM using a BP monitor widely available in our clinic and have created video and written instructions to teach AOBPM. A teaching session has been held with residents and individual instruction is available. A QR code linked to the instructions will be attached to BP monitors for easy access. We have run a pilot project with a single resident to validate our AOBPM protocol and obtain initial feedback.

MEASURES OF SUCCESS: Residents will be asked to document use of AOBPM in their visit notes and to record AOBPMs in a logbook kept in the precepting workroom. Inferential statistics will be used to validate resident performance of AOBPM. Residents will be sent a survey 3 months after project initiation to obtain feedback. Percent of residents who have performed AOBPM at least once and use over time will be evaluated. Descriptive statistics will be used to show change in distribution of hypertension categorization (based on 2017 ACC/AHA guidelines) among patients following AOBPM compared to routine OBPM.

FINDINGS TO DATE: For the pilot, AOBPM was performed on 13 patients during visit “dead time.” Mean difference (MD) between routine OBPM and AOBPM was 12.8 mmHg (p<.001) for systolic BP and 3.3 mmHg (p=.186) for diastolic BP. MDs were similar to those seen in prior studies per a recently published meta-analysis. Of the 13 patients, 7 (54%) fell by at least one hypertension category, 4 (31%) fell by at least two categories, and 2 (15%) fell from stage 2 hypertension to normal blood pressure. Starting AOBPM took

1-2 minutes, a similar amount of time as would be required to take a second routine OBPM. AOBPM was always complete by the time the resident returned to the room after presenting to the attending physician. No patient objected to performance of AOBPM.

KEY LESSONS FOR DISSEMINATION: AOBPM is a high-value intervention that is likely to alter treatment decisions for patients with hypertension. Training clinic support staff to perform a new process can be challenging especially given current staffing shortages. Residents can implement AOBPM with minimal disruption to workflow due to presence of “dead time.” Video and written instructions can eventually be used to teach clinic support staff so that AOBPM is more widely available in our clinic.

INTERDISCIPLINARY CLINIC FOR THE USE OF BUPRENORPHINE FOR CHRONIC NON- CANCER PAIN (CNCP) IN PRIMARY CARE WITHIN THE VETERANS HEALTH ADMINISTRATION (VHA): A PILOT PROGRAM

Sara Spinella¹; Rebecca McCarthy²

¹General Internal Medicine, University of Pittsburgh, Pittsburgh, PA; ²Primary Care, Veterans Health Administration, Washington, DC. (Control ID #3868245)

STATEMENT OF PROBLEM/QUESTION: Buprenorphine is safer than full opioid agonists, yet patient and primary care provider’ (PCP) discomfort with this medication is a barrier to its use for CNCP.

DESCRIPTION OF PROGRAM/INTERVENTION: In 2022, VHA released a practice guideline recommending buprenorphine over full opioid agonists for Veterans on long-term opioid agonist therapy (LTOT) because it safer. Many PCPs are uncomfortable with transitioning from LTOT to buprenorphine. Veterans with CNCP face stigma, and nonconsensual tapers are associated with risks. Changes to LTOT can provoke anxiety in both Veterans and PCPs. We developed a consult service within a VHA primary care clinic. PCPs referred patients on LTOT at particular risk for opioid-related harms. Veterans met with both a clinical pharmacist with expertise in CNCP and a PCP with substance use disorder (SUD) expertise for 60 minutes via telehealth. We used both FDA-approved buprenorphine formulations for pain (transdermal and buccal) and off-label sublingual (SL) formulations. Follow-up visits with the pharmacists ranged from weekly to every 3 months.

MEASURES OF SUCCESS: Patients who tried buprenorphine for pain were monitored for efficacy and adverse drug reactions. We reviewed patients who declined buprenorphine for pain to determine whether they continued LTOT or tapered, and if they experienced any harms.

FINDINGS TO DATE: From 3-11/2022, 15 Veterans attended at least one appointment. The mean age was 58 (range 30-76) and 40% were female. The most common pain diagnoses were low back pain and fibromyalgia. Medical and psychiatric comorbidities were common, particularly COPD (6) and ongoing non- opioid substance use or concerning opioid behaviors (7). While most Veterans were on LTOT opioids prior to our clinic evaluation, we offered buprenorphine to 3 Veterans with frequent short-term opioid prescriptions. Four Veterans declined to transition to buprenorphine following shared decision making. Two remain on LTOT and 2 are tapering; none had adverse events. Nine Veterans were placed on buprenorphine. Two experienced worsening pain and went back on LTOT and 1 was lost to follow-up. One Veteran developed an allergy to the adhesive in the transdermal formulation but responded well to SL buprenorphine-naloxone. In all, six Veterans had improvements in pain or function with SL (4) or buccal (2) buprenorphine.

KEY LESSONS FOR DISSEMINATION: This clinic is an effective model for use of buprenorphine for CNCP among patients already on LTOT. We found that many Veterans benefited from off-label use of sublingual buprenorphine, rather than transdermal or buccal formulations. Veteran buy-in was a potential barrier. The extended intake appointments with our interdisciplinary team facilitated shared decision making. Most patients had prior or current substance use, perhaps due to our referral model. While it is important to distinguish CNCP from SUDs and to destigmatize both diseases, out expertise in both pain and SUD treatment enabled us to care for people who may not easily fit into either pain or SUD clinics.

LOW BARRIER ELECTRONIC INTERPRETATION HAS SURPRISING LEVEL OF IMPACT ON PATIENT UNDERSTANDING AND SATISFACTION WITH HEALTH CARE

Veronica R. Jacome Lopez¹; Natasha Rastogi¹; Erion Sulaj²; Kaitlyn McDowell²; Paul N. Foster¹

¹Internal Medicine, Englewood Health, Englewood, NJ; ²North Hudson Community Action Corporation, Union City, NJ. (Control ID #3867711)

STATEMENT OF PROBLEM/QUESTION: Low barrier electronic interpretation devices improve patient's experience during clinical encounters.

DESCRIPTION OF PROGRAM/INTERVENTION: As of 2021, almost 26 million Americans (8%) have limited English proficiency (LEP). A 2005 systematic review by Flores et al demonstrated how language barriers impact health and health care. Our Internal Medicine training clinic is located in a New England community safety-net setting. Approximately 70% of patients speak Spanish with LEP. Until December 2021, translation occurred through laptop or mobile phone, with long delays in patient care and frustrations for our residents. As a quality improvement project, our residency team applied for a hospital grant that led to placement of active video interpreter tablet in each exam room. This resulted in three interventions: a ready interface, a single-click process for access to multiple languages, and a visual aspect to the relationship. We present our assessment of the impact of this change on patients and residents.

MEASURES OF SUCCESS: We surveyed Internal Medicine residents and Spanish speaking patients seen in clinic from June to July 2022, with a focus on patient perception of efficiency, understanding of their disease process, and patient impression of provider engagement. We also collected age, gender, and educational level. A quantitative analysis was performed to calculate the degree of agreement across the group, as well as the impact of age, educational level, and gender.

FINDINGS TO DATE: In preliminary data from 42 Spanish-speaking patients with most of them having minimal to no English skills, and 50% of them having formal high school education, we saw almost universal approval in all three categories of assessment. Beyond the subjective impact, the residents reported improvements in patient follow up. We are currently evaluating whether further impact on clinical variables such as diabetic control occurred. From the perspective of our residents and faculty, the video devices greatly impacted their commitment to interpretation in every encounter. It improved their overall experience in the clinic.

As we made multiple changes, we could not discriminate which aspect of the video interpreter system may have been most important, but observed that the combination of consistent access, efficient process and video were likely synergistic. Further study may be helpful in fine tuning the interpretation experience.

KEY LESSONS FOR DISSEMINATION: Our study emphasizes that interpretation is not a simple black and white variable, and that small changes may have an outsized impact. Improving technology makes immediate appropriate personal interpretation feasible. In the COVID era, many patients have become comfortable using video technology to overcome communication barriers. Interestingly, we especially saw this in our least educated patients, who proportionally had the strongest positive response. We encourage health systems to explore a roll out of this technology to potentially every clinical bed, and continue QI studies to further define best practices.

ORDERED IN BULK: CLOSING THE CARE GAP FOR DIABETIC RETINOPATHY SCREENING Sarah W. Takimoto, Sylvia Lambrechts, Matthew J. Freeby, Sitaram Vangala, Maria Han. Internal Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #3876107)

STATEMENT OF PROBLEM/QUESTION: Early detection of diabetic retinopathy (DR) allows for vision-saving treatment; however, less than half of patients with type 2 diabetes (T2DM) are up to date with recommended screening guidelines.¹

DESCRIPTION OF PROGRAM/INTERVENTION: Standardized bulk ordering of retinal fundus photos was implemented to increase annual diabetes eye exam completion rates. A total of 5,665 patients aged 18 to 70 with T2DM, an active patient portal, an attributed primary care provider, and an incomplete care gap were identified. Patients were excluded if they had a history of DR, an active ophthalmology referral, or an active order for a retinal fundus photo. Patients were randomized into four bulk order dates (April to July 2022) to allow for scheduling availability within 2 weeks. An electronic message was sent about the importance of a diabetes eye exam and how to schedule a retinal fundus photo appointment through their patient portal. The care gap was automatically closed after the retinal fundus photo was completed.

MEASURES OF SUCCESS: Our primary outcome measure was completion of the diabetes eye exam care gap. Process measures included opening of the patient message, scheduling a retinal fundus photo appointment, and completion of a retinal fundus photo appointment. A logistic regression model at the patient-month level, clustering observations by patient, was used to evaluate the effect of the bulk order intervention on completion of the eye exam on an intention-to-treat basis.

FINDINGS TO DATE: The bulk order intervention had a statistically significant impact on diabetes eye exam completion rates, with an odds ratio of 1.79 (95% CI: 1.50, 2.14). Six months after the first bulk order, almost 50% of patients (n=2,715) opened the electronic message sent with the bulk orders. Of those who opened the message, 26.1% (n = 710) scheduled an appointment for a retinal fundus photo, and 73.9% (n = 525) of those who scheduled had completed their retinal fundus photo appointment. 16.8% (n = 954) of patients originally randomized to receive a bulk order were documented to have completed their eye exam care gap by the end of follow-up.

KEY LESSONS FOR DISSEMINATION: Bulk ordering is an effective population health approach to proactively engage patients in their care. Use of retinal screening bulk orders shows an improvement in closing the diabetes eye exam care gap measure for patients with T2DM.

References:

1. Benoit, S. R., Swenor, B., Geiss, L. S., Gregg, E. W. & Saaddine, J. B. Eye Care Utilization Among Insured People With Diabetes in the U.S., 2010-2014. Diabetes Care 42, 427–433 (2019).

REDUCING HOSPITAL-ONSET CLOSTRIDIUM DIFFICILE INFECTIONS WITH TESTING APPROVAL STRATEGY

Daniel Kazmierski¹; Diane H. Johnson^1,4; Jasmine Beria¹; Dina Chenouda²; Saul Blecker³

¹Medicine, NYU Langone Hospital - Long Island, Mineola, NY; ²Hospital Medicine, NYU Langone Hospital - Long Island, Mineola, NY; ³Population Health, NYU School of Medicine, New York, NY; ⁴Infectious Disease, NYU Langone Hospital - Long Island, Mineola, NY. (Control ID #3873921)

STATEMENT OF PROBLEM/QUESTION: Clostridium difficile (C difficile) infections are the most common cause of antibiotic-associated diarrhea, and reflect a significant healthcare cost. Hospital acquired C difficile infections (HO-CDI) is defined by the Center for Disease Control National Healthcare Safety Network as a positive test collected and resulted on hospital day 4. Asymptomatic C. difficile colonization, prevalent especially in hospitalized patients, is not a precursor to C. difficile infection and does not require treatment. Hospital systems have enacted various measures to reduce false positive HO-CDI and unnecessary treatment of C. difficile colonization. Our hospital system implemented a system-wide, standardized process of C. difficile testing approval. The purpose of this study was to evaluate the effect of this intervention on HO-CDI rates.

DESCRIPTION OF PROGRAM/INTERVENTION: A multidisciplinary team was formed in January 2021 to identify barriers to early C. difficile testing and reduce the incidence of HO-CDI. Education was given to providers to encourage more frequent testing of potential C. difficile cases early in the hospitalization. A tip sheet was distributed to hospital staff to reinforce criteria for C. difficile testing later than hospital day 3 to reduce unnecessary testing. Additionally. In November 2021, medical unit director (MUD) approval became required for any C. difficile testing later than hospital day 3 to ensure all testing criteria were met, and to reduce potential false positive cases from patients with C difficile colonization. In addition, a best practice alert was implemented within the electronic medical record to include the same criteria within the tip sheet that required completion prior to signing the order. Apparent cause analyses were performed on all HO-CDI cases to identify opportunities for improvement.

MEASURES OF SUCCESS: The incidence and monthly rate of HO-CDI were measured throughout this period of intervention.

FINDINGS TO DATE: The median monthly rate of HO-CDI from January 2021 to October 2021, prior to implementation of MUD approval, was 4.29 per 10,000 patient days. Following implementation of the MUD approval process, the median monthly rate dropped to 1.68 per 10,000 patient days (p=0.006), representing a 61% difference in case rate per month and a drop in 3 HO-CDI median cases per month.

KEY LESSONS FOR DISSEMINATION: Early recognition and testing of potential C. difficile infections, coupled with implementation of a tip sheet, best practice alert and MUD approval to ensure proper testing criteria, led to a statistically significant and sustained decrease in HO-CDI across our healthcare system. This can be attributed to a decrease in detection of false-positive C. difficile colonization. These measures have implications in both optimal medical treatment, along with reduction of hospital stay and patient harm. Similar measures involving oversight approval for in-hospital C. difficile testing could yield similar success across other healthcare systems.

RELATIONAL COORDINATION IN A VERTICALLY INTEGRATED DEPARTMENT OF VETERANS AFFAIRS MEDICAL PRACTICE GROUP

Avery Z. Laliberte¹; Martha Gerrity²; Brian Park³; Jennie Fleischmann⁴; Samuel T. Edwards¹

¹Center to Improve Veteran Involvement in Care, Portland VA Medical Center, Portland, OR; ²Medicine, Oregon Health & Science University, Portland, OR; ³Family Medicine, Oregon Health & Science University, Portland, OR; ⁴VA Portland Healthcare System, Portland, OR. (Control ID #3872234)

STATEMENT OF PROBLEM/QUESTION: The COVID-19 pandemic, increased demand for care, and staff shortages contributing to increased employee burnout and turnover at Veterans Health Administration (VA).

DESCRIPTION OF PROGRAM/INTERVENTION: The COVID-19 pandemic exacerbated existing challenges that led to record levels of employee burnout and turnover. Relational coordination (RC) is a theory whereby improving relationships and communication enable stakeholders to coordinate their work effectively. RC is associated with delivering effective, reliable, highly coordinated care and is linked to performance outcomes that are at the heart of VA’s mission. VA Portland Health Care System serves more than 95,000 Veterans, is vertically organized, and is led by an executive leadership team (ELT) that oversees seven major service lines.

Using a validated 25-item survey, we assessed RC within the tripartite leadership of each service line (physician, nursing, administration), across service lines, between service line leaders, and the ELT. Findings were debriefed with participants in a virtual meeting, and priorities were set for a planned in-person retreat.

MEASURES OF SUCCESS: Results include a score (1-5) for each of the seven RC dimensions: frequent, timely, accurate, and problem-solving communication; shared goals; shared knowledge; mutual respect; and an overall RC score. Scores are separated into three tiers based on norms across multiple industries, including healthcare, and are displayed as heat maps and network diagrams. The survey also measured the degree to which participants experienced work-related burnout, satisfaction, enthusiasm, and tenure in their current role. After the retreat, the survey will be repeated to assess changes in RC and burnout.

FINDINGS TO DATE: The survey had a response rate of 100% (N=22). Most respondents reported being in their role for five years or less (77%), feeling burned out at least once a week (55%), and feeling enthusiastic about their jobs at least several times a week (50%).

The overall RC score among respondents was 3.87 (middle tier). Frequent communication was scored in the upper tier (4.58), whereas shared knowledge was scored in the lower tier (3.16). All other dimensions were scored in the middle tier. The executive leadership team’s overall RC with the service line leaders was in the upper tier (4.03). After reviewing these results in a facilitated meeting, respondents identified shared knowledge and timely communication as dimensions they want to specifically address in their relationships with each other.

A report detailing within and between group RC will be presented during the upcoming retreat, and participants will discuss and co-create interventions that impact communication structures and relationships within their organization.

KEY LESSONS FOR DISSEMINATION: RC interventions can be feasible and effective among leadership in large healthcare systems in addressing staff burnout and turnover contributors. The RC survey provides leaders and respondents with data-driven tools to enhance relationships to improve their organization’s performance.

SAFE AND (COST-)EFFECTIVE ACTIVITY: DEPLOYMENT OF A DEDICATED MOBILITY TECHNICIAN ON AN ADULT INPATIENT GENERAL MEDICINE UNIT

Stephen Telloni¹; Jennifer McIlvaine²; Melissa Kandel²; Diandrea McCotter²; Victoria Orto²; Adam Glenn²

¹Medicine, Duke University Hospital, Durham, NC; ²Duke University Health System, Durham, NC. (Control ID #3873119)

STATEMENT OF PROBLEM/QUESTION: Immobility during hospitalizations is prevalent, harmful to patients, and costly to healthcare systems; solutions are urgently needed.

DESCRIPTION OF PROGRAM/INTERVENTION: A multidisciplinary team composed of physicians, nurses, and physical and occupational therapists at a healthcare system in the Southern Region designed a mobility technician (MT) program based on other published standardized mobility programs. The goals were to improve mobility and prevent functional decline of patients, while demonstrating cost-effectiveness for the healthcare system. The MT program launched in July 2021 on a single adult general medicine unit at an academic hospital. The MT encouraged and assisted all eligible hospitalized patients to meet daily mobility goals, which were created for each of the four Bedside Mobility Assessment Test (BMAT) levels and include various range-of-motion (ROM) exercises, ambulation of 1,000 feet, and getting out-of-bed (OOB) at least once daily. BMAT levels were assigned to patients by nurses during every 12-hour shift and range from patients unable to leave the bed (level 1) to those who can dependently or independently ambulate (level 4). The MT worked 5 days per week from 9 am to 5 pm.

MEASURES OF SUCCESS: Performance was compared between the pilot unit and a control unit with a similar general medicine patient population but without an MT during pre-implementation (August 2020- June 2021) and post-implementation (August 2021-June 2022) time periods. Process metrics measured daily include ROM exercises, OOB at least once, ambulation of any kind, ambulation of at least 1,000 feet, delirium, and falls. Outcome metrics at the hospital encounter level include average length of stay (ALOS), 30-day readmission rate, BMAT level trend from admission to discharge, and percentage of patients admitted from home who discharge home.

FINDINGS TO DATE: After deployment of the MT, the pilot unit demonstrated a: 9-fold increase in ROM exercises; 1.5-fold increase in getting OOB; 3-fold increase in any ambulation and 10-fold increase in optimal ambulation of 1,000 feet; 7% decrease in delirium; and no difference in falls. In addition, compared to the control unit over the same time periods, the pilot unit was found to have: 0.19-day better reduction in ALOS; 8% better 30-day readmission rates; 10% fewer patients experiencing a decline in BMAT level from admission to discharge; and 14% more patients who were admitted from, and discharged to, home. Based on the 0.19-day ALOS reduction for our 32-bed adult general medicine unit that typically sees 1,250 discharges per year, at an estimated cost of $1,000 per patient-day, deployment of the MT saved our healthcare system $237,500 for the year, easily off-setting the $48,367 for annual salary with benefits.

KEY LESSONS FOR DISSEMINATION: Mobility Technicians are a safe and cost-effective strategy to significantly improve adult inpatient mobility and function while bolstering key healthcare system outcomes. Hospital leaders should strongly consider deploying Mobility Technicians on all adult hospital units.

SHARED DECISION-MAKING FOR ASPIRIN DEPRESCRIPTION IN OLDER VETERANS Luke Morrey, Aron Evans, Tong Yu, Michael Shlossman, Grace Alexander, Brittnee Haynes, Ashten Sherman, Hunter Frederiksen, Justin Smock

Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA. (Control ID #3874655)

STATEMENT OF PROBLEM/QUESTION: The April 2022 US Preventative Services Task Force (USPSTF) guidelines on aspirin for primary prevention of cardiovascular disease (CVD) recommend against prescribing aspirin for adults 60 years or older and suggest clinicians and patients consider stopping aspirin around age 75. Many patients in our University of Iowa Internal Medicine Residency Continuity of Care (COC) Clinic at the Iowa City Veterans Affairs (VA) Medical Center remain on aspirin for primary prevention and are uninformed of the updated guidelines.

DESCRIPTION OF PROGRAM/INTERVENTION: Our quality improvement (QI) team consisted of 8 residents and 1 faculty mentor. In our clinic, 111 of 2842 patients (3.9%) were over the age of 75 and prescribed aspirin without a secondary prevention indication on their problem list (e.g., coronary artery disease). We alerted residents prior to clinic appointments with these patients and instructed them to discuss the risks and benefits for ongoing aspirin use. We also asked residents to document the result of their shared decision-making discussions in a clinical note template, which we used for data extraction.

MEASURES OF SUCCESS: Recognizing that some patients have undocumented aspirin indications for secondary prevention of CVD, our primary outcome was shared decision-making discussions rather than deprescription alone. Our aim was to perform shared decision-making with 30% of patients aged 75 or older taking aspirin for assumed primary prevention of CVD within 12 months.

FINDINGS TO DATE: Of 111 veterans over age 75 on aspirin without a documented secondary prevention indication, 33 had a COC clinic appointment during the study period from 9/5/2022 to 12/15/2022. Residents documented shared decision-making discussions with 9 (27%) patients. Six patients decided to stop aspirin or were no longer taking it. Two decided to continue due to undocumented secondary prevention indications and 1 preferred the aspirin be managed by an outside physician. Of the 9 patients with documented shared decision-making discussions, 5 (55%) were seen by residents on our QI team, compared to 3 of 24 patients (13%) without documented discussions.

KEY LESSONS FOR DISSEMINATION: Shared decision-making is an outcome measure that balances clinical uncertainty with patient values and can be utilized when patient care is individualized, guidelines are not definitive, and balancing harms is important. Early in our intervention phase, our shared decision-making documentation is short of our 30% target. Residents in the COC clinic outside of our QI team are less familiar with the project and may be less motivated to include aspirin on the appointment agenda. We have recently included more detailed instructions for residents and elicited help from in-clinic pharmacists to address these issues.

STANDARDIZING DEPRESSION SCREENING IN AN ACADEMIC PRIMARY CARE SETTING

Kira C. Watson¹; Anne Cioletti²

¹General Internal Medicine, University of Utah Health, Salt Lake City, UT; ²Internal Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #3873768)

STATEMENT OF PROBLEM/QUESTION: Depression is a significant cause of disability, linked to poor health outcomes; rates have increased by three- to four-fold since the onset of the COVID pandemic. However, despite 2016 USPSTF recommendations to screen, depression screening remains low, potentially exacerbating undertreatment. Due to time constraints and competing health concerns, primary care providers (PCPs) do not consistently screen for depression despite accessible and validated questionnaires, highlighting an opportunity for standardized intervention.

DESCRIPTION OF PROGRAM/INTERVENTION: We surveyed a convenience sample of physicians and medical assistants working in the outpatient general internal medicine (GIM) group and confirmed that no standardized screening process exists. We developed a workflow to implement standardized captive electronic medical record screening for depression at each new patient visit and annual visits, modeled after a successful intervention implemented in our institution’s subspecialty clinics. Questionnaires are automatically assigned for patient completion 24-48 hours prior to the specific visits. Abnormal screening will be directed to the behavioral health team using a workflow developed in the subspecialty pilot.

MEASURES OF SUCCESS: The impact of the standardized electronic medical record depression screening will be measured in multiple ways. First, we will track the change in screening rates following the implementation of the captive questionnaire. Currently, about 60% of eligible pimary care patients are screened for depression with the goal to increase this to 85%. We will compare our rates to similar GIM clinics to confirm the intervention’s impact. Second, we will compare the incidence of patients with moderate or severe depressive symptoms (phq-9 scores >10) before and after implementation. Finally, we will track the rate at which patients with moderate and severe depressive symptoms access mental health services.

FINDINGS TO DATE: Preliminary data identified depression screening occurs by PCPs at annual and new patient visits 58-75% of the time. Forty-five percent of patients are screened verbally or receive a paper form after being roomed. Not only is verbal questioning not recommended due to the potential perceived stigma, but this also illustrates provider- and time-dependent modalities instead of efficient and equitable care. Completing the questionnaire prior to the visit allows the patient to complete screening in a safe space and the PCP to be prepared to discuss results prior to the visit start.

KEY LESSONS FOR DISSEMINATION: With rising rates of depression, this is an excellent opportunity for an innovative quality improvement project as universal screening reduces depression care disparities and allows for early identification and treatment of depression. Patients have become savvy in using technology to access and manage their medical care; the use of captive questionnaires helps to improve clinical workflow efficiency, creates safe care, and allows for improved mental health and overall health outcomes.

THE OPPORTUNITY FOR HOSPITALIZED VETERANS TO LISTEN TO MUSIC IN THE MEDICAL INTENSIVE CARE UNIT

Albert Jang^1,2; Rebecca Ramm^1,2; Monica Romanko¹; Eunice Benson²; Amanda M. Raines³; Lauren D. Reyes³; Angelle McGehee⁴; Thomas Petterson⁵; Cesar Aguilar Lopez²; Alexandra Leigh²; Caitlin M. Martin Klinger²

¹Internal Medicine, Tulane University School of Medicine, New Orleans, LA; ²Internal Medicine, Southeast Louisiana Veterans Health Care System, New Orleans, LA; ³Psychiatry, Southeast Louisiana Veterans Health Care System, New Orleans, LA; ⁴Nursing, Southeast Louisiana Veterans Health Care System, New Orleans, LA; ⁵Physical Medicine & Rehabilitation, Veterans Health Administration, Washington, DC. (Control ID #3874766)

STATEMENT OF PROBLEM/QUESTION: Can music improve quality of care for veterans admitted to the medical intensive care unit (MICU)?

DESCRIPTION OF PROGRAM/INTERVENTION: Previous studies have revealed that relaxing music can be effective for hospitalized patients, with many prior studies revealing it can decrease anxiety, decrease delirium, improve pain control, and decrease the need for sedative medications. A quality improvement (QI) project during the 2022-2023 academic year was undertaken at a southern region Veterans Affairs (VA) hospital to determine whether veterans admitted to the ICU would overall benefit from music being played in terms of these variables.

MEASURES OF SUCCESS: This project was deemed to be exempt from review by the IRB. A short survey was distributed to ICU team members including nurses, MICU fellows and attending physicians, physical therapists, occupational therapists, and respiratory therapists to assess whether admitted veterans in the past have wanted music and to increase awareness of this QI project in September and October 2022. The availability for music entertainment in the ICU was determined to be poor. Radios with compact disc (CD) players and CDs of various music genres were made available for veterans in the ICU, as well as an automatically included order for nurses to provide music entertainment in the admission order set, on November 1, 2022. Pre-intervention data includes July through October 2022, which will be compared to post-intervention data November 2022 through March 2023. Data collected include patient demographics and home medications prior to admission, and for the ICU included the use of restraints, a bedside sitter, medications (sedatives, benzodiazepines [BZDs], opioids, antipsychotics, and sleep aids) for patients prior to and after November 1st. A post-intervention survey for ICU team members will be distributed in March 2023.

FINDINGS TO DATE: Sixty-five ICU team members filled out the pre-intervention survey, with 70% responding music had the potential to decrease the need for a sitter, 66% it could decrease the need for benzodiazepines and antipsychotics, and 52% that it could decrease opiate use. From July 1 through October 31, 2022, 120 unique veterans (97% male) were admitted to the MICU. In terms of total number of admissions (N=149), 14% involved intubation, 7% restraints and 15% sitters. For medications, the admissions involved 11% IV/IM and 9% oral BZDs, 5% IV/IM and 16% oral antipsychotics, 6% dexmedetomidine drip, 26% melatonin, and 26% IV and 13% oral opioids. Post-intervention qualitative data reported so far include some intubated patients remaining calm with music playing in the room.

KEY LESSONS FOR DISSEMINATION: This project to provide music entertainment for veterans admitted to the MICU is feasible, with enthusiasm and support from most ICU team members and goals of decreasing anxiety and delirium and improving pain control for the veterans. Ensuring all ICU staff are aware of this music availability remains a challenge. Post-intervention data is actively being collected and will be reported at the meeting.

THE ROLE OF TELE-THORACIC SURGERY CONSULT SERVICES IN REDUCING PATIENT TRANSFERS BETWEEN COMMUNITY AND TERTIARY HOSPITALS.

Teresa Varghese¹; Kimberley Ott²; Khwaja Saad Haq¹; Irfan Muhammad¹; Ashok kumar Kanugula¹; Hari Madichetty⁴; Urvish K. Patel³; Daniel Fortes²

¹Internal Medicine, Wellstar Spalding Regional Hospital, Griffin, GA; ²WellStar Kennestone Hospital, Marietta, GA; ³Public Health and Neurology, Icahn School of Medicine at Mount Sinai, Jersey City, NJ; ⁴Pulmonary Critical Care, Wellstar Spalding Regional Hospital, Griffin, GA. (Control ID #3876487)

STATEMENT OF PROBLEM/QUESTION: Patient transfers from community hospitals to tertiary centers due to lack of provider availability or need for higher level of care are often unnecessary and costly.

DESCRIPTION OF PROGRAM/INTERVENTION: First, an observational cross sectional study of 44 patients transferred from community hospitals to a tertiary center in a single healthcare system was obtained from July, 2022 to November 2022. The type of transfer(emergent vs non-emergent), reason for transfer, level of care (inpatient, ER, ICU), patient class, the outcome of the transfer (surgery, thoracic surgery intervention, observation, medical management) were determined. Unnecessary transfers were defined as those not requiring surgery but rather an intervention that could be done at the referral site.

A virtual tele-thoracic surgery consult service is to be implemented in the next few months which will allow thoracic surgeons in tertiary centers to remotely observe patients in community hospitals and appropriately determine need for transfer. It will also allow for shared decision making between providers, more educational and teaching opportunities between specialists and non-specialists to improve patient care.

MEASURES OF SUCCESS: Post intervention of tele-thoracic consult service: Quantitative: Number of unecessary transfers that were avoided Reduction in patient/hospital costs, length of stay, readmission rates, clinical outcomes

Qualitative: Improrvement in high quality care when a specialist is able to consult remotely for a community setting (measured by physician and patient satisfaction surverys).

Improveement in non-ICU departments management of complicated chest tube and plueral effusion cases (ex: currently 89% of the thoracic surgery transfers are from the ER or In patient floors vs the ICU).

FINDINGS TO DATE: Observational study findings: Of the 44 transfers, 25% required treatment plans that could have been performed at the referral site alone while 75% beneffited from cardiothoracic surgery services upon transfer. The reasons for transfer included service unavailability (82%) and need for higher level care (18%). The primary diagnoses for transfer were Pleural Effusion +/- chest tubes(40%) Pneumothorax (25%).

Findings post intervention of tele-thoracic surgery services is actively being collected and will be reported in the future.

KEY LESSONS FOR DISSEMINATION: Inquiry into past patient transfers is needed to understand the improvements that can be made at a referral site to reduce costly transfers while improving patient care and clinical outcomes at a referring community hospital.

Surges and scarcity of healtcare resources have paved the way for tele-health consult services to assist community hospital physicians and caregivers to optimize and elevate the services they are able to provide. Shared decision making in patient care between specialists and community hospital physicians can allow for increased educational opportunities to better improve healthcare delivery.

TRIALS AND TRIBULATIONS OF IMPLEMENTING A NURSE DRIVEN OXYGEN WEANING PROTOCOL FOR HOSPITALIZED PATIENTS

Claire Ciarkowski¹; Valerie M. Vaughn²; Trent Fuller²; Collin Seabourne³; Gene Scerbo¹; Casey Rommel³; Shegi Thomas³

¹Internal Medicine , University of Utah, Salt Lake , UT; ²Internal Medicine, University of Utah Health, Salt Lake City, UT; ³University of Utah Health, Salt Lake City, UT. (Control ID #3873991)

STATEMENT OF PROBLEM/QUESTION: Unnecessary use of supplemental oxygen is common in hospitalized patients.

DESCRIPTION OF PROGRAM/INTERVENTION: Supplemental oxygen use for non-ICU hospitalized patients is common. Although often perceived as harmless, guidelines recommend against oxygen use in patients who are breathless but not hypoxic due to potential for harm. Like any medicine, oxygen therapy should require a prescription; however in the hospital, it is often applied without a physician order. Nursing staff are capable of weaning supplemental oxygen but may feel uncomfortable doing this without clear guidance.

A multidisciplinary group including nursing leadership, hospitalists, and respiratory therapists developed a nursing driving oxygen weaning protocol to create clear guidelines for nurses to wean patients on acute care units off oxygen. IT designed an innovative tool in Epic to document oxygen weaning progress. Following approval of the protocol, education was disseminated.

To improve adherence, the weaning procedure can be initiated two ways: (1) the physician places an order for oxygen weaning which is followed by nursing or (2) the nurse is empowered to place a ‘Low Flow Oxygen Therapy’ order in the electronic medical record (EMR) and follow the associated weaning protocol. Once the weaning procedure is initiated, the nurse will be assigned a “task” in the EMR which identifies their patient is on the weaning protocol and prompts them every shift to wean their patient. The prompt links to the weaning protocol in the EMR.

MEASURES OF SUCCESS: The primary study outcomes are duration of supplemental oxygen use while inpatient and prescriptions for oxygen on discharge. Secondary outcomes include length of stay (LOS), 30- day hospital readmission rates, and rapid response calls

FINDINGS TO DATE: Despite best efforts and buy in from nursing, hospital, and physician leadership, implementation of a nursing driven protocol in an academic setting across multiple hospital units has been limited. Barriers and delays encountered include needed sign off from multiple leadership groups, poor nursing comfort with weaning despite education, large initial scope of project, nurse champion turn over, information technology failures, alert fatigue, and communication breakdown between heath care aide taking vital signs and nurse adjusting the oxygen level. Small improvements have been seen in average hours on supplemental oxygen per patient across the medical acute care units; however, this change could be related to a decrease in COVID cases during the study period.

KEY LESSONS FOR DISSEMINATION: This project illustrates the marathon we run when implementing quality improvement projects and the grit needed to continue improving via the PDSA (Plan, Do, Study, Act) cycle. When disseminating system wide change, it is important to have buy in from leadership, but also a front line champion to recognize problems and address areas for improvement.

USE IT TO LOSE IT: INCREASING ANTI-OBESITY MEDICATION UTILIZATION AMONGST ELIGIBLE PATIENTS IN A RESIDENCY PRIMARY CARE CLINIC

Alexander Paschke, Stephen Peltier, John Smestad, Megan Vree, Michael Tabet, Alyssa Ray, Samuel Zetumer, Krista M. Johnson

Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA. (Control ID #3877176)

STATEMENT OF PROBLEM/QUESTION: Many patients with obesity who meet eligibility for treatment with anti-obesity medications are not being prescribed these medications in the primary care setting.

DESCRIPTION OF PROGRAM/INTERVENTION: Obesity is a prevalent, clinically significant, and costly disease. Over 40% of American adults are clinically obese with BMI ≥ 30 kg/m2. While weight loss of 5-10% has been shown to reduce health care costs, multiple FDA approved anti-obesity medications (AOMs) remain underutilized. Notable barriers to utilization include unfamiliarity with AOM efficacy, dosing, coverage, and medication contraindications. Through a resident-led initiative, we implemented an educational smartphrase within our EMR system to guide shared decision-making regarding weight loss pharmacotherapy. We placed placards in clinic workrooms to promote the smartphrase and to remind residents to consider weight loss pharmacotherapy for their patients.

MEASURES OF SUCCESS: Data were collected from all Internal Medicine resident clinic patients at our organization using our EMR reporting tools. Inclusion criteria were individuals aged 18-75 seen by PGY1-3 internal medicine residents who had documented BMI > 30 kg/m2. Prescription rates, or AOM utilization, were determined by reviewing eligible patients’ current medication lists for active AOM prescriptions. Data was collected every 5 weeks. Our goal was to increase AOM prescription rates among eligible resident clinic patients by a 30% relative increase by 6 months.

FINDINGS TO DATE: Of the 413 patients in resident continuity clinic, 173 (41%) had BMI >= 30 kg/m2. Of these, 44 (25%) were already on weight loss pharmacotherapy at the beginning of the intervention. At 10 weeks post-intervention, of 378 patients remaining in resident continuity clinic, 157 (41%) had BMI >= 30 kg/m2, and 44 (28%) were on weight loss pharmacotherapy (chi-square statistic: 0.2828, p-val: 0.59). We plan to continue monthly data pulls and analyses to gauge further progress.

KEY LESSONS FOR DISSEMINATION: We identified that provider unfamiliarity with AOMs (particularly relating to insurance coverage) is a significant barrier to overall AOM utilization. We therefore partnered with our clinical pharmacy team to clarify and simplify the clinical and insurance information within our educational smartphrase tools. While creating and sharing EMR smartphrases is technically simple, we recognize that utilization of these tools varies among providers.

USING AN ULTRA-BRIEF SAFETY HUDDLE TO BOOST SAFETY REPORTING AND IMPROVE SAFETY CLIMATE AT A VETERANS AFFAIRS HOSPITAL.

Kara Gaerlan¹; Cecilia Wykes²; Marie Rossi¹; Brittany L. Garcia³; Stephen G. Henry^4,1

¹Hospital Medicine, VA Northern California Health Care System, Mather, CA; ²Primary Care/Women's Health, VA Northern California Health Care System, Mather, CA; ³General Internal Medicine, Geriatrics and Bioethics, University of California Davis, Davis, CA; ⁴University of California Davis Department of Internal Medicine, Sacramento, CA. (Control ID #3870747)

STATEMENT OF PROBLEM/QUESTION: Safety huddles are accepted as a best safety practice, but controlled studies that assess the impact of huddles on safety outcomes are rare. A 65-bed Veterans Affairs (VA) hospital wanted to incorporate safety huddles, but because of staffing shortages and low staff morale, acute care unit leaders were concerned about the time and bandwidth required to hold regular safety huddles.

DESCRIPTION OF PROGRAM/INTERVENTION: We added an ultra-brief safety huddle to an existing multidisciplinary, patient care huddle. This approach preserved the core principles of a safety huddle but minimized the additional time to less than two minutes, creating an ultra-brief safety huddle. The ultra-brief nature of our intervention permitted facile deployment into the acute care interdisciplinary team (IDT) huddle. The safety huddle was compromised of two questions that were asked at the daily IDT: Question 1) Have you seen any patient safety incidents in the last 24 hours? If answer is yes, then we proceeded to Question 2) Should this safety incident be entered into Joint Patient Safety Report (JPSR)? The VA emergency department, which also conducts multidisciplinary huddles, was our comparison group. Measures were compared before and after implementing the intervention.

MEASURES OF SUCCESS: Intervention fidelity; impact of intervention on 3 subscales from the Agency for Healthcare Research and Quality (AHRQ) Survey of Patient Safety Culture v2 (response to error, communication openness, reporting patient safety events) and number of non-fall incident reports submitted in the intervention and comparison groups.

FINDINGS TO DATE: The safety huddle questions were asked during 89% of team huddles over the 4-month intervention period. A safety concern was raised in response to Question 1 18% of the time. All 3 safety culture subscales improved for the IDT (intervention) group (response to error: 41% pre versus 47% post; communication openness: 51% versus 75%; reporting events: 30% versus 54%) but not for the emergency department (control) group (response to error: 67% pre versus 40% post; communication openness: 71% versus 51%; reporting events: 54% versus 46%). Mean number of monthly incident reports increased for both the IDT (intervention) group (15.4 pre versus 20.8 post) and the emergency department (control) group (5.6 pre versus 11.8 post). IDT facilitator continued to ask the safety questions after the formal study period ended.

KEY LESSONS FOR DISSEMINATION: Safety huddles can be modified to best fit the needs of the individual healthcare facility. If consistently practiced, even a brief safety huddle could improve unit safety culture and increase safety incident reporting.

UTILIZATION OF HIGH-SENSITIVITY TROPONIN IN THE EMERGENCY DEPARTMENT AND ITS IMPACT ON HOSPITAL ADMISSION FOR ACUTE CORONARY SYNDROME

Siraphob Chansangavej¹; Amy Meyer¹; Claire Mickey¹; Deven Gulick¹; Gurjit Kaur²; Rajiv Heda¹; Nicholas Tolat¹

¹Internal Medicine, Tulane University School of Medicine, New Orleans, LA; ²Internal Medicine , Tulane University, New Orleans, LA. (Control ID #3877320)

STATEMENT OF PROBLEM/QUESTION: Confusion and unfamiliarity with high-sensitivity troponin implementation precludes its appropriate utilization and potential to reduce chest pain admissions. DESCRIPTION OF PROGRAM/INTERVENTION: Utilization of hs-cTn is advantageous in shortening the previous 0/6-hour "troponin-blind" period to 0/3-hours, decreasing utilization of functional cardiac testing, ED length of stay, and hospital admissions. Importantly, hs-cTn's negative predictive value at 30-day acute myocardial infarction (AMI) and death are non-inferior to traditional troponins.

Proper interpretation of hs-cTn depends on interpreter understanding of evidence surrounding hs-cTn as well as the institutional-specific assay used. A qualitative investigation including a Gemba walk and interviews with ED physicians and nurses, hospital admission physicians, and laboratorians at our urban-center institution identified confusion and unfamiliarity associated with hs-cTn utilization.

MEASURES OF SUCCESS: Intervention will be education of ED and hospitalist providers on institution- specific hs-cTn assays and evidence on hs-cTn interpretation. Pre-intervention data include hospital admission and ED discharge rates for diagnosis codes associated with chest pain before and after hs-cTn introduction; as well as before a pre-intervention/education survey on familiarity with hs-cTn interpretation. Post-intervention data includes hospital admission and ED discharge rates after hs-cTn introduction and post- education survey. This project was deemed to be exempt from IRB review.

FINDINGS TO DATE: Five diagnosis codes related to chest pain for patients presenting to the Emergency Department were selected before and after institutional introduction of hs-cTn and analyzed for rates of hospital admission. At this stage of the project, hospital admission rates 4 months prior to hs-cTn introduction resulted in 219 patients, of which 47 (21.46%) were admitted and 172 (78.54%) were discharged from the ED with an admission/discharge ratio of 0.27. Qualitative analysis determined that provider familiarity is a major barrier in hs-cTn interpretation. The study intervention is provider education of hs-cTn use for ACS, planned for February 2023. Data on pre- and post-intervention provider survey responses as well as post-intervention hospital admission rates will be collected.

KEY LESSONS FOR DISSEMINATION: Qualitative analysis indicates that confusion regarding hs-cTn interpretation is a major barrier for its effective implementation. Herein, we aim to address provider familiarity with hs-cTn utilization for AMI. By providing education on background and appropriate interpretation of hs-cTn, we hope to establish a framework for effective incorporation of hs-cTn that can be adopted by multiple hospital systems to improve patient care, reduce rate of chest pain admissions, and lower hospital costs.

UTILIZING A DATA ANALYTICS PLATFORM TO IDENTIFY HIGH-RISK MEDICATION INTERACTIONS FOR PATIENTS ON DIRECT ORAL ANTICOAGULANTS (DOACS)

Nathan Richards¹; Lauren Kirk¹; Jodi M. Grandominico-Bradford²; Neeraj H. Tayal³

¹Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²Internal Medicine, The Ohio State University, Columbus, OH; ³Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #3875508)

STATEMENT OF PROBLEM/QUESTION: Use of DOACs has steadily increased since the first one was approved in 2010 due to their ease of use, efficacy, and safety profile, however, many patients take medications that can have significant interactions with DOACs resulting in increased risk for bleeding or treatment failure.

DESCRIPTION OF PROGRAM/INTERVENTION: To safely prescribe DOACs, physicians must be aware of medication interactions that can result in adverse effects. Primary care physicians may not be fully aware of the numerous medication interactions that can occur with DOACs. Furthermore, patients may see other physicians who prescribe interacting medications. Thus, periodic monitoring for drug interactions to improve safe prescribing is important. Using a data visualization tool called Qlik Sense®, we developed a physician support tool to assist primary care physicians (PCPs) in the division of general internal medicine at an academic medical center in identifying patients in their panel treated with DOACs who were also being prescribed medications with significant DOAC interactions. Using the Lexicomp interaction tool, we specifically aimed to identify the most dangerous interactions which included interactions with a rating of D or X. A central team was able to review all patients prescribed DOACs in each faculty member’s panel and identify those patients with D or X interactions with other medications in an efficient manner using this tool. An outreach message to the PCP was then sent within the health record to allow an opportunity for review and therapy alteration or discussion of risks/benefits of medication continuation.

MEASURES OF SUCCESS: Number of significant interactions identified; Number (%) of patients where therapy was changed; Number (%) where therapy was not changed. Physician feedback.

FINDINGS TO DATE: We identified a total of 2,524 patients being treated with DOACs within the division of general internal medicine. Of these, 97 patients were found to be on medications with potential for significant interaction with DOACs (Lexicomp interaction rating of D or X). On follow up, we found that 51 (52.5%) of the 97 patients had appropriate medication adjustments made. We found that 46 (47.5%) of the 97 patients did not have a medication adjustment made. Physician feedback included a recommendation to engage a multidisciplinary team to help make medication adjustments when needed rather than only reaching out to the PCP.

KEY LESSONS FOR DISSEMINATION: Data analytics tools can be helpful in managing patients on high-risk medications, such as DOACs, and can be useful in uncovering previously unidentified significant and potentially dangerous drug interactions in an efficient manner for a large group of patients. Identification of these interactions can lead to discussions with prescribers that may alter therapy leading to safer prescribing practices. This model has potential to be useful for other high-risk medications. Physician input is needed to ensure a workflow that results in a higher rate of medication adjustments when significant drug interactions are present.

UTILIZING ELECTRONIC HEALTH RECORD- BASED TOOLS TO IMPROVE HIV PREVENTION CARE IN AN URBAN FEDERALLY QUALIFIED HEALTH CENTER

Irving Ling^1,2; Diana Aycinena²; Katherine Marx²; Audrey Ng²; Clarissa Ospina-Norvell²; Jennifer C. Sun²; Rence Uson²

¹Internal Medicine, Kaiser Permanente Northern California, Oakland, CA; ²San Francisco Community Health Center, San Francisco, CA. (Control ID #3871882)

STATEMENT OF PROBLEM/QUESTION: How can electronic health record (EHR)- based tools help improve rather than disrupt post-exposure prophylaxis (PrEP) screening at San Francisco Community Health Center, an urban federally qualified health center (FQHC)?

DESCRIPTION OF PROGRAM/INTERVENTION: SFCHC is an urban FQHC that primarily serves low income, unhoused, and LGBTQ+ people of color. Between April and September 2021, 183 patients were tested for sexually transmitted illnesses (STIs), yet only 28 (15.3%) patients were on PrEP. In that same timeframe, of the 17 patients who had tested positive for one or more STIs only 8 (47%) were screened for PrEP initiation. Since 2021 SFCHC expanded its street medicine outreach efforts to increase STI and PrEP screening. However, a recent transition to a new electronic health record (EHR) system in 2022 has disrupted prior workflows for tracking patient data resulting in clinical nursing staff manually identifying patients who may be at high risk of HIV infection. This approach has been labor and time intensive and may be limited in its ability to track all patients who receive clinic and street medicine services at SFCHC.

We used quality improvement (QI) tools to analyze the current state of PrEP care at SFCHC. We are working on developing EHR-based tools, including 1) report algorithms to automate the process of accurately identifying patients at high risk for HIV infection who should be screened for PrEP and those who have fallen out of prior PrEP care, and 2) EPIC smartphrases for PrEP care to standardize documentation and generate extractable quality metrics. In utilizing the EHRo-based tools to better identify care gaps, the clinic can increase PrEP screening and engagement.

MEASURES OF SUCCESS: Using EHR-based toools we aim to: 1) increase PrEP screening in patients who have been tested for STIs by 15%, from 15.3% to 17.6%, 2) increase PrEP screening in those who have tested positive for one or more STIs by 20%, from 47% to 56.4%. We will also be surveying clinical providers regarding the impact of the EHR-based tools on their PrEP care practice.

FINDINGS TO DATE: A prototype report algorithm has already been able to generate a list of 132 patients who have been screened for STIs compared to the prior EPIC reporting algorithm, which only generated a list of 13 patients. A series of EPIC smartphrases designed for PrEP initiation and follow-up embedded with fields for extractable data are currently being workshopped by clinic providers. Post-intervention PrEP screening will be measured from February to April 2023.

KEY LESSONS FOR DISSEMINATION: While transitioning to new EHR systems may disrupt prior workflows for patient monitoring and engagement, there are several opportunities in utilizing EHR-based tools to improve patient care that can be applied to HIV prevention care and beyond. EHR-based tools can be high impact interventions that standardizes and optimizes data tracking and generation through integration with clinic workflows and provider documentation.

Innovation in Healthcare Delivery (IHD) - Vulnerable Populations

DEVELOPMENT AND IMPLEMENTATION OF CONTEXTUALIZED HEPATITIS C PROTOCOLS TO ENHANCE TREATMENT ACCESSIBILITY FOR HIGH-RISK, VULNERABLE POPULATIONS

Lauren O'Neal¹; Anmol Desai¹; Kia Reinis¹; Cristal Brown^1,2; Deepak Agrawal^1,2; Michael Stefanowicz^2,1; Audrey Kuang^2,1; Darlene Bhavnani¹; Timothy Mercer^1,2

¹The University of Texas at Austin Dell Medical School, Austin, TX; ²CommUnityCare, Austin, TX. (Control ID #3874946)

STATEMENT OF PROBLEM/QUESTION: Vulnerable populations at high risk of Hepatitis C have limited access to curative treatment due to individual-level and systemic barriers.

DESCRIPTION OF PROGRAM/INTERVENTION: Hepatitis C virus (HCV) is a significant contributor to liver-related morbidity and mortality. Despite the development of direct acting antivirals and a simplified treatment algorithm, vulnerable populations at high risk of HCV experience barriers to care and a disproportionate associated disease burden. Expanding treatment is imperative not only for public health and eventual HCV eradication, but also for health equity and improved care for underserved populations.

The primary goal of our intervention is the implementation of contextualized, simplified HCV treatment protocols by non-specialist providers at community health centers serving vulnerable populations in the Southern region. These primary care and non-traditional clinic settings provide care targeted toward people experiencing homelessness and people who inject drugs.

The first phase of the intervention identified HCV treatment facilitators and barriers through staff and patient interviews. We anchored these factors to steps in the HCV care cascade, from diagnosis to cure. Iterative site- specific design workshops used these findings to adapt the simplified treatment algorithm to existing workflows and produce HCV treatment protocols contextualized for each community health center site. Providers were trained using protocols for their site.

The second phase of this study will evaluate cure and implementation outcomes following the 6-month recruitment period and 2 to 3-month treatment window. This approach could serve as a model for future interventions aiming to develop and implement contextualized treatment protocols for vulnerable populations.

MEASURES OF SUCCESS: The primary outcome is the proportion of participants who achieve cure by sustained virologic response 12 weeks after treatment (SVR12). Secondary outcomes include time from offer to initiation of treatment, proportion of participants who initiate treatment, and proportion of participants who complete treatment. We will use a mixed-methods approach to evaluate implementation outcomes defined by the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance).

FINDINGS TO DATE: The initial phase identified individual and systemic barriers, such as patient HCV treatment knowledge, medication adherence, tracking patients who miss key appointments, transporting medication to patients, and follow-up with patients for laboratory tests confirming cure. Solutions were incorporated into clinic workflows, including standardizing medication adherence counseling, augmenting existing staff roles, and employing HCV navigation throughout the care cascade.

KEY LESSONS FOR DISSEMINATION: Identifying facilitators and barriers to treatment in a specific community context can help to inform protocols that innovate and improve on current systems. Collaborative development of protocols that adapt existing workflows can improve uptake by staff and providers.

EXPANDING HARM REDUCTION & OUD TREATMENT OPTIONS BY COMBINING MOBILE HEALTH & TELEMEDICINE

Amanda Johnson^1,6; Shifra Goldenberg⁶; Spencer Worley²; Michael Shen³; Yinan Lan^7,6; Noah Isaacs⁴; Christopher Philippou⁵; Erfan Karim⁵; James Beaubrun⁸; Kecia-Ann Blissett⁴; Marlaina Balaban⁶; Chris Keeley⁶; Theodore G. Long⁶

¹Division of General Internal Medicine & Clinical Innovation, NYU Langone Health, New York, NY; ²Test & Trace, New York City Health and Hospitals Corporation, New York, NY; ³Medicine, New York City Health and Hospitals Corporation, New York, NY; ⁴Office of Behavioral Health, New York City Health and Hospitals Corporation, New York, NY; ⁵Quality & Safety, New York City Health and Hospitals Corporation, New York, NY; ⁶Office of Ambulatory Care and Population Health, New York City Health and Hospitals Corporation, New York, NY; ⁷Internal Medicine, Bellevue Hospital Center, New York, NY; ⁸Operations , Doxgo, New york, NY. (Control ID #3874377)

STATEMENT OF PROBLEM/QUESTION: How can a large, urban healthcare system improve access to harm reduction & opioid use treatment services for people experiencing homelessness during & after the COVID-19 emergency response?

DESCRIPTION OF PROGRAM/INTERVENTION: In April 2021 a large, mid-Atlantic city launched a specialized fleet of mobile COVID-19 testing & vaccination units to engage people experiencing homelessness. In addition to COVID services, the teams address general medical concerns (including wound care) & unmet social needs, distribute hygiene kits, & offer harm reduction interventions. A social worker, advanced practice provider, & EMT canvas parks, subway stations, & sidewalks surrounding each unit to care for patients where they are while a RN & LPN remain stationed on the van. From April 2021, team members have dispensed naloxone kits & trained people in overdose reversal; they’ve also administered naloxone to people displaying symptoms & signs of an opioid overdose. In November 2021 this program became one of the public health department's fentanyl test strip access points. In December 2021 the program started scheduling telephone appointments for patients interested in starting buprenorphine. Six months later, one unit partnered with the city hospital system’s on-demand, video- & audio-enabled service for OUD evaluations & buprenorphine inductions. The team also accompanied patients to pick up & pay for medications & distributed mobile phones to facilitate follow-up.

MEASURES OF SUCCESS: Qualitative measures of success include new funding for program expansion, staff satisfaction, & patient encounter anecdotes. Quantitative measures of success include:

-Patient encounters (including return patients)

-COVID tests & vaccines

-Naloxone kits

-Fentanyl test strip kits

-Telemed visits with buprenorphine provider

-Social work referrals

FINDINGS TO DATE: Between April 2021 & December 2022, the program rendered 185,414 unique patient encounters. Care teams distributed 2,316 naloxone kits & 172 fentanyl test strip kits. Team social workers referred 24 patients to community-based substance use treatment providers. 7 patients completed a telemedicine visit with a buprenorphine provider. In the 1st year, the program expanded from 3 to 8 mobile units. In January 2023 healthcare personnel, including x-waivered providers, from the city’s public hospital system will staff the mobile units using their enterprise medical record.

KEY LESSONS FOR DISSEMINATION: This program’s investment in harm reduction services from the beginning, partnerships with local community-based organizations, and consistent physical & visual presence laid the foundation for conversations about OUD treatment down the line.

This program continued to evolve its approach to care in response to feedback from its clients and to emerging public health concerns, from influenza to xylazine.

An on-demand, one-step solution for connecting patients to OUD treatment was the most successful delivery model & decreased the burden on the patient to plan ahead in spite of uncertainty in their daily routine.

NEW MODEL FACILITATES EXIT FROM ENCAMPMENTS IN BOSTON BY COMBINING LOW-BARRIER HOUSING WITH ACUTE STABILIZATION CARE FOR ADDICTION Miriam Komaromy^1,2; Jessica Taylor^3,1; Andrea Stone¹; Alicia Peterson⁴; Rob M. Koenig⁴

¹Grayken Center for Addiction, Boston Medical Center, Boston, MA; ²Internal Medicine, Boston University, Boston, MA; ³General Internal Medicine, Boston University School of Medicine, Boston, MA; ⁴Boston Medical Center, Boston, MA. (Control ID #3874094)

STATEMENT OF PROBLEM/QUESTION: Tent encampments in the neighborhood surrounding Boston Medical Center (BMC) grew to include 336 individuals between 2019-21, prompting humanitarian and public health concerns.

DESCRIPTION OF PROGRAM/INTERVENTION: BMC, the City of Boston, and the Commonwealth of Massachusetts partnered in 1/2022 to offer low-barrier housing to people living in encampments and to provide clinical stabilization services for people experiencing homelessness who have substance use disorders (SUDs).

MEASURES OF SUCCESS: In a former hotel, BMC established: 1) 60 beds of transitional housing for encampment residents, with housing not contingent on substance use status. Residents were provided with external private lockers, naloxone and sterile injection equipment, and round-the-clock guestroom safety checks. Couples were housed together. 2) A low-barrier SUD-focused urgent care clinic offering medications for SUD and infection screening/prevention services; and 3) A 24/7 short-stay stabilization unit to manage over-intoxication, withdrawal, and complications of substance use (e.g., abscesses, HIV risk, psychosis). A secure medication dispensing cabinet allows methadone administration for opioid withdrawal management under the provisions of the 72-hour rule. Housing program key performance indicators include persistence in housing, transition to permanent housing, and engagement in SUD treatment and case management. Clinical program key performance indicators include patient volume, rates of BH and SUD diagnoses, rates of initiation on medication for SUD, and impact on ED utilization.

FINDINGS TO DATE: Housing: Between January and October 2022, 84 people have been housed (50 from encampments and the rest chronically unsheltered). Sixteen transitioned to permanent supportive housing, and 3 residents died (1 overdose plus 2 medical deaths); residents spent >15K nights in beds. No residents have chosen to return to homelessness. 83 (98%) engaged with case management services, and 51 (61%) engaged with SUD treatment. Clinical: In the first 9 months, 1554 patients had 5135 visits. The average stay in the stabilization unit was 12 hours. 321 patients received emergency opioid withdrawal management with methadone and were referred to an Opioid Treatment Program (OTP). The most common SUD diagnoses were opioid (76%), cocaine (52%) and alcohol (50%). Overall, 58% of patients had a non-SUD BH diagnosis. Early data suggest a reduction in Emergency Department visits for patients seen in the clinical units, as well as an increase in engagement with outpatient mental health services.

KEY LESSONS FOR DISSEMINATION: Low-barrier transitional housing combined with clinical stabilization care resulted in former encampment residents remaining housed, and provided SUD stabilization services to a substantial population of people experiencing homelessness in the first 9 months of clinical operation.

ONSITE PRIMARY CARE DELIVERY TO ADDRESS MEDICAL NEEDS AMONG PERMANENT SUPPORTIVE HOUSING RESIDENTS: A FEASIBILITY AND ACCEPTABILITY DEMONSTRATION PROJECT

Brian Redline^1,2; Patrick C. Brown¹; John Nusser⁴; Janae Brill⁴; Brian Chan³

¹School of Medicine, Oregon Health & Science University School of Medicine, Portland, OR; ²OHSU-PSU School of Public Health, Portland, OR; ³Medicine, Oregon Health & Science University, Portland, OR; ⁴Family Medicine of Southwest Washington, PeaceHealth, Vancouver, WA. (Control ID #3875144)

STATEMENT OF PROBLEM/QUESTION: Can a weekly onsite primary care delivery intervention improve primary care engagement and care continuity for formerly chronically homeless adults living in permanent supportive housing?

DESCRIPTION OF PROGRAM/INTERVENTION: Permanent supportive housing via Housing First (PSH-HF) effectively ends chronic homelessness by providing low-barrier access to housing and support services for individuals with complex social, medical, and behavioral health comorbidities. While there is strong evidence that PSH-HF improves housing stability, significant concerns remain regarding its ability to meet residents’ complex health care needs. This study aims to help fill this gap by evaluating the feasibility and acceptability of a weekly onsite primary care intervention for residents living in a single-site PSH-HF program in a mid-sized, Pacific Northwest city.

The primary care team included a physician (0.1 FTE) and part-time nursing, pharmacy, and phlebotomy providers working closely with preexisting case managers. Operations began in November 2020. Services included onsite routine and acute care visits, door-to-door outreach, and follow-up care coordination between medical and case management providers.

MEASURES OF SUCCESS: Chart review assessed primary care engagement (e.g., PCP visits, team “touches”), ED visits, and hospitalizations during the 180 days prior to implementation and 180 days following a 2-month washout (“post”). We used paired t tests to compare utilization in pre- and post-periods and summarized qualitative provider feedback that was collected during monthly meetings with housing, clinical, and research staff.

FINDINGS TO DATE: Of 31 residents living in the housing program when operations began, one resident died during the washout period; the remaining 30 underwent chart review and were included in our analysis. The average age was 51.6 (SD 10.4), 53% were male, and 90% were non-Hispanic white. Half the residents were diagnosed with serious and persistent mental illness and 90% with substance use disorder. Pre- intervention, 37% had any PCP engagement, compared to 80% post-intervention. Residents averaged 2.4 more PCP visits during the post period compared to the pre period (95% CI 1.4, 3.4), with 5.7 PCP team “touches” on average (SD 5.8). There were slight decreases in hospitalizations (-0.03) and ED visits (-0.23) between the pre and post periods, although these differences were not statistically significant. Qualitative feedback indicated perceived improvements in care continuity among housing program staff, decreased stigma among resident patients, and improved chronic disease management among PCP team providers.

KEY LESSONS FOR DISSEMINATION: This study indicates that onsite primary care delivery is a feasible and acceptable approach for increasing primary care engagement for PSH-HF residents. Future studies should investigate how these approaches may be scaled up and the extent to which increased engagement in preventive care may facilitate further decreases in hospital and ED utilization over longer evaluation periods.

PARTNERING WITH COMMUNITY-BASED ORGANIZATIONS TO DESIGN AND IMPLEMENT A LOW-BARRIER PREP PROGRAM FOR LATINO SEXUAL MINORITY MEN.

Jonathan Ross¹; Gabriela Betancourt²; Eli Andrade¹; Sage Rivera³; Gustavo Morales⁴; Lissette Marrero⁵; Viraj V. Patel¹

¹Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY; ²New York City Department of Health and Mental Hygiene Bureau of Chronic Disease Prevention and Tobacco Control, Long Island City, NY; ³Destination Tomorrow, Bronx, NY; ⁴Latino Commission on AIDS, New York, NY; ⁵Voces Latinas, Inc, Jackson Heights, NY. (Control ID #3868696)

STATEMENT OF PROBLEM/QUESTION: Community-based strategies to increase access to HIV pre- exposure prophylaxis (PrEP) for Latino sexual minority men (LSMM) are critical to ending the HIV epidemic in the U.S., yet community-based organizations (CBOs) are not typically included in designing and implementing sexual health services for this population.

DESCRIPTION OF PROGRAM/INTERVENTION: Use of PrEP among LSMM remains unacceptably low, as current primary care delivery strategies do not adequately address key barriers of HIV stigma, immigration fears, medical mistrust, lack of health insurance, and competing priorities. CBOs provide services in ways that address these barriers and could effectively partner with health centers to deliver sexual healthcare that meet the needs of LSMM. Our primary care-based HIV prevention program engaged in a fully collaborative process with patient-facing staff at three diverse CBOs serving LSMM in New York City

(NYC) to develop and then pilot CBO-PrEP. This model of care includes co-navigation by both CBO and health center staff to engage patients in care, and use of low-barrier options such as evening telemedicine appointments and geographically-convenient diagnostic testing through a commercial laboratory network. As CBO-PrEP has expanded, we have continued to meet regularly with CBO partners to refine workflows and implement additional strategies including a web-based referral form and print and social media outreach materials.

MEASURES OF SUCCESS: We evaluated the feasibility of CBO-PrEP by calculating: the proportion of patients referred who were scheduled for an appointment, evaluated by a physician, received a PrEP prescription, and were seen for a follow-up visit, as well as time from referral to first appointment and to PrEP prescription. To more broadly evaluate the implementation of CBO-PrEP, we are currently utilizing quantitative program measures and qualitative interview data to assess outcomes including program reach, acceptability to patients and providers, adoption by staff at each CBO, adaptations being made, and sustainability across the three CBOs.

FINDINGS TO DATE: Among 73 patients referred to the CBO-PrEP program, 60 (82%) identified as men, mean age was 31 years, 46 (57%) reported Spanish as their preferred language and 45 (62%) were uninsured at time of referral. In total, 58 (79%) were scheduled for an appointment and 47 (63%) had a medical provider visit within a median of 7 days after referral (interquartile range [IQR] 2-21 days). Of 47 initial appointments, 40 (85%) were by telemedicine. PrEP was prescribed in 41 (87%) of these encounters, with a

median time from referral to PrEP prescription of 15 days (IQR 2-34). In total, 29 of 47 patients (62%) had at least one follow-up visit.

KEY LESSONS FOR DISSEMINATION: CBO-PrEP effectively and rapidly linked LSMM in NYC to sexual healthcare, demonstrating the feasibility of health center-CBO partnerships to design and implement low-barrier models of care. This collaborative approach is easily adaptable for other institutions and marginalized populations in diverse settings.

UNINTENTIONAL FENTANYL USE AND ASSOCIATED HARM REDUCTION STRATEGIES Megan Wade¹; Frances Vernon¹; Jessica Phan¹; Jennifer Adams²

¹Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²General Internal Medicine, University of Colorado, Denver, CO. (Control ID #3876031)

STATEMENT OF PROBLEM/QUESTION: Since the early 2000’s, synthetic drug production and consumption has increased nationwide, leading experts to highlight fentanyl as the number one drug threat to public health and safety in the Rocky Mountain Region. Unintentional fentanyl use from a contaminated drug supply, especially methamphetamines (meth) and heroin, is of particular concern. The purpose of this study was to provide a descriptive statistical report characterizing substance use, unintentional fentanyl use, and harm reduction strategies in a large, urban community health organization and needle access center (termed harm reduction center).

DESCRIPTION OF PROGRAM/INTERVENTION: A mixed-methods, cross-sectional survey was distributed at a harm reduction center located in Denver, Colorado between July and October 2022. Two hundred participants who self-identified as people who use drugs (PWUD) were recruited on a volunteer basis during the center’s community hours. Standardized surveys were verbally administered and electronically recorded. Data were analyzed using descriptive statistics.

MEASURES OF SUCCESS: 200 completed surveys was the measurement of sucess for this program.

FINDINGS TO DATE: Nearly all participants self-reported polysubstance use within the past month (97%).Fifty-seven percent of participants used at least 5 substances in the last month and 74% in the last two years. Tobacco (92%) and meth (90%) were the most commonly used substances, followed by fentanyl (84%), marijuana (77%), and heroin (64%).

More than half of participants reported unintentional fentanyl use in the past two years (66%) and the past month (59%). In the last two years, only 16.5% of participants reported no fentanyl use.

When asked how the emergence of fentanyl has changed how participants use drugs, participants reported: “more likely to carry Narcan/Naloxone” (70%) and “would use a safe consumption site (SCS) if available” (76%). Only 9% of participants used fentanyl test strips all of the time; 51% of participants have never used test strips. Forty percent reported occasional use of fentanyl test strips.

When asked about a friend overdosing on various substances, participants were nearly twice as likely to respond “very worried” in regards to fentanyl (52%) vs heroin (27.1%)

KEY LESSONS FOR DISSEMINATION: This study highlights the importance of recognizing polysubstance use among PWUD in a large urban area, including the high prevalence of anecdotal unintentional fentanyl use most likely as a result of contamination of intended drug supply.

Harm reduction strategies targeting fentanyl are critical. Nearly three quarters of participants were likely to carry and use naloxone to counteract a potential fentanyl overdose, indicating the need to make the medication readily available for PWUD. Participants also vocalized strong support of SCS, supporting that SCS may be the next frontier of harm reduction policy in the U.S. Finally, further research is needed to better understand why fentanyl test strips are under-utilized amongst PWUD, despite being available at the harm reduction center.

WIDEN THE SCOPE WITH ICOPE

Rebecca Glassman, Kiandra Antenor, Sandra Tarpey, Ruchi Mehta

Medicine, Westchester Medical Center, Valhalla, NY. (Control ID #3872082)

STATEMENT OF PROBLEM/QUESTION: As patients living with HIV (PLWH) age, little is known about the specific complications that they may face and how primary care physicians should address these needs. A validated tool such as the iCOPE may provide insight into specific areas of needs.

DESCRIPTION OF PROGRAM/INTERVENTION: In New York State, 56.6% of PLWH are over the age of 50. PLWH have a higher life expectancy, near that of the general population, as a result of improved access and tolerability of antiretroviral therapy. As PLWH live longer, they are developing chronic medical conditions, in addition to deficits that may effect their ability to live and thrive independently at home. Primary care providers must be adept at addressing deficits that may affect ones ability to thrive independently at home. At our hospital-based primary care clinic for PLWH, we utilized the integrated care for older people (iCOPE) validated screening tool. Patients were asked a series of questions related to memory, mobility, nutrition, vision, hearing, and mood. The goal of this intervention was to better understand individual patient needs as well as globally understand our populations’ needs to create new services. This study was performed with the AIDS Intitute HIV Aging Screening Pilot.

MEASURES OF SUCCESS: 1. Percentage of PLWH over the age of 50 successfully screened

2. Percentage screening positive in each of the domains of the iCOPE

3. Qualitative needs assessment

FINDINGS TO DATE: Of the 357 PLWH in our clinic, 132 are over 50 years old. Over two months, we screened 94 (71%) patients. Screenings took less than 5 minutes and were integrated into medical visits.

46.8% of patients identified issues with memory, 20.2% mobility, 16% nutrition, 48% vision, 13.8% hearing, and 31.9% mood. On discussion of positive screening areas, additional needs were identified most notably related to financial and immigration. Patients with positive screens were referred to ophthalmology, audiology, and our integrated behavioral health team as indicated. We performed additional screenings on patients with positive memory screens to determine if additional evaluation or assistive devices could be provided.

KEY LESSONS FOR DISSEMINATION: As PLWH grow older, it will be important for primary care providers to assess needs that may effect their ability to live and thrive independently. The iCOPE screening tool provides a quick in-depth view of individual needs that may not be readily apparent to providers. It has previously been validated in the general population, but not previously used specifically to address the needs of PLWH. We identified a need to connect to specialty services, to improve access to durable medical equipment, and to add resources to ensure appointment and medication adherence (additional reminder calls, convenience packaging for medications, larger print on medication bottles and after visit summary). We will create a community team to perform home visits for patients with mobility limitations. As a result of this study, our providers are more in tune with the needs of aging PLWH.

Innovation in Healthcare Delivery (IHD) - Women’s Health, Sex, and Gender-Informed Medicine

BRIDGING THE GAP: A POSTPARTUM PRIMARY CARE TRANSITION PROGRAM FOR CHRONIC DISEASE MANAGEMENT AND PREVENTION

Seuli B. Brill¹; Rachel D'Amico¹; Naleef Fareed²; Shengyi Mao³; Amethyst Gauthier⁴; Bethany Panchal⁴; Shadia Jallaq⁵; Allison Lorenz⁵; Stephen Thung⁶

¹General Internal Medicine, The Ohio State University, Columbus, OH; ²Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH; ³General Internal Medicine, The Ohio State University College of Medicine, Columbus, OH; ⁴Family Medicine, The Ohio State University College of Medicine, Columbus, OH; ⁵Ohio Colleges of Medicine Government Resource Center, The Ohio State University Wexner Medical Center, Columbus, OH; ⁶Obstetrics, The Ohio State University College of Medicine, Columbus, OH. (Control ID #3875956)

STATEMENT OF PROBLEM/QUESTION: Severe maternal morbidity (SMM) prevalence has tripled over the last 3 decades in the US, but few primary care structures address postpartum chronic disease care. DESCRIPTION OF PROGRAM/INTERVENTION: One-third of women of childbearing age have at least one chronic disease, but postpartum primary care engagement to improve early disease control remains low. Postpartum primary care programs may prevent care gaps and improve maternal health outcomes, particularly in underserved populations with disproportionaly high SMM. The Multimodal Maternal Infant Perinatal Outpatient Delivery System (MOMI PODS) facilitates obstetric to primary care transition for individuals with SMM risk factors, with a special focus of providing care to women who are publicly insured. The program accepts clinician and community referrals, ensures warm handoffs across disciplines and care settings, delivers interdisciplinary parent/baby primary care, and engages with community partners.

MEASURES OF SUCCESS: We measured the percentage of referred patients ≥ 3 months postpartum who enrolled in MOMI PODS and compared select postpartum health measures of enrolled vs. unenrolled patients, including primary care visit frequency, tobacco screening and contraception counseling rates. We also compared delivery of disease-specific care for individuals with gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP), two common pregnancy-related conditions that significantly increase the risk of chronic disease.

FINDINGS TO DATE: MOMI PODS received 203 patient referrals over a 12 month period, 89 of whom are ≥ 3 months postpartum. Among these patients, 54% (48/89) of patients enrolled in the program. The mean age of enrollees was 30.9 years; 35% of enrollees identified as Black, 33% White, 19% Hispanic/Latinx, and 13% Asian/Pacific Islander. A total of 44% of enrollees were publicly insured. Enrollees had more PCP visits in the first year postpartum with a mean of 2.3 visits compared to 0.28 visits for unenrolled patients (p <0.001). Enrollees were significantly more likely than unenrolled patients to receive preventive care, including tobacco screening (81% vs 37%, p < 0.001) and contraception counseling (96% vs 26%, p < 0.001).

Enrollees with GDM were more likely to complete follow up diabetes screening compared to unenrolled patients with GDM (86% vs 26%, p= 0.001). Enrollees with HDP were more likely to have blood pressure controlled (< 140/80) at follow up (95% vs 71%, p= 0.045) and more likely to be prescribed antihypertensive medications (60% vs 21%, p < 0.001) compared to unenrolled patients with HDP. Future evaluation will focus on longterm health outcomes and barriers to enrollment.

KEY LESSONS FOR DISSEMINATION: Formalized obstetric to primary care transition programs may increase preventive service delivery and chronic disease management for postpartum individuals, including among minoritized and publicly insured patients. Expanding postpartum primary care transition programs may equitably reduce long-term morbidity through chronic disease prevention and management.

ENHANCING REPRODUCTIVE CARE: A SPECIALIZED, COORDINATED CLINIC FOR WOMEN VETERANS

Brianna Rossiter^1,2; Deborah DiNardo^3,2

¹Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²VA Pittsburgh Healthcare System, Pittsburgh, PA; ³Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #3876473)

STATEMENT OF PROBLEM/QUESTION: Women Veterans (WVs) are the fastest growing Veteran population but often lack dedicated, coordinated provision of reproductive care.

DESCRIPTION OF PROGRAM/INTERVENTION: Women Veterans (WVs) are the fastest growing segment of health care users in the VA Healthcare System (VAHS). This population requires gender-specific healthcare including reproductive services. This is more relevant than ever given the Protecting Moms Who Served Act, a bill passed by Congress requiring VAHS to improve maternity care. As recently as July 2022, the Ensuring Women’s Right to Reproductive Services Act passed through the House of Representatives, potentially expanding reproductive care even further. This legislation provides an opportunity for innovation in the delivery of high-quality reproductive healthcare for WVs.

While the VA is committed to providing this care, specialized reproductive services can be challenging to cover in an already busy, primary care visit. Available evidence suggests gaps in provision; from increased rates of unintended pregnancy and lower rates of contraceptive use among WVs. Further, maternity care, which is almost exclusively provided in the community, is often limited by clinical expertise at VA sites and challenges with coordination. This is of particular concern as WVs have a higher prevalence of psychiatric comorbidities and are at increased risk for both maternal and fetal complications.

Prior to October 2021, VA Pittsburgh Healthcare System (VAPHS) did not offer a comprehensive reproductive health program for WVs. To address this gap, we developed a specialized clinic with a consultant internal medicine physician with advanced training in reproductive health. This physician works within an interdisciplinary team to provide timely, individualized access to behavioral health (BH), gynecology, pelvic PT and social work across VA and non-VA systems.

MEASURES OF SUCCESS: To evaluate our efforts, we are collecting and reviewing consult data for quality improvement. This includes number of and reason for clinic referrals. Specifically for maternity care, we are tracking the number of initial pregnancy visits, post-partum visits, and engagement with BH peripartum. Similarly, we are assessing for underlying comorbidities that can impact pregnancy, and conversely, pregnancy complications that can impact a WV’s future health.

FINDINGS TO DATE: Analysis is ongoing but initial data shows that among 66 referrals over 13 months, 48 virtual appointments occurred. Thirty of these appointments were initial pregnancy encounters of which 7 patients have since delivered and completed a postpartum visit. Maternal complication and BH referral data is pending.

KEY LESSONS FOR DISSEMINATION: The coordination of reproductive care through an integrated, multi-disciplinary clinic can drive innovation and reduce inequities in both access to and delivery of high quality, gender-specific healthcare.

IMPROVING POSTPARTUM MENTAL HEALTH SCREENING AND MANAGEMENT THROUGH A MATERNAL-INFANT DYAD PRIMARY CARE CLINIC

Rachel D'Amico¹; Naleef Fareed²; Shengyi Mao¹; Amethyst Gauthier³; Shadia Jallaq⁶; Stephen Thung⁴; Seuli B. Brill⁵

¹General Internal Medicine, The Ohio State University, Columbus, OH; ²Biomedical Informatics, The Ohio State University, Columbus, OH; ³Family Medicine, The Ohio State University, Columbus, OH; ⁴Obstetrics & Gynecology, The Ohio State University, Columbus, OH; ⁵Internal Medicine, Ohio State University College of Medicine, Columbus, OH; ⁶Government Resource Center, The Ohio State University, Columbus, OH. (Control ID #3873185)

STATEMENT OF PROBLEM/QUESTION: Does coordinated transition to postpartum primary care in a maternal-infant dyad clinic improve postpartum mental health screening and follow up?

DESCRIPTION OF PROGRAM/INTERVENTION: Postpartum depression (PPD) affects 1 in 7 new mothers, increases the risk of chronic mental illness and substance use disorders, and disproportionately impacts women with high social vulnerability. The US Preventive Services Task Force recommends universal mental health screening for pregnant and postpartum women, but screening rates remain low. Although 23% of US maternal deaths are attributed to mental illness, among women who screen positive for PPD, 60% do not receive follow up care. While primary care clinicians manage approximately 80% of chronic depression cases, existing primary care structures inadequately address postpartum mental health. Our aim was to understand the impact of an ambulatory maternal-infant dyad clinic on postpartum mental health care. Community and obstetric referrals for individuals affected by pregnancy complications or chronic disease were sent to a structured parent/infant dyadic postpartum primary care program staffed by Internal Medicine- Pediatrics and Family Medicine clinicians. Enrolled physicians were educated on appropriate postpartum screening and management, and an outreach nurse provided integrated care coordination.

MEASURES OF SUCCESS: We measured clinic utilization by number of follow up visits and nurse coordinator outreaches. Rates of positive mental health screening (PHQ, GAD, or EPDS), as defined by the Ohio Department of Health perinatal behavioral health standards, or a history of mental illness were determined by EHR review. We determined antidepressant prescriptions, counseling referrals and initiation, and primary care follow up among those with a mental health diagnosis or positive screen.

FINDINGS TO DATE: To date, 50 women are enrolled in the postpartum dyad clinic (38% Black, 30% White, 16% Hispanic, 14% Asian). At the first postpartum visit, 47/50 patients (94%) were screened for mental illness. In total, 44% either screened positive or had a preexisting mental illness. Of patients with positive screening or preexisting diagnosis, 50% received prescriptions for antidepressant medication and 86% received postpartum counseling referrals, with 47% of women confirmed to have initiated counseling. Excluding contacts made for infant care, enrolled parents with mental illness had a median number of 3.22

completed provider visits in the first year postpartum and 4.45 encounters with an outreach nurse.

KEY LESSONS FOR DISSEMINATION: Innovative clinical structures to transition women from obstetrics to postpartum primary care increase mental health screening, diagnosis, and management. This care model provides a promising ambulatory approach to address poor rates of postpartum mental health screening and treatment.

Innovation in Medical Education (IME) - Assessment of Learners

A NATIONAL INDIVIDUALIZED LEARNING PLAN PILOT FOR THE TRANSITION TO INTERNAL MEDICINE RESIDENCY

Eli Falk¹; Ashish Gandhi²; John H. Choe³; Amber Pincavage⁴

¹Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; ²Department of Medicine, University of Chicago Department of Medicine, Chicago, IL; ³Medicine, University of Washington, Seattle, WA; ⁴Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL. (Control ID #3871889)

SETTING AND PARTICIPANTS: The transition from medical school to residency poses unique challenges for trainees. Although Individualized Learning Plans (ILP) have been proposed to improve the transition, they have not been previously used systematically in internal medicine (IM).

DESCRIPTION: The Alliance for Academic Internal Medicine Learner Handoff Standards Task Force created an ILP for IM to assist incoming interns in identifying goals and skills they wanted to improve. The ILP incorporated diverse expert stakeholder input as well as student and resident feedback.

The ILP asked interns to identify their top 3 goals and their top 3 areas for improvement for the first 6 months of residency. Interns were also asked to self-identify preparedness across 16 domains (e.g., performing a physical exam and recognizing when to ask for help) on a 5-point Likert scale. Lastly, interns selected 3 core IM topics for which they felt least prepared (e.g., diabetes or shock).

The ILP was piloted in the spring of 2022 with 52 volunteer IM residency programs. Programs sent the ILP to incoming interns with instructions to complete it with a faculty advisor if possible. Residency programs utilized ILP results at their discretion.

EVALUATION: We evaluated the ILP based on a post-pilot survey of residency program leaders with a response rate of 87% (45/52). Overall, 89% of programs participated as intended. 995 interns enrolled in the program, and 782 interns completed it (79%). The most common barrier to ILP completion was finding a faculty advisor to participate (n=30/40, or 75%).

Respondents reported that the ILP impacted interns in several ways, including encouraging self-reflection (n=34/40, or 85%), signaling program commitment to their development (n=33/40, or 83%), and an interest in getting to know them (n=28/40, or 70%). Half of respondents (n=20/40) stated that the ILP took minimal or slight effort and only 5% (n=2/40) said the ILP took great effort. Over half (n=26/45, or 58%) of respondents stated that using an externally managed electronic system would reduce the workload. Nearly three quarters (n=32/45, or 71%) of respondents surveyed said that no section of the ILP should be removed. Most respondents (n=32/45, or 71%) also agreed that the ILP should be continued for future interns

DISCUSSION / REFLECTION / LESSONS LEARNED: Post-pilot results demonstrate that most programs found the ILP to be valuable and feasible. Additionally, it is notable that many programs did not believe that any changes needed to be made to the ILP. One area to explore for future dissemination is the potential for an electronic system to further decrease any implementation burden. Furthermore, a more systematic way for graduating medical students to be paired with faculty mentors for ILP completion could help decrease barriers.

ASSIGNING ONLINE EDUCATIONAL MODULES PRIOR TO ORIENTATION INCREASES MEDICINE INTERNS’ LEVEL OF READINESS FOR INTERNSHIP

Christine P. Beltran¹; Brielle Blatt²; Jeffrey Manko³; Sondra R. Zabar¹; Lynn Buckvar-Keltz¹

¹Medicine, New York University Grossman School of Medicine, New York, NY; ²NYSIM, NYU Langone Health, New York, NY; ³Emergency Medicine, NYU Langone Health, New York, NY. (Control ID #3874511)

SETTING AND PARTICIPANTS: Incoming Medicine interns at an academic medical center in the Mid- Atlantic region.

DESCRIPTION: Transition to residency is stressful for new physicians as they bear significantly increased patient care responsibilities, as well as clinical leaders who are concerned for patient safety and resident preparedness. To mitigate resident and faculty concerns, we created a series of 12 online educational modules to address acute presentations of common clinical problems, such as abdominal pain, fever/sepsis, and oliguria. Modules were designed for early interns and emphasize distinguishing life-threatening diagnoses from more benign causes, recognizing potentially critical situations, initiating management, and escalating concerns to seniors.

We began assigning a subset of five modules to selected residency programs in 2017 as part of residency orientation until all incoming interns were required to complete all 12 modules prior to internship in 2021.

EVALUATION: Interns from 2018-2022 completed an exit survey at the end of orientation and were surveyed 6 months (in 2018 and 2019) or 9 months (in 2021) into their intern year. We studied whether and why interns found these modules helpful in their preparation for residency.

Across the 5 years (n=495), 90% of interns agreed that the modules increased their readiness for internship, while 91% agreed that it provided them with a framework to organize clinical information during orientation.

Of those who completed the 6-month survey (cohorts 2018 and 2019, n=73), 63% of interns agreed that the modules prepared them for internship and 69 % of interns reported that they would recommend to future interns. For interns who completed the 9-month survey (cohort 2021, n=49), 36% agreed that the modules prepared them for internship, while 51% of interns would recommend to future interns.

When asked in the 9-month survey about what ‘stuck’ from the modules, many interns described learning a systematic approach to creating a differential diagnosis and handling acute and urgent situations. Suggestions for improvement included adding content related to arrhythmias, optimal fluid and electrolyte resuscitation, alcohol withdrawal, opioid withdrawal, dizziness, and agitated patients.

DISCUSSION / REFLECTION / LESSONS LEARNED: Decrease in the percent of learners who would recommend the modules in the 9-month survey may be due to the addition of required modules and longer follow up time. Our results show that online educational modules can help trainees develop a framework for organizing clinical information and feel more prepared to handle emergent clinical scenarios. Providing interns with these modules prior to orientation is a highly feasible and acceptable approach to ensuring resident preparedness to handle emergent situations before being integrated into a fast-paced and complex healthcare system.

CULTURALLY APPROPRIATE NUTRITION COUNSELING: ASSESSING RESIDENT KNOWLEDGE AND ATTITUDES - IMPLICATIONS FOR EDUCATION

Galit Benoni¹; Ayoola Kalejaiye¹; Eleanor Bathory²; Shwetha Iyer¹

¹Internal Medicine, Montefiore Medical Center, Bronx, NY; ²Pediatrics, Montefiore Medical Center, Bronx, NY. (Control ID #3876537)

SETTING AND PARTICIPANTS: We created a workshop for residents on providing culturally specific dietary counseling to patients based on a needs assessment of residents in a residency training program in Bronx, NY.

DESCRIPTION: Immigrant patients have a higher risk of cardiometabolic disease than nonimmigrant patients due to structural barriers and low access to healthy eating options. There is substantial evidence on the benefits of dietary lifestyle interventions yet knowledge and confidence delivering dietary counseling are low among resident physicians. Training however, positively impacts residents’ counseling abilities, self-efficacy, and attitudes.

We conducted a needs assessment among residents in primary care tracks to assess familiarity with culturally appropriate dietary counseling.We developed a workshop to address these gaps focused on: components and evidence of whole food plant based (WFPB) diet on health outcomes, WFPB diet on a budget, culturally appropriate meals, and tools for counseling patients in clinic. The 3 hour workshop will be delivered to primary care residents.

EVALUATION: Our needs assessment included a pre-survey adapted from the Lifestyle Medicine Residency Curriculum and 3 focus groups (using questions developed by lifestyle medicine teachers and an expert on medical education assessment). Our pre-survey assessed comfort, importance and frequency of counseling, providing written materials and recommending community resources on healthy eating. Focus groups assessed resident experiences in providing nutrition counseling to patient populations in our community (Bangladeshi, Latinx and West African), knowledge of community resources for healthy eating and barriers to providing culturally appropriate counseling. Focus groups were conducted over Zoom with 21 primary care residents. Pre-surveys were administered at the beginning of the focus groups.

All 14 residents who responded to the pre-survey felt it was important to counsel patients, provide written materials and community resources. Only 52% felt comfortable providing counseling and 17% felt comfortable providing written materials. No residents felt comfortable recommending community resources. 21% of respondents counseled patients at most visits. Written materials and information about community resources for healthy eating were provided half or less than half the time by all respondents. Focus groups highlighted the need to be familiar with culturally congruent community resources and how to find WFPB food on a budget.

DISCUSSION / REFLECTION / LESSONS LEARNED: Residents believe healthy eating counseling is important but are not aware of resources to guide our specific patient populations. Our assessment suggests the need to develop training that includes culturally congruent counseling and community resources for patients. We collaborated with community members to create a training session that will be delivered to primary care residents and will assess changes in residents’ knowledge, attitudes and self efficacy 3 months after their training.

DOTPHRASES TO DISCUSSIONS: ADVANCE CARE PLANNING IN RESIDENCY CLINIC Kaitlyn Greiner¹; Patricia Lee¹; Quinn Hosler¹; Aubrey Husak¹; Alexis Barnes³; Lisa Kearns¹; Neeraj H. Tayal²

¹Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ³Division of Cardiology, University of Pittsburgh, Pittsburgh, PA. (Control ID #3874903)

SETTING AND PARTICIPANTS: This is a two-phase study, consisting of a pilot and expansion phase. During the pilot,16 residents at two ambulatory sites were recruited to participate in a three-month study. The initial intervention consisted of a 5-minute tutorial on ACP dotphrase usage, shown to each resident. ACP dotphrase usage during clinic visits was tracked before and after intervention of educational videos. During the expansion phase, the same dotphrase video was shown in-person to all residents, in addition to an ACP education video.

DESCRIPTION: Video tutorials were created with busy residents in mind: a 5-minute video explained how to find the existing ACP tab, document a healthcare proxy in the chart, and accurately fill out an ACP dotphrase. A resident “champion” each block at each site showed this video to pilot participants. During the expansion phase, this video was displayed at intern clinic orientation and senior “re-orientation." For the interns, this was accompanied by a 10-minute video, made in collaboration with a Palliative Care fellow, on tips and tricks of carrying out ACP discussions. The 10-minute education video was emailed to senior residents with a survey on confidence in ACP discussions.

EVALUATION: The number of ACP discussions in residency clinic increased from 20 in the three months pre-pilot intervention to 55 in the three months post-intervention, a 175% increase. Although 16 residents were recruited at the beginning of the pilot phase, an additional 14 residents were noted to have used the dotphrase. Data from the 6-month expansion phase is ending soon and will be analyzed using paired T-test between the pre- and post-intervention period. We anticipate there will be a statistically significant increase between these time periods based on data available from the pilot phase. Notably, despite an email of the 10- minute tips and tricks education video to senior residents in a clinic block, no residents filled out the accompanying survey.

DISCUSSION / REFLECTION / LESSONS LEARNED: Although residency clinic is busy, there are opportunities to increase ACP discussions. Residents already need to discuss ACP during Medicare Wellness Visits. However, the teaching of ACP is not standardized and may be done through a “hidden curriculum” by preceptor teaching in clinic or Palliative consults at different times during residency training. With the pandemic limiting in-person workshops, there needs to be an option to allow for broad and quick distribution of educational materials. We show in this study that the creation of two short videos - one on dotphrase usage and the other on the art of conversations - can increase ACP discussions in residency clinic. However, the sustained success of an electronic intervention may depend on regular in-person check-ins and faculty and resident champions who can encourage the consistent use of a dotphrase. For future direction, we hope to increase exposure of the supplemental tips and tricks video in order to increase confidence of interns in conducting ACP discussions in clinic.

EFFECT OF REFLECTIVE THINKING FORMAT OF NOTE-WRITING ON THE CLINICAL DECISION MAKING OF THIRD AND FOURTH-YEAR MEDICAL STUDENTS

Kejal Shah¹; Barath Rangaswamy²; Sarah Kiani¹. ¹Internal Medicine, Texas tech university of health sciences - Permian basin, Odessa, TX; ²internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX. (Control ID #3877110)

SETTING AND PARTICIPANTS: 3^rd and 4^th-year medical students participated in the study at the simulation center at Texas Tech University of Health Sciences – Lubbock

DESCRIPTION: The Reflective Thinking Format (RTF) is a template that guides the student through a series of questions, to aid in development of the history and physical documentation (H&P) assessment and plan section. A randomized, crossover, interventional, in-person clinical simulation study was planned. For the pilot study, nine 3^rd and 4^th-year medical students from TTUHSC were recruited. Each student underwent two different clinical encounters; randomly assigned to use their format of choice (FOC) for one H&P and the RTF for the other. Students were encouraged to use online resource to guide their plan. De-identified H&Ps were exported into an anonymized data sheet and reviewed by three expert clinicians for IDEAS-score and CDM-score. Time taken and search frequency for each note were also captured in this sheet.

EVALUATION: The mean CDM-scores were higher for RTF 8.67 (SD 4.33) compared to 5.89 (2.80) for FOC (p=0.11). Mean IDEAS-score were also higher at 6.00 (2.12) for RTF versus 5.11 (1.36) for FOC (p=0.25). Average time taken was expectedly higher for RTF 46.4(25.4) versus 31.2(13.5) for FOC(p=0.11). Search frequencies were comparable for RTF 9.00 (0.8836) and 8.44 (10.9) for FOC (p=0.88).

DISCUSSION / REFLECTION / LESSONS LEARNED: Clinical Decision Making (CDM) errors are an important cause of morbidity and mortality in healthcare. Reflective thinking can help students develop CDM skills. It does so by stimulating student metacognition, which is a key variable in clinical reasoning that enables self- regulated learners to choose the best way to approach a learning task. Additionally, we encouraged using available online resources to enhance practice-based learning and promote evidence-based medicine. This study investigated if incorporating RTF into H&P templates improves student’s CDM skills. The response variables, CDM and IDEAS-score, showed positive but statistically insignificant effects for RTF. Interpreted within the context of a small sample size (n = 9), the p-value is indicative of a potentially significant effect. This signals the need for a larger sample size to effectively determine the utility of RTF for student CDM. If a new clinical documentation format can be validated for enhancing medical student’s CDM, in the short term, it will decrease the dependence on medical students on their supervising physicians for developing CDM. In the long term, this would be a simple step for academic and hospital systems to incorporate into electronic health records to improve the clinical reasoning of their future practitioners.

ENTRUST BUT VERIFY: ADDRESSING THE CLINICAL SKILLS ASSESSMENT VACUUM IN UNDERGRADUATE MEDICAL EDUCATION

Winter Williams²; Ryan Flaherty¹; James Willig²

¹Pediatrics, The University of Alabama at Birmingham, Birmingham, AL; ²Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL. (Control ID #3875828)

SETTING AND PARTICIPANTS: The UAB Heersink School of Medicine (UABHSOM) is a public medical school with ~800 students across 4 clinical campuses. Since May 2021, ~400 students have participated in a clinical skills assessment overhaul.

DESCRIPTION: The changing landscape of Undergraduate Medical Education (UME), from cancelling

Step 2 CS to Pass/Fail determination of Step 1 and preclinical grades, has led to growing scrutiny of clinical grading and assessment. To improve clinical feedback and assessment, the UABHSOM changed skills assessment to an Entrustable Professional Activity (EPA) based framework. We implemented a multi-tiered assessment and monitoring system consisting of the following:

Required encounters: standardized clinical cases expected within each clerkship

Observed professional activities (OPAs): discrete elements of the history, exam, and oral presentation using checklists and a modified Chen entrustment scale (EPA 1,6)

Formative feedback form (F3): workplace-based assessment providing structured feedback by domains of competency (EPA 1,2,6,7,9,12)

Entrustable Clinical Medicine (ECM): longitudinal course of 3-4 station OSCEs and post-encounter activities delivered in August, January, and April of the MS3 year (EPA 1,2,3,6,10,12) EVALUATION: To ensure efficient data capture and monitoring, we created a “Clerkship App” using student-specific Qualtrics surveys linked to Tableau dashboards. Dashboards were created for three levels of monitoring:

Student: encourages self-reflection and identification of areas for development

Clerkship Director: ensures accountability for activity completion and timely intervention

School: allows leadership to ensure equitable experience and assessment across student demographics and campuses

As of December 2022, students have collected 6,740 individual OPA responses with a mean rating of 3.03 on a 4-point scale (1 = not yet performing this skill, 2 = direct supervision, 3= indirect supervision, 4 = independent). Early trends follow the academic year with a 2.62 average in May 2021 that rose gradually to 3.4 by April 2022 and then decreased to 2.86 in May. Additionally, we now have >90% completion of all required encounters for each clerkship, and our longitudinal course has used novel assessment methods, such as a problem representation/structured reflection tool to assess clinical reasoning (tools and figures available upon request).

DISCUSSION / REFLECTION / LESSONS LEARNED: As many schools face the challenge of clinical instruction and assessment within an evolving UME landscape, our experience highlights the benefit of data- driven competency assessment. This innovation has allowed us to make progress towards competency-based medical education and shows that, with thoughtful design, large scale change can be implemented within existing clinical workflows.

ONLINE RESOURCE URL: Sample Formative Feedback Form (F3): https://uab.co1.qualtrics.com/jfe/preview/SV_b0Y6EFf5UCFK8tw?Q_CHL=preview& Q_SurveyVersionID=current&previewID=0da9c90f-6b91-4b49-8f58-7e5468a42d46& StudentFirstName=Jane&StudentLastName=Doe%20Medical%20Student

EVALUATING CLINICAL INTEGRATION OF POINT-OF-CARE ULTRASOUND SKILLS Nalinee C. Srisarajivakul-Klein¹; Michael Janjigian¹; Anne Dembitzer^3,2; Aron Mednick¹; Isaac Holmes; Deborah Cooke⁴; Harald Sauthoff⁵

¹Hospital Medicine, NYU Grossman School of Medicine, Long Island City, NY; ²Medicine, New York University Grossman School of Medicine, New York, NY; ³Medicine, VA NY Harbor Healthcare System, New York, NY; ⁴DGIM, NYU Langone Health, New York, NY; ⁵Pulmonary and Critical Care Medicine, VA NY Harbor Healthcare System, New York, NY. (Control ID #3865434)

SETTING AND PARTICIPANTS:

Point-of-care ultrasound (POCUS) training programs have proliferated, but the best method of skills assessment remains unclear. Published testing protocols assess only image acquisition and interpretation. In a clinical case, recognizing an indication for POCUS, selecting the appropriate exam, and integrating findings with the other data are critical skills that need to be tested.

Over the past four years, we taught internal medicine PGY-2 residents at an academic medical center image acquisition and image interpretation skills for four organ systems: lung, cardiac, abdomen, and lower extremity vasculature. We developed an objective structured clinical examination (OSCE) to assess three questions:

1) Does the resident know what ultrasound view to perform in a given case?

2) Can the resident acquire adequate images on a standardized patient (SP)?

3) Can the resident integrate abnormal ultrasound clips in their approach to a case?

DESCRIPTION: Thirty-seven residents took this OSCE 9-12 months following their initial course. The OSCE comprised three cases: identification of B-lines in a dyspneic patient, identification of tamponade in a patient with shock, and identification of hydronephrosis in a patient with acute kidney injury. In each case, the resident was asked to obtain images from an SP and then view abnormal images via slideshow. They were asked to identify the abnormalities, then to propose a differential diagnosis and management plan.

EVALUATION: The OSCE was scored via 45-question rubric by POCUS faculty. Questions pertaining to machine usage and clinical correlation were scored on a binary scale (yes/no). Quality of images were scored with a three-point scale (not done, partially done, well done).

The correct view was correctly selected by the majority of residents in all cases (dyspnea - 92% [34/37], tamponade - 100% [37/37], hydronephrosis - 97% [36/37]).

In regards to image acquisition, in the dyspnea case, 65% (24/37) residents examined bilateral lungs. For the tamponade case, 86% (32/37) acquired a ‘Well-’ or ‘Partly done’ subcostal view. In the hydronephrosis case, all residents obtained a ‘Well-’ or ‘Partly done’ view of the right kidney and 95% (35/37) did the same on the left.

All residents identified an abnormal B-line pattern, however 51% (19/37) generated a complete differential diagnosis for the finding. All residents identified a pericardial effusion and diagnosed cardiac tamponade. All residents identified hydronephrosis with distended bladder.

DISCUSSION / REFLECTION / LESSONS LEARNED: The majority of PGY-2 IM residents identified the appropriate view to perform for all cases and achieved adequate images for the abdomen, though performed less well with cardiac and lung. Only 65% of the learners scanned both lungs in the dyspnea case and half were able to generate a broad differential for the abnormal finding. The results of this OSCE provide evidence that POCUS can be learned by PGY-2 IM residents but that instruction aimed at clinical integration is needed for improved competency in POCUS.

EVALUATING THE COMFORT LEVEL OF RECENT RESIDENCY GRADUATES WITH DIAGNOSIS AND MANAGEMENT OF COMMON ALLERGY AND IMMUNOLOGY CONDITIONS

Ruizhi Dong¹; Tiffany J. Owens²; Matthew J. Flanigan¹

¹General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ²Otolaryngology - Head and Neck, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #3875319)

SETTING AND PARTICIPANTS: Survey of recent IM/Med-Peds residency graduates of single academic center in the Midwest affliated with an Allergy/Immunology department

DESCRIPTION: Allergy and Immunology (A/I) conditions are extremely common and are primarily managed by non-specialists. However, several research studies have demonstrated poor physician understanding of these conditions. While there have been studies looking at short term targeted interventions, there has been limited research on efficacy of longitudinal curriculum development. Our goal with this project is to identify the comfort level of recent residency graduates on the diagnosis and management of common allergy conditions and to use this data as a launching point for further residency curriculum development.

EVALUATION: We anonymously surveyed recent graduates within the last 5 years (2018 – 2022) of both the internal medicine and combined internal medicine/pediatrics residencies of a single academic center in the Midwest with an affiliated A/I program. We assessed their comfort level in diagnosing and treating common A/I conditions and how well they felt the residency prepared them to manage these conditions. The results were analyzed using descriptive statistics.

The survey had 27 respondents, 15 (56%) of whom were currently practicing as a generalist (hospitalist or primary care) and the rest practicing in a subspecialty that is not A/I. Only 12 (44%) had rotated with A/I during residency. The amount of respondent who felt at least somewhat comfortable diagnosing and/or managing common A/I conditions were as follows: 23 (85%) for asthma, 25 (93%) for rhinitis and environmental allergies, 17 (63%) for anaphylaxis, 14 (52%) for angioedema, 9 (33%) for urticaria, 10 (37%) for food allergies, 9 (33%) for penicillin allergies, 13 (48%) for dermatitis conditions, and 1 (4%) for immunodeficiencies. This corresponds relatively well with how well they felt their residency prepared them for these conditions: 26 (96%) felt at least somewhat prepared for asthma, 25 (93%) for rhinitis and environmental allergies, 19 (70%) for anaphylaxis, 17 (63%) for angioedema, 9 (53%) for urticaria, 9 (53%) for food allergies, 13 (48%) for penicillin allergies, 15 (56%) for dermatitis conditions, and 4 (15%) for immunodeficiencies. 25 (93%) felt they would have benefited from more A/I lectures during residency.

DISCUSSION / REFLECTION / LESSONS LEARNED: There is overall low comfort level in diagnosing and/or managing common A/I conditions outside of asthma, rhinitis, and environmental allergies. This correlates with lower exposure to these topics during residency. As a result, a targeted residency curriculum aimed at addressing this will likely be highly beneficial.

HEALTH AFTER CANCER: A CONTINUING MEDICAL EDUCATION COURSE TO PREPARE CLINICIANS TO CARE FOR CANCER SURVIVORS

Kendra Jackson¹; Jayzona Alberto²; Stephanie M. Smith³; Lidia Schapira⁴; Jennifer Kim⁵

¹Stanford University School of Medicine, Stanford, CA; ²Continuing Medical Education, Stanford University School of Medicine, Stanford, CA; ³Division of Hematology/Oncology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA; ⁴Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA; ⁵Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, CA. (Control ID #3876275)

SETTING AND PARTICIPANTS: The online Health After Cancer: Cancer Survivorship for Primary Care continuing medical education (CME) course launched in April 2020. Learners who earned CME credit (n=881) completed a survey that assessed satisfaction, engagement, and intent to change practice.

DESCRIPTION: The transition to primary care after cancer therapy is challenging for cancer survivors. Lack of knowledge about the health needs of cancer survivors is a known barrier to incorporating survivorship care into primary care practice. Formal training in cancer survivorship is rarely included in medical education and presents an opportunity for intervention. With the aim of filling this training gap, a team of oncologists, a primary care physician, and instructional designers developed an online course for clinicians that combines primary care-focused instruction with case-based vignettes. The four patient cases showcase physical and psychological effects of cancer treatment while a primary care narrator offers practical resources and tips related to communication in clinical practice. The course employs learning reinforcement strategies such as supplemental tools for use in practice, knowledge checks, and reflective statements.

EVALUATION: Learners who earned CME credit (n=881) completed a survey that assessed satisfaction, engagement, and intent to change practice. Quantitative survey data were analyzed descriptively, and qualitative survey data were coded to generate latent themes relevant to learning outcomes.

DISCUSSION / REFLECTION / LESSONS LEARNED: Aggregate data from 881 evaluations indicated high marks in the quality of content, delivery and effectiveness, and value of the topic. The majority of learners also stated that they intended to implement changes in their practice. The most common reported change to practice was improved communication with patients, namely improvement in the quality of questions about a patient’s cancer history and enhanced emotional awareness when discussing survivorship concerns. Additional common changes reported were increased knowledge of late effects of cancer treatment and challenges faced by cancer survivors, and improved delivery of survivorship care. Learners also reported that the course improved their knowledge, attitudes, and skills that support interprofessional collaboration.

Learner evaluation data suggest that this innovative approach of case-based learning is effective and may contribute to closing the training gap and preparing clinicians to deliver survivorship-informed care to their patients.

ONLINE RESOURCE URL: https://mededucation.stanford.edu/courses/health-after-cancer/

STUDY HABITS IN INTERNAL MEDICINE CLERKSHIP AND A LONGITUDINAL STUDY PLAN TO IMPROVE SHELF EXAM SCORES

Barath Rangaswamy¹; Srikanth Mukkera²; Stephanie Stroever³; Duc Le⁴

¹Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ²Rheumatology, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; ³Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; ⁴School of Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX. (Control ID #3876843)

SETTING AND PARTICIPANTS: Third (MS3) and fourth year (MS4) medical students at School of Medicine, Texas Tech University Health Sciences Center, Permian Basin.

DESCRIPTION: There is evidence that performance on Internal Medicine Clerkship exams (SHELF) is associated with performance on the Step 2 CK exam, and the quantity of practice questions/proportion of those completed from a question (Q) bank is correlated with scores on the Step 2 CK exam. Our objective was to determine the preferred study methods among students and evaluate a longitudinal program designed to support success on exams. We conducted a cross sectional study and all MS3 and MS4 completed a survey of their preferred resources, preferences for time allocation, and barriers to success. The majority of questions used a Likert-type response. We used descriptive statistics to summarize the results and Fisher’s Exact test to assess differences between cohorts. P < 0.05 was set a priori for hypothesis testing.

EVALUATION: The response rate was 60% (n=27). All MS4 and half of the MS3 students had previously taken the SHELF exam. About half (55%) of the students responded that they were most likely to use Q banks/board review books for preparing for ward rounds, and all reported they were most likely to use the same for SHELF exam prep. Fifty-five percent of respondents perceived the time available for learning and revising the Q bank material before the exam was adequate though half responded it was inadequate. Forty- four percent reported that time is the primary barrier for working through the Q bank. Burnout and questions with complex clinical concepts were endorsed as barriers by 37.0% and 14.8%, respectively. For 3.70%, it was simply a boring task to do. Almost all participants responded that a longitudinal focus in learning the Q banks from week one of clerkship is preferred over the last week just before the exam. Half of the MS3 neither agreed nor disagreed that regular meetings with faculty or house staff to review Q bank progress would be valuable while only 1 MS4 was neutral. Meanwhile, 30.8% of MS4 strongly disagreed that this practice would be valuable while none of the MS3 had a similar endorsement. An equal proportion of MS3 and MS4 positively endorsed this practice. This was the only question with significant differences between MS3 and MS4 (p = 0.012). Half of the respondents preferred weekly meetings with faculty while 30% preferred biweekly. Among the students who have already taken the SHELF exam, 55% agreed that the longitudinal study plan helped to improve their SHELF scores.

DISCUSSION / REFLECTION / LESSONS LEARNED: Exploring study habits revealed strong preference to use Q banks over traditional learning resources. The longitudinal study plan is a tool that can be used to improve exam performance. These meetings are an opportunity to coach students on best practices and apply mitigation strategies for barriers to practice more questions and provide necessary encouragement and motivation.

USING NIGHT-ONCALL TO ASSESS NEAR-GRADUATES ABILITY TO ADDRESS A PATIENT’S PAIN ASSESSMENT AND MANAGEMENT

Maureen Francis²; Elizabeth L. Wargo¹; Tavinder K. Ark³; Cristina M. Gonzalez⁴; Sondra R. Zabar¹; Adina Kalet³

¹General Internal Medicine, New York University Grossman School of Medicine, New York, NY; ²Medical Education, Texas Tech University Health Sciences Center El Paso, El Paso, TX; ³Kern Institute, Medical College of Wisconsin, Milwaukee, WI; ⁴Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, New Rochelle, NY. (Control ID #3873216)

SETTING AND PARTICIPANTS: Graduating medical students at a Southern region medical school.

DESCRIPTION: Night-onCall (NOC) is an activity during which near-graduating medical students rotate through a series of three simulated scenarios, a phone call to an attending, an Evidence-Based Medicine Literature Search and a Patient Safety Activity. This medical school integrated NOC into their mandatory transition to residency bootcamp for graduating students since 2019. In 2022, they replaced one of the original NOC cases with a case focused on pain management to assess the students’ ability to evaluate the level of pain and determine appropriate treatment. The results of the Pain Management Case provided both meaningful individual student feedback and program evaluation.

EVALUATION: The NOC Pain Management Case involves a 48-year-old female patient who presents with right-sided chest pain 3 days after a fall. After initial treatment in the ED and admission, the intern is called to address recurrent pain. A Standardized Patient (SP), a Standardized Nurse (SN), and a faculty member assess student performance from different perspectives. The SN and SP rate the learner on Communication Skills, Trust and Professionalism, while the SP also rates the learner on Organization, History Gathering, Physical Exam and Management and Plan. The faculty member rates the documentation of the encounter.

Students are rated using a 3-point not done (ND), partly done (PD) and well done (WD) or 4-point (poor to strong) scale by SP and SN. This cohort of students performed best on communication skills, performing a physical exam and demonstrating trust and professionalism. Lower scores from the raters identified key areas for improvement. Students received weaker ratings in History Gathering; SPs rated 37% of students performing WD, 29% PD and 34% ND. SP subdomain ratings highlight that less than 30% of students acknowledge their history of depression and 1% of students screen for domestic violence.

Although most students received WD ratings within two of the three Management and Plan subdomains, the cohort performed weaker in providing additional counseling. 20% of students received WD, 53% PD and 27% ND ratings.

The Case Note Summary assesses pain management documentation and represents another area for improvement for this cohort. Faculty raters gave 94% of students a “beginning” score and 6% of students a “poor” score. The Case Note sub-domains indicate that 98% of students did not provide risks of treatment, 82% of students did not explain the expected impact of appropriate treatment and 97% did not discuss consequences of no intervention.

DISCUSSION / REFLECTION / LESSONS LEARNED: The Pain Management Case provided valuable individual feedback to the graduating students and was helpful in identifying programmatic areas for educational improvement in several domains including pain assessment, management and documentation. Overall, the flexibility to substitute new cases based on local priorities adds to the value of NOC which continues to be a highly rated experience.

VIRTUAL TEACHING: WHAT MAKES IT STICK?

Jacob H. Johnson¹; Courtney E. Harris²; Erik K. Alexander³

¹Infectious Diseases, Brigham and Women's Hospital, Boston, MA; ²Infectious Disease, Brigham and Women's Hospital, Boston, MA; ³Endocrine, Brigham and Women's Hospital, Boston, MA. (Control ID #3874081)

SETTING AND PARTICIPANTS: Virtual teaching has become essential during the COVID-19 pandemic, but optimal teaching strategies remain unknown. To address this need, we designed an assessment instrument for virtual lectures to identify which domains of virtual teaching correlated with expert and learner lecture ratings as well as delayed learner recall of take-home messages. Infectious disease (ID) fellows and faculty at an academic center participated.

DESCRIPTION: We adapted a previously designed in person assessment tool to the virtual arena via iterative expert review. Reliability was assessed via intra-class correlation (ICC) and scale reliability via Cronbach’s α. Tool domains were correlated to a single-item teaching effectiveness score, delayed learner ratings, and delayed learner recall (asking learners to identify 2 key take-home messages 6 months after the lecture). Each response was rated on a scale of 0-3 by 2 raters.

EVALUATION: The assessment instrument has 13 domains each with a 5-point behavioral anchored Likert scale:

1. Goals

2. Virtual Expectations and Etiquette

3. Importance of Topic

4. Organization and Cognitive Load

5. Enthusiasm

6. Command of Topic

7. Explanations

8. Audience Engagement

9. Monitor Audience’s Understanding

10. Virtual Platform

11. Audio Visual Aids

12. Mechanics of Communication

13. Conclusion

Five faculty members rated 32 lectures. Two raters reviewed 8 lectures; 10 domains showed ICC > 0.6, the effectiveness score ICC was 0.68 and the overall instrument score (average of all 13 items) ICC was 0.91. Scale reliability was 0.87 (Cronbach’s α). Twelve ID fellows participated as learners in the assessment and recall. Overall instrument score and effectiveness score were correlated with delayed recall (r=0.59, P=0.0009; r=0.62, P<0.0001, Pearson’s r). Delayed learner ratings were not correlated with delayed recall (r=0.3, P=0.11) nor instrument score (r=0.10, P=0.59).

Monitor Audience’s Understanding, Explanations, and Audience Engagement were significantly (P<0.01) correlated with delayed recall score (r=0.64, 0.56, 0.50 respectively). Five others reached significance at P<0.05. Eleven domains were correlated (P<0.05) with effectiveness score and 7 reached high significance (P<0.01); the most being Organization and Cognitive Load (r=0.71).

DISCUSSION / REFLECTION / LESSONS LEARNED: The 13-point instrument is a reliable measure that correlated with learner recall supplying validity evidence that this tool can predict memorable teaching. Monitor Audience’s Understanding was the most correlated domain and aligns with decades of research showing active learning promotes long-term retention. Assessing lectures based on learner outcomes is difficult given trainees acquire knowledge over time; despite this, delayed recall was able to distinguish between teaching domains.

In summary, this study adds to the literature in 3 key areas: First, it establishes a robust assessment tool for virtual teaching; second, it shows the power of delayed recall to assess lectures; and lastly, it identified high- yield domains of virtual teaching.

WHAT CAN YOU ACTUALLY ASSESS?: A MODIFIED DELPHI PROCESS FOR TRANSITIONING RESIDENT ASSESSMENT FORMS FROM MILESTONES TO PRACTICAL, OBSERVABLE BEHAVIORS

Richard E. Greene^1,2; Kevin Hauck¹; Anne Dembitzer¹; Barbara Porter¹; Patrick Cocks¹; Margaret Horlick¹

¹Medicine, NYU Langone Health, New York, NY; ²Internal Medicine, Bellevue Hospital Center, New York, NY. (Control ID #3873922)

SETTING AND PARTICIPANTS: We sought to improve our process for the written assessment of 245 residents in our multi-hospital urban academic Internal Medicine Residency Program.

DESCRIPTION: Our previous end-of-rotation evaluation tool used a milestone-based framework. Triggered by a poor completion rate and suggestions that our assessment system did not provide meaningful or actionable feedback, we sought to improve our assessment process. We used a modified Delphi technique, engaging faculty and residents to identify items they observe and for which they can provide actionable feedback and to identify challenges with the current feedback tool.

EVALUATION: Faculty and residents identified over 90 specific observable behaviors in both the inpatient and outpatient settings.

They identified that broad feedback perceived as negative might potentially harm a resident in the future or disrupt an important working relationship. Residents additionally identified feeling that knowledge feedback is easier to give than characterologic (e.g. peers who are disorganized, or who demonstrate unprofessional behavior when stressed). Inpatient faculty reported more comfort observing resident behavior than intern behavior, as residents often provide support to struggling interns that faculty may not observe.

An expert panel of clinical faculty and senior educators convened to review results and relevant literature and move forward to design new assessment tools. This team collectively categorized each observable item, made items developmentally specific when necessary, and assigned each a rating type (binomial, scale, or

narrative) and rating frequency.

Results were converted into novel assessment tools that include retrospective assessment items and prospective entrustment decisions. Separate assessment tools were created for each learning environment. The tools rely on directly observed clinical encounters and anchor actionable feedback to exemplar cases.

The outpatient tool has 9 developmental iterations over the course of 3 years of training and the inpatient tool consists of 4 iterations, for interns and residents in ICU and floors.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our outpatient assessment tool has been used for 6 months, and the faculty completion rate is 56%. Follow-up faculty focus groups at our outpatient sites are scheduled for early 2023. Our inpatient evaluation tools are now in a pilot testing phase, with a goal of distributing widely in March 2023. Faculty completion rates will be studied, and follow-up faculty focus groups will be held after 6 months of use. Additionally, our internal resident surveys will query residents about the quality of written feedback they are receiving.

No form fixes the challenge of delivering negative feedback, and faculty development remains essential to ensure that our trainees receive feedback they can use to develop into competent physicians.

WHAT HAPPENS IN THE ZOOM?: A WORKPLACE-BASED ASSESSMENT OF RESIDENTS’ POST-DISCHARGE SKILLS IN A TELEMEDICINE VISIT WITH A STANDARDIZED PATIENT Renee E. Heller¹; Zoe Phillips²; Jeffrey A. Wilhite³; Daniel Sartori³; Sondra Zabar⁴; Rachael Hayes¹

¹Division of General Internal Medicine, NYU Langone Health, New York, NY; ²General Internal Medicine, NYU Langone Health, New York, NY; ³Medicine, New York University Grossman School of Medicine, New York, NY; ⁴Medicine, NYU School of Medicine, New York, NY. (Control ID #3874036)

SETTING AND PARTICIPANTS: 43 Residents in the Internal Medicine (IM) Residency Program at two urban FQHC clinics participated in a virtual visit with an Announced Standardized Patient (ASP).

DESCRIPTION: The post-discharge period is a vulnerable time for patients as they risk clinical deterioration, readmission and increased mortality. It is therefore essential that IM residents are equipped with the skills to provide high-quality Transitional Care Management (TCM). We initiated a workplace-based assessment using ASPs during virtual, post-discharge clinic visits to 1) provide training and education for residents through feedback from the patient’s perspective, 2) evaluate resident’s competency for TCM and telemedicine skills, 3) assess the need for TCM and telemedicine curriculum.

During the first appointment slot of their regular clinic, residents participated in a video visit with an ASP, a 60-year old woman with history of congestive heart failure (CHF), recently discharged after a hospital admission for CHF exacerbation. Case objectives included: assessing symptoms since discharge, medication review, ensuring appropriate follow-up and constructing a management plan. After the visit, ASPs provided verbal feedback to the resident and completed a behaviorally anchored checklist to rate skills as not, partly, or well done (WD) in 6 domains focused on communication and patient management skills. Residents received individualized feedback reports and were asked to complete a survey on the experience. Resident notes are being reviewed to assess proper documentation of the HPI, medical reconciliation, physical exam, and treatment plan.

EVALUATION: Overall, residents performed well for information gathering (93% WD) and relationship development (91% WD) but performed less well for education/counseling, telemedicine, and TCM skills (76%, 73%, and 68% WD, respectively) and least well on case-specific skills (56% WD). Behaviors commonly partly done included: evaluating symptoms since discharge, making a plan for lifestyle modification and addressing barriers to follow-up. Behaviors that were frequently not done included: performing a virtual physical exam and utilizing live video to augment information gathering. ANOVAs revealed that PGY2s scored significantly better than PGY1s on TCM skills (80% WD vs 56% WD, p<0.01), however, there were no other significant trends between resident year and performance. We expect to find areas for improvement in visit documentation after analyzing the notes. In the follow-up survey, 100% of learners agreed this program provided valuable feedback; many wrote they would like more training in telemedicine.

DISCUSSION / REFLECTION / LESSONS LEARNED: This study indicates that ASP encounters are an effective tool for training and assessing resident TCM skills and thereby identifying areas for improvement.

A targeted curriculum focusing on partly and not done skills as well as proper documentation is necessary to supplement the current experiential learning in order to achieve high-quality, virtual post-discharge care.

Innovation in Medical Education (IME) - Career Development, Professionalism, and Wellness

AN INNOVATIVE APPROACH TO PROMOTE EARLY STUDENT INVOLVEMENT IN COMBATING FOOD INSECURITY

Shiva A. Nuti¹; Vivek S. Patel¹; Roshan B. Tom¹; Jed Janecek¹; Jenieve Chapa¹; Alicia Cano¹; Jacob Alaniz¹; Nikhil Gogineni²; Sagar Kamprath³

¹The University of Texas Medical Branch at Galveston School of Medicine, Galveston, TX; ²Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; ³Family Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX. (Control ID #3876671)

SETTING AND PARTICIPANTS: A prominent medical institution based in the Southern US espouses a holistic curriculum that explores numerous population health trends within the ‘Practice of Medicine’ course in year one but provides few avenues for students to apply these principles through practical application outside of the classroom. As such, students fail to fully grasp the tenets of the biopsychosocial model of medicine as their first exposure to the community is in year three during clinicals. We hypothesize that student-based nonprofit organizations such as ours promote early education of students regarding the social determinants of health through real-life exposure while bridging the gap between the underserved and student doctors in training.

DESCRIPTION: Our organization is a nonprofit lead by 16 volunteers that connects underserved residents to food resources. We first identified 30 home-bound families tabbed as food insecure through databases provided by free health clinics. We then acquired food and donations in partnership with local nonprofits and grocery chains for delivery to these families during our annual food drive. Two surveys were then administered: one analyzing population health trends amongst the residents and another assessing the volunteers’ educational/personal growth post food drive.

EVALUATION: Here, the goal was to assess whether our organization’s food drive was transformative for the students with regards to their professional identity formation.

Select Student Survey Data (16/16 responses):

87.5% indicated enhancement of their population health knowledge

93.8% indicated that our organization had a positive impact on their professional identity formation 100% would like to see this opportunity be offered again

DISCUSSION / REFLECTION / LESSONS LEARNED: Qualitatively, student quotations revealed that they learned more about community diversity regarding cultures, living situations, and diet habits. Additionally, volunteers stated that they appreciated the opportunity to be able to interact so closely with the community and that for many, this event reinforced their personal motivations for choosing medicine.

While the first two years of medical education are classroom-focused, our organization allows for early exposure to community members/future patients on the basis of the biopsychosocial model of medicine. That is, students visit patients in their home and understand them on a personal basis, something even trained physicians do extremely rarely. Thus, as a result of our efforts, students are afforded early and unique field experiences and perspectives that will mold them into more empathetic and dynamic physicians able to integrate numerous diverse experiences into their practice.

CRAFTING THE FUTURE DOCTOR: CLINICAL MENTORSHIP DURING FIRST YEAR OF MEDICAL SCHOOL CAN IMPACT FUTURE CAREER TRAJECTORY FOR CHOOSING RESIDENCY PROGRAMS

Sarah Shidid¹; Natalia Orihuela¹; Pakinam Mekki²; Haram Abdelmajid³; Tamar A. Smith-Norowitz³

¹Internal Medicine, Montefiore Medical Center, Bronx, NY; ²Vanderbilt University Medical Center, Nashville, TN; ³SUNY Downstate Health Sciences University, Brooklyn, NY. (Control ID #3872756)

SETTING AND PARTICIPANTS: First year medical school students (N=77) at an academic medical center in the Mid-Atlantic region (freshman classes of 2020-2022) who participated in clinically reimagined apprenticeship for physician training (CRAFT) program were followed from freshman year until their medical school graduation. Information regarding first year mentor’s specialty and student’s match list data were collected. The specialty of medicine that each student matched into for residency was compared with the specialty of medicine that the students were exposed to during the CRAFT program. Exclusion Criteria consisted of students who did not match into residency and those who took gap years during medical school, where match data was unavailable.

DESCRIPTION: The CRAFT Program is a volunteer student-run clinical mentorship program that started in 2015 at an academic medical center in the Mid-Atlantic region. The goal of this program is to connect first year medical students with mentors in their desired specialty. The CRAFT program allows medical students to experience clinical exposure during the first year of medical school.

EVALUATION: A retrospective chart analysis of CRAFT program volunteers was conducted. Students (51%) who participated in CRAFT matched into the same specialty of medicine as their CRAFT program mentors (P= 0.765, Chi Square Test). Of students (23%) who chose mentors in Internal Medicine, 50% matched into Internal Medicine residency programs (P<0.0001, Chi Square Test). Our results demonstrate the importance of early clinical mentorship in medical school. Clinical exposure during the first year of medical school may influence a student’s decision to pursue Internal Medicine for their residency program of choice.

DISCUSSION / REFLECTION / LESSONS LEARNED: Clinical mentorship programs during the first year of medical school may be important for choosing future residency programs, leading to successful career goals. Timely engagement with mentors can be crucial in influencing career choices in the field of Internal Medicine.

DEPARTMENT OF MEDICINE FELLOWS’ COUNCIL: AN INNOVATIVE PLATFORM TO PROMOTE FELLOWS’ PROFESSIONAL DEVELOPMENT AND ENHANCE WELLBEING

Gayathri Krishnan, Julie Byington, Abby Spencer

Internal Medicine, Washington University in St Louis, St Louis, MO. (Control ID #3839823)

SETTING AND PARTICIPANTS: The structure of fellowship training is unique and differs from residency in a variety of aspects: there are fewer trainees per program, less peer interaction as fellows’ function more independently, and fewer opportunities for professional and social networking given the siloed nature of subspecialty training. This is particularly true for smaller subspecialty programs. Despite these shared challenges, clinical divisions within the Department of Medicine (DOM) do not have standardized funding, resources, or the personnel to independently conduct wellness, career, and professional development activities for their fellows. This is a missed opportunity as trainees at this career stage can gain valuable insights from peer collaboration. To better address these unmet needs of professional development and shared ACGME curricular requirements of our fellows across all divisions of Internal Medicine, we developed our inaugural DOM Fellows’ Council.

DESCRIPTION: Our DOM has 16 ACGME accredited and 4 unaccredited medicine subspecialty fellowship programs with 163 fellows altogether. The Inaugural Fellows’ Council consists of 8 fellows nominated by their respective program directors from cardiology-electrophysiology (1), endocrinology (1), gastroenterology (1), hematology-oncology (2), infectious diseases (1), nephrology (1) and pulmonary- critical care (1). Our annual goals fall into 3 categories: 1) Professional and Career development programming 2) Wellness activities 3) Family friendly social events. The council is supported by a skilled administrative coordinator and mentored by the DOM Vice Chair of Education. The council has an annual budget to support its programming and is intentional about supporting diversity, inclusion, and belonging.

EVALUATION: Qualitative feedback received during the inaugural event included “fellows council is something we did not know we needed before this,” “it is good to see other specialists outside of work environment.” Post session evaluations from the event ‘How to effectively transition to a consultant’ revealed: 79.13% reported the workshop helped with onboarding, 87.5 % of the participants were at least moderately comfortable with teaching during rounds, helping the consulting team formulate a question, leading an interprofessional team and 87.5% were at least moderately comfortable on methods to solicit the consult question most effectively from a team, and triaging consults.

DISCUSSION / REFLECTION / LESSONS LEARNED: Dedicated platforms with leadership support are vital for advancement of fellows. Fellows Council programming also supports our DOM fellowship program directors by supplementing their curricula and wellbeing efforts. Our preliminary assessment data reflects this programming is well received by DOM Fellows. Future directions include maximizing fellow participation, finding the right balance of virtual and in-person events, and implementing events to forge meaningful connections.

ONLINE RESOURCE URL: https://internalmedicine.wustl.edu/an-update-from-the-office-of-the-vice- chair-of-education-3/

IMPACT OF A FACILITATED PEER MENTORING PROGRAM WITH A DEDICATED CURRICULUM TO FOSTER CAREER ADVANCEMENT OF ACADEMIC HOSPITALISTS

Doris Lin¹; Rosa Schmidt¹; Chirayu Shah¹; Andrew Caruso¹; Xiaofan Huang²; Kristen Staggers²; Joslyn Fisher¹

¹Internal Medicine, Baylor College of Medicine Margaret M and Albert B Alkek Department of Medicine, Houston, TX; ²Baylor College of Medicine, Houston, TX. (Control ID #3871810)

SETTING AND PARTICIPANTS: Our academic hospital medicine program has over 100 hospitalists and mirrors those across the country with a high number of junior and relatively few senior faculty. We recruited 29 junior faculty and divided them into five small groups each guided by one senior faculty. At the end of the program, 19 completed both pre- and post-program surveys.

DESCRIPTION: With the dearth of senior faculty in hospital medicine, traditional dyadic mentoring poses a challenge. We developed an innovative facilitated peer mentoring program with a dedicated curriculum that included four sessions: 1) Intro to Facilitated Peer Mentorship and Identifying Career Goals, 2) Building a CV, 3) Developing an Academic Portfolio, and 4) Strategies for Hospitalists to Achieve Scholarly Success.

Each session was presented to all members in a large group setting. The small groups were directed to meet individually after each large group session so peer members could review and begin work on previously presented topics with senior facilitator guidance. All sessions occurred over 12 months with alternating large and small group sessions. Our aims included: 1) determine feasibility of the program measured through participation, 2) enhance knowledge of curriculum-specific topics, and 3) evaluate participant’s perception of the program regarding career advancement.

EVALUATION: We aimed to achieve an average participation rate of at least 50% in the large and small group sessions to assess feasibility of the program. The average participation rate for the large group sessions was 57.4% which was non-inferior to 50% with a margin of -10% (p=0.042). The participation in the small groups was more variable. One small group did meet three times and participation in all the sessions was >50%. Another group met once with all mentees in attendance. The facilitator then met individually with two of the more engaged members throughout the study period. One senior facilitator met individually with three of his peer members citing schedule as barriers to meeting all together. The other two small groups were unsuccessful in meeting citing schedule and time as barriers. The surveys demonstrated significant knowledge improvement (p<0.05) in pathways to promotion, patient care and educational portfolios, activities that would count towards each portfolio type, and articles they have the skills to write. Moreover, 84% (n=16) of participants were satisfied with the program, 79% (n=15) felt participation would help in achieving career goals, and 95% (n=18) would recommend the program to their colleagues.

DISCUSSION / REFLECTION / LESSONS LEARNED: Facilitated peer group mentoring is a low cost, replicable solution for academic mentoring when gaps exist in the availability of traditional mentor mentee dyads. Our program was unique as we incorporated a dedicated curriculum to meet the needs of the busy hospitalist. We found that attention to senior mentor availability is critical when recruiting effective facilitators.

IMPROVING INTERNAL MEDICINE INTERN CLINICAL TRANSITION VIA INTENSIVE GUIDANCE SESSIONS

Nandhini Bindukumari Sureshkumar¹; Rinki Pandya²; Maneet Chatha²; Foram J. Bhagat²; Amog Jayarangaiah²; Hiral Patel²; Gary Van Oudenhoven¹

¹Internal medicine, Marshfield Clinic Health System, Marshfield, WI; ²Internal Medicine, Marshfield Clinic Health System, Marshfield, WI. (Control ID #3874530)

SETTING AND PARTICIPANTS: Graduate medical education is the crucial step of professional development between medical school and autonomous clinical practice. The transition from a medical student to an intern is a turbulent journey for many new incoming residents. Our project aims to breakdown and fix the factors which limits an intern to achieve an adequate level of competency.

The most important factors impacting the confidence of an intern were measured using a self-evaluation tool.

The ‘control group’ was the intern batch of class of 2024, belonging to an internal medicine (IM) residency program in a community setting at Mid-West. The ‘test group’ was the intern batch of class of 2025, from the same program.

DESCRIPTION: The most important skills that impacted the confidence levels of intern were identified as follows: familiarity with electronic health record (EMR), writing a patient note, case presentation, communication with patient, time management, formulating appropriate assessment and plan, and self- sufficiency in responding to acute emergencies in inpatient settings. On these seven factors, the control group of interns evaluated their confidence levels themselves using a self-evaluation tool.

In the intervention phase, a group of second-year residents provided practical lessons about the seven factors to the test group. It was carried out in 4 phases. ‘Orientation phase’ introduced all the topics. ‘Extensive intervention phase’ involved working with interns individually, and teaching them each of the seven skills. In ‘open question phase’, all queries of the interns were addressed. Finally, in ‘teach back phase’, simulation cases were created and the interns were encouraged to apply their learned skills. Three months post intervention, the test group self-evaluated themselves using the self-evaluation tool.

EVALUATION: On a scale of 1-5, the test group had higher average in all areas post intervention, compared to the control group: Time management (3.4 vs 2.2) patient note writing (3.8 vs 3.1), self-sufficiency in responding to acute emergencies in inpatient settings (3.9 vs 3.3), formulating appropriate assessment and plan (3.0 vs 2.7), case presentation (3.3 vs 3.0), EMR familiarity (3.5 vs 3.2), and patient communication (3.6 vs 3.4). Most amount of average percent increase was seen in time management skills (55%).

DISCUSSION / REFLECTION / LESSONS LEARNED: All of the participants in the study were international medical graduates with at least 6 months of prior clinical experience in the United States; however, none with exposure to our EMR system.

Our study showed improved outcomes in confidence levels of the interns which is notable in the post intervention data. The overall impact of improvement in all these areas led to improvement in time management skills, which is very essential for interns and the program. Based on our results, we recommend pro-active intensive guidance to improve the confidence of interns during their clinical transition.

LEADING WITH PURPOSE: A LEADERSHIP DEVELOPMENT PROGRAM FOR WOMEN TRAINEES IN MEDICINE

Gayathri Krishnan¹; Maria Q. Baggstrom²; Abby Spencer¹; Caline Mattar³; Rakhee Bhayani¹

¹Internal Medicine, Washington University in St Louis, St Louis, MO; ²Internal Medicine/Oncology, Washington University in St Louis, St Louis, MO; ³Internal Medicine/Infectious diseases, Washington University in St Louis, St Louis, MO. (Control ID #3874814)

SETTING AND PARTICIPANTS: Despite near parity of women and men entering medical school, there is still marked gender inequity in academic medicine as reflected in leadership positions, promotion, assessments, and job opportunities. Awareness and engagement, mentoring and networking, and leadership development are valuable interventional strategies to advance women in medicine until systemic barriers have been addressed. Structured leadership development programs create safe space for learning, networking, enhanced leadership competencies and workplace retention. A group of 5 women leaders from different stages of academic medicine at Washington University (WUSM) developed a skill-based longitudinal leadership development program for women trainees in the Department of Medicine (DOM) for AY 2022- 2023. Through an application and selection process, 6 subspecialty fellows and 6 internal medicine residents within the DOM were selected to participate in this 8-month long certificate program that commenced Fall 2022 and concludes Spring 2023.

DESCRIPTION: In-person sessions were held every 6 weeks and included topics such as finding meaning and purpose in medicine, communicating effectively, building your academic team for success, leadership and communication skills, creating your career development plan, negotiation, and conflict management. An active learning environment was created through small and large group discussions, self-reflection activities, and negotiation scenarios in the simulation center. Each participant was paired with a woman faculty mentor for the duration of the program to support goal-directed advancement.

EVALUATION: In the pre-course survey only 42% (5/12) had primary mentors and 25% (3/12) had an individual career development plan. Using the Kirkpatrick framework for Levels of Program Evaluation, satisfaction with the program was assessed through post session surveys on the effectiveness of the speaker, satisfaction with the content delivery and pre/post assessment surveys to check knowledge acquisition and skills. At the end of the program, self-reflective survey questions combined with an observed role play will be implemented to demonstrate skill acquisition. We plan to disseminate impact surveys after program completion at 6 months, 1 year, and 2 years to evaluate retention and implementation of new skills acquired.

DISCUSSION/REFLECTION/LESSONS LEARNED: Leadership Development courses provide vital skills to support the future women leaders in medicine reach their full potential. Role plays and simulation tests help practice and develop negotiation and communication skills. To create a sustainable program, we have obtained buy-in from key stakeholders such as the Department chair, Vice Chairs, and Program Directors. We have secured funding to provide meals during the evening sessions, administrative support to handle program logistics, and recorded sessions to accommodate varying trainee schedules

ONLINE RESOURCE URL: https://internalmedicine.wustl.edu/diversity/forum-for-women-in-medicine/fwim-trainee-leadership- development-program/

PREDICTORS OF CHIEF MEDICAL RESIDENT SELECTION

Richard Cartabuke

Internal Medicine, Cleveland Clinic, Painesville, OH. (Control ID #3869730)

SETTING AND PARTICIPANTS: The number of subjects enrolled included Cleveland Clinic Internal Medicine trainees from the academic year 2013-2019. We obtained permission from the program director in Internal Medicine to review this data. Approximately 605 trainees have available competency and sub- competency data and ITE scores since 2013.

Descriptive statistics were presented to characterize the residents that do and do not become chief resident. Logistic regression models were utilized to investigate whether year 1 competencies are associated with later becoming a chief resident and therefore useful in early identification. A linear mixed model will explore the competency profiles over the three years for both chief residents and other residents.

DESCRIPTION: We reviewed the Accreditation Council for Graduate Medical Education (ACGME) competency data, demographic information and In-training Examination scores utilized in the selection of Chief Internal Medicine residents at a large academic program to determine if there is an association of one or more components with Chief residenct (CR) selection and develop a predictive model.

EVALUATION: The data from a single institution suggets the need for an expanded pool of subjects to apply the predictive model more readily to confirm these findings. This could serve as the basis for generating more directed "Leadership Tracks" within residency programs to augment and prepare our learners for future administrative roles. We have partnered with Saint Louis University and George Washington University in an attempt to expand our dataset in an attempt to draw further conclusions and test our predictive model in environments with different processes for CR selection.

DISCUSSION / REFLECTION / LESSONS LEARNED: Based on demographic data, the largest single predictor of CR is medical school – those that attended allopathic medical schools were more likely to be selected. Furthermore, matriculating from an international medical school had negative predictive value on being selected as CR.

After review of ITE scoring data, there is no evidence to claim that in-service year one percentile is associated with chief residency selection (mean 59.8 vs. 61.7 chief residents vs. non-chief residents respectively, P = .68). Additionally, while none are statistically significant, the competencies showing the strongest relationship in our year one predictive model are PROF2, PROF3, PROF4 & ICS3. The predictive model correctly identifies 20 out of 28 (71%) chief residents & 254 out of 301 (84%) non-chief residents.

With regard to ITE scoring data, there is no evidence to claim that in-service year 2 percentile is associated with chief residency selection (mean 60.4 vs. 61.1 chief residents vs. non-chief residents respectively, P = .89). The competencies significantly associated with chief residency selection are PC5, SBP1, SBP3, PBLI3, PROF2, PROF4, ICS1 & ICS2. Interestingly, when running a regression model and allowing both year 1 & year 2 data to be a candidate variable, the single strongest predictor is ICS2.

RESIDENTS AS COACHES PROGRAM: A COMMUNITY OF PRACTICE TO SUPPORT THE TRANSITION TO RESIDENCY

Kavita Renduchintala^1,2; Alyssa Kimble³; Shanu Gupta³

¹Hospital Medicine, The University of Chicago Medicine, Chicago, IL; ²Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, FL; ³Internal Medicine, University of South Florida, St Petersburg, FL. (Control ID #3872883)

SETTING AND PARTICIPANTS: The Residents as Coaches (RAC) program started in the 2020-2021 academic year with 4 coaches and 22 medical students and expanded in the 2021-2022 academic year to 13 coaches and 39 medical students at an academic center in the Southern region.

DESCRIPTION: The RAC program utilizes near-peer coaching to create a bidirectional experience that supports the development of residents into educators and students into interns. Internal Medicine (IM) resident coaches are paired with a medical student coachee participating in the fourth year IM track. The goal of the program is to develop a community of practice for resident coaches, contribute to the process of professional identity formation, and help prepare students for their transition to intern year. Throughout the program, residents receive instruction on their role as a coach, learn about coaching model frameworks, complete practice coaching sessions, and aid in core IM content mastery. In addition to quarterly meetings, residents provide guidance throughout the year as the students complete their IM track requirements and navigate the residency application process.

EVALUATION: A quantitative and qualitative survey was administered to resident coaches at the end of 2021-2022 academic year. Coaches were surveyed using a Likert scale (1-strongly disagree; 5-strongly agree). Out of the 13 surveys, 9 responses were received. Overall, the coaches agreed that the program helped them identify learners at risk (weighted mean 4.22), develop individual coaching plans (4.56), and create a sense of professional community and mutual engagement within the coaching group (4.56). Coaches also agreed they learned specific coaching skills of effectively communicating with a coachee (4.78), giving valuable feedback (4.56), and setting effective goals with their coachee (4.78). Coaches noted they would recommend the program (4.89) and felt confident in coaching skills (4.22). Residents valued that the program, “.... helped me collaborate to make student driven goals” and learned that “... the role of a coach does not have to be all encompassing, but can be specific to the type of coach that you are serving for the student”.

DISCUSSION / REFLECTION / LESSONS LEARNED: The Resident as Coaches program has successfully created a more structured approach to near-peer coaching for medical students seeking to matriculate into an Internal Medicine residency. Although both students and residents have exhibited enthusiasm, time remains a limited resource. Residents often have competing demands, and thus ensuring flexibility in the delivery of workshop content is an area of opportunity.

Areas of focus for next year include ensuring all of the interactive virtual sessions occur in the beginning of the year so that the residents feel well prepared for becoming successful coaches. The content will continue to be delivered virtually and recorded for those unable to attend. Additionally, the medical students will receive instruction on the role of the coach to optimize the coaching relationship.

SET UP FOR SUCCESS: THE FUNDAMENTALS OF PERSONAL FINANCE - WORKSHOPS BY AND FOR MEDICAL TRAINEES

Elizabeth Batista

Internal Medicine-Pediatrics, Mount Sinai Health System, New York, NY. (Control ID #3877326)

SETTING AND PARTICIPANTS: We delivered a three-part series of interactive noon-conference workshops to small groups (10-20 per session) of Internal medicine and pediatric residents.

DESCRIPTION: Personal finance is a crucial topic for long-term financial wellness. Many medical professionals incur significant educational debt, experience delays in earnings due to extended training and perceive little time to focus on finances relative to clinical work. Despite this need there are very few curricula on personal finance for medical trainees, and none designed by current trainees. Based on personal experience of current trainees in an academic health center we developed a series targeted on the knowledge and skills needs of trainees with minimal exposure to formal financial education. We aimed to introduce the basics of personal finance as part of a longitudinal curriculum early on in training, discuss the importance of learning about this topic to ensure better financial practices down the line and provide trainees with basic but necessary information to position themselves to be in the best financial position under their respective circumstances. We delivered the series as part of a noon conference series, with each interactive session lasting 50 minutes. Topics included setting goals, making a budget, managing recurring payments, debt management, emergency funds and “tips and tricks to reduce expenses and increase income.” Facilitators included current trainees with thorough knowledge on the topic and the ability to tie in applicable examples from the perspective of current trainees, including Public Service Loan Forgiveness (PSLF), board preparation and licensing costs and housing.

EVALUATION: Evaluation data include pre and post surveys as well as post-series feedback surveys.

DISCUSSION / REFLECTION / LESSONS LEARNED: We designed and delivered an interactive three part series focused on the foundations of personal finance and debt management as it relates to medical trainees. To our knowledge this is the first such session designed by and for medical trainees. In creating and disseminating the information we found the importance of assessing the baseline knowledge trainees have on the topic of personal finance to develop the most well rounded presentation. Beyond the allotted time given for presentations we recognize the importance of one-on-one or small group discussions to coach individuals on better practices given their specific situation. This individualized coaching component highlights the need for more individualized personal finance support built formally into training programs. Next steps include formal evaluation of financial knowledge and skills gained through this series and scaling the sessions up to include trainees from specialties outside of Internal Medicine and Pediatrics.

THE UTILIZATION OF ETHICAL SITUATIONAL SCENARIOS IN A GROUP SETTING DURING INTERNAL MEDICINE RESIDENCY RECRUITMENT INTERVIEWS

Melissa A. Rusli, Keisha Ellis, Luis Daniel Lugo

Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #3855674)

SETTING AND PARTICIPANTS: Lakeland Regional Health (LRH) is a tertiary care medical center in Central Florida. The Internal Medicine residency program received initial accreditation and is recruiting for the first class of PGY-1 residents during the 2022-2034 Residency cycle. ~350 residency candidates are scheduled to interview virtually. Virtual group interview sessions consist of 5 applicants. The sessions are solely led by two faculty moderators, often-times led by both concurrently, to ensure consistent and calibrated moderator practices and evaluation of candidates.

DESCRIPTION: The shift toward virtual interviews in the wake of the COVID-19 pandemic has provided barriers concerning some unstructured components of the residency interview experience, such as the observation of applicant interactions with peers in a group setting. As a newly ACGME accredited Internal Medicine program, a trait that the LRH recruitment committee prioritizes for the inaugural class of residents is the ability to communicate well in a team-oriented environment. In addition to incorporating other well- accepted interview day best practices, we decided to implement a group interview session, in which five candidates talk through 3-5 scenarios they may encounter during their residency experience. The AAMC, in their Interview Guidance for the 2022-2023 Residency Cycle recommended the use of a group interview setting for the virtual interviews; however, we have not heard of many other residency programs executing a similar experience. "Thalamus," a third-party platform, was utilized for all virtual interview days.

EVALUATION: Multiple forms of evaluation will be used to assess this novel interview activity. (1) Applicant performance scores: Applicants are evaluated on a 1-10 numeric scale based on their level of participation, interaction with peer applicants, and quality and appropriateness of their responses to match the program's cultural fit. (2) Anonymous post-interview day surveys by applicants: Applicants can anonymously submit their perspectives of the interview day. These evaluations are optional and do not influence their overall recruitment score. (3) Group session scores compared to the program's final overall rank list of candidates. (4) Group session scores compared to final matched residents.

DISCUSSION / REFLECTION / LESSONS LEARNED: Faculty moderators and applicants have well- received group interview sessions. These sessions allow one to get to know each applicant during the interview day in ways that may not have been captured during the one-on-one interview. For example, applicants that lead conversation vs. follow groupthink, applicants who are not afraid to disagree with a peer's opinion, and applicants that help peers experiencing technical issues. By sharing our experience with group interview sessions, we hope to capture a more accurate and holistic view of our applicants and determine whether those characteristics fit LRH's work culture.

UNDERSTANDING HOW MEDICAL STUDENTS EXPERIENCE A PROFESSIONAL IDENTITY FORMATION (PIF) CURRICULUM

Lisa Altshuler²; Elizabeth L. Wargo¹; Linda Tewksbury²; Adina Kalet³; Lynn Buckvar-Keltz²

¹General Internal Medicine, New York University Grossman School of Medicine, New York, NY; ²Medicine, NYU Langone Health, New York, NY; ³Kern Institute, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3872233)

SETTING AND PARTICIPANTS: Third and fourth year medical students at a Mid-Atlantic medical school.

DESCRIPTION: Professional Identity Formation (PIF) is a developmental process that occurs during transition from medical student to physician. Objectives of the PIF Curriculum are to teach students the process of PIF, identify the interplay between professional behavior and identity, and facilitate recognition of challenges in managing personal and professional identity. The curriculum includes Professional Identity Essays (PIEs) completed at 3 time-points, workshops, role modeling, and individual coaching. In this qualitative improvement study, we sought to understand how M3 and M4 students think about their professional identity and experience the PIF Curriculum at a Mid-Atlantic medical school.

EVALUATION: Two researchers conducted 15 semi-structured interviews via Zoom to investigate the impact of and students’ experience with the PIF Curriculum. Interviews were framed to express medical educators’ interest in understanding how to better support students as they develop their professional identity. Questions focused on the development of their own professional identity, PIF Curriculum, and curriculum improvement suggestions. Three readers independently conducted a thematic analysis and met to clarify findings.

Participants understand their professional identity to be an individual learning experience that accelerates during clinical immersion in Clerkship year. Students are exposed to near-peer and more experienced physicians in clinical environments which allows them to reflect on values they would like to assume and behaviors they would like to emulate. Participants discussed the varying impact of the PIF Curriculum. Some medical students valued the structured time allocated for reflection, while others found it stressful given competing pressures to demonstrate performance. As PIEs require students to reflect thoughtfully about their professional identity, the activity was seen as both welcoming and uncomfortable, depending on the student and timing. Participants reported that the PIE questions plant the seeds to reflect on their PIF and provide the framework to deepen future reflections. Several participants also cited the value of the small group, interactive workshops using cases of unprofessional behavior. Suggestions for improving the curriculum included providing PIF activities that utilize discussion-based formats.

DISCUSSION / REFLECTION / LESSONS LEARNED: PIF is influenced by both formal and informal curricula and experiences. While some participants recalled the PIEs as less valuable due to the stress of competing demands, many recollected the usefulness of the exercise as it provides the structure and language to reflect on their professional identity. Suggestions for curriculum improvement focused on providing more engaging activities that connect related to ongoing experiences on clinical rotations. Overall, participants viewed the PIF Curriculum as a fundamental foundation to guide their professional identity development.

USING THE PROFESSIONAL IDENTITY ESSAY TO PROMOTE DEVELOPMENT IN INTERNAL MEDICINE RESIDENTS

Kathlyn E. Fletcher^1,2; Devarati Syam³; Alicia Pilarski^3,4; Amy H. Farkas⁵

¹Internal Medicine and Kern Institute, Medical College of Wisconsin, Milwaukee, WI; ²VA Milwaukee Healthcare System, Milwaukee, WI; ³Kern Institute, Medical College of Wisconsin, Milwaukee, WI; ⁴Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI; ⁵General Internal Medicine, Medical College of Wiscponsin, Milwaukee, WI. (Control ID #3869824)

SETTING AND PARTICIPANTS: A large urban internal medicine residency program. Internal medicine residents, including categorical internal medicine (PGY1s and PGY2s), medicine-pediatrics (PGY1s and PGY2s) and preliminary year interns (PGY1s).

DESCRIPTION: Professional identity development is based on theories of young adult development such as identity, cognitive, and moral development. The Professional Identity Essay (PIE) has been validated as a method for assessing medical student development but its use has not been reported in residents. The PIE is comprised of 6 essay questions and is formally analyzed resulting in a score that corresponds to a stage between being an “Independent Operator” at Stage 2 through being a “Self-transforming Professional” at Stage 5.

In an effort to address a gap in our professional development curriculum and to incorporate more self- reflection, we decided to utilize the PIE. During protected academic time, we delivered a talk about professional identity development and introduced the PIE. For PGY1s this occurred at the beginning of internship and for PGY2s in the middle of the academic year. After the presentations residents were emailed a link and encouraged to complete the PIE on their own time. The PIEs were analyzed by a trained team led by an educational psychologist off site and each resident received their PIE report as part of their semi-annual evaluation with program leadership. Faculty were also provided with education on how to facilitate discussion about the PIE and the PIE report during these meetings.

EVALUATION: In total we had 69 residents complete the PIE out of a total of 82 residents. For this analysis 31 PGY1s and 24 PGY2s gave consent to participate (67% response rate). The PGY1s had a mean PIE score of 3.67 (SD 0.28). One was at a level 3, 14 at level 3.5 and 9 at level 4 (7 did not provide enough text to reliably assign a score). The PGY2s had a mean score of 3.37 (SD 0.37). Eight were at a level 3, 8 were at 3.5 and 3 were at 4 (5 did not provide enough text). Although not formally evaluated, some residents found the process of doing the PIE and reflecting on it helpful. For example, one described the questions as helpful for preparing for fellowship interviews and another thought the reflection helped clarify her view of an ideal physician.

DISCUSSION / REFLECTION / LESSONS LEARNED: The PIE is a validated resource for reflecting on professional identity development, although its use in residents is not described. Initially, our program had some discomfort discussing the PIE reports with our trainees. However, through faculty development we have grown in our ability to have meaningful discussions with our trainees assisted by the PIE report. Several residents did not provide enough text for analysis. Going forward we hope to address this in our introduction to professional development and the PIE report. We plan to continue assessments at the beginning and middle of residency.

WELL-BEING MINI-AWARDS: PROMOTING INTERDEPARTMENTAL CONNECTIONS AMONG TRAINEES

Amy H. Farkas¹; Kathlyn E. Fletcher^2,1; Alicia Pilarski¹; Devarati Syam¹

¹Kern Institute and General Internal Medicine, Medical College of Wiscponsin, Milwaukee, WI; ²Internal Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3874422)

SETTING AND PARTICIPANTS: Residents and fellows from multiple departments at one academic medical center taking part in a variety of interdepartmental well-being events.

DESCRIPTION: Graduate Medical Education (GME) is often siloed, with the preponderance of educational and social events occurring exclusively within a single department. The actual work, however, often occurs across departments. The goal of this innovation was to increase social connectedness, cultivate professional relationships and improve collaboration and well-being across GME programs. In collaboration with our GME office, the Kern Institute GME Pillar designed a mini-awards program (up to $500 per project) to fund interdepartmental well-being events. The proposals had to 1) include a trainee organizer; 2) involve at least 2 different GME programs; and 3) broadly address well-being and social connection. Eleven proposals were funded, which included 12 different residency programs and 5 fellowships. Events included baseball tailgates, a bowling night, ongoing fitness gatherings, a tennis tournament, among others.

EVALUATION: Post-activity surveys were completed by the trainee organizer and attendees. The mean number of participants per event was 22 with a range of 7-35. All 10 (100%) of the organizers who responded to the survey reported a very positive impact of the event. 90% of the organizers reported a “very positive” impact of having another program involved, and 80% reported a “very positive” impact on the workplace climate. 77% of attendees reported the event help build community between programs and 88% indicated that the event had a very positive impact on their personal well-being. Free text comments demonstrated the impact on social connectedness and the work environment. “I now know every Maternal Fetal Medicine fellow by name. This is important as we interact in high-stress high-reward delivery room situations where communication is key.” “We have been able to create an environment of improved collegiality especially in a time of a very stressed system.” As evidence of continued impact, this academic year 16 proposals were submitted, and we were able to fund 11 new well-being mini grants.

DISCUSSION / REFLECTION / LESSONS LEARNED: A small investment resulted in creative events and impactful interactions across programs. Those who attended found the events to improve relationships and well-being which was the objective of this program. Particularly after COVID-19 with increased isolation, stress, and burnout among medical trainees, it is critical to promote social connectedness, well- being, and professional relationships. The literature suggests that knowing our colleagues and strong personal relationships can improve workplace collaboration that is critical to promoting patient care. We plan to continue this program and find ways to demonstrate the impact of this intervention on longer term outcomes such as well-being and networks.

Innovation in Medical Education (IME) - Curriculum Development- CME

COACHING NEW HOSPITALISTS: IMPROVING SKILLS IN CLINICAL AND DELIBERATE PRACTICE

Nancy Choi, Nicole Curatola, Sandra Martinez-Oreper

Hospital Medicine , University of California San Francisco, San Francisco, CA. (Control ID #3874944)

SETTING AND PARTICIPANTS: At the main site of an academic tertiary care center (UCSF), all faculty in their first year in the Division of Hospital Medicine (2021-2022) were enrolled as the inaugural cohort of the Clinical Coaching Program (CCP). These 25 faculty were hospitalists with an academic career interest, and they participated as “coachees”, each paired with one of the five coaches (mid to senior-level faculty).

DESCRIPTION: CCP was created in 2021 in response to junior faculty interest in receiving clinical feedback as well as recent literature describing inferior patient outcomes for first year faculty. The transition from residency to early-career hospitalist is abrupt and ends the structured clinical feedback in the residency training model. CCP was developed to ease this transition and aimed to support, assess, and improve multiple facets of hospitalist clinical skills.

Coaches attended a skill-development workshop that explored their new coaching identity and built frameworks for reviewing cases and developing lifelong learning habits.

CCP provided the following layers of clinical coaching encounters:

1. Year-round availability for any clinical questions or challenges

2. Scheduled check-ins (via phone, in-person, zoom) to review real-time cases and challenges at least once during or immediately after each clinical block

3. Coachee Development Meeting quarterly focused on deliberate practice (reflection, growth, goals) and review of individual quality performance metrics

EVALUATION: CCP during November 2021 - October 2022 is currently being evaluated with a three-fold method:

1. Coachee pre- and post-program survey assessing needs and clinical skills confidence ratings. Preliminary data post-1-year survey shows strong agreement that this program improved skills in reflection, managing diagnostic uncertainty, and navigating challenging patient interactions; additionally that coaching has led to at least one change in clinical management, developed new habits for clinical work, and fostered a stronger sense of community in the division.

2. Coach surveys at 6-month intervals assessing confidence and personal/professional satisfaction with this new role

3. Coaches logged entries of primary clinical themes during clinical coaching encounters. Of 239 entries, the most common themes included: Diagnostic Accuracy/Uncertainty, Clinical Management Change, Assessing Readiness for Discharge, and Emotional Support/Strategies

DISCUSSION / REFLECTION / LESSONS LEARNED: In its first year, CCP is novel in its longitudinal relationship focused on developing new hospitalists in clinical skills, reflection, and habits, and it has demonstrated the immense benefits of a coaching relationship for both coachees and their coaches. Encounter entries reflect unique challenges for first-year hospitalists spanning a wide range of themes. Preliminary results offer insight for ways medicine programs can target faculty development for new faculty to improve both patient care and the physician experience.

DEVELOPMENT, DISSEMINATION, AND EVALUATION OF A VIRTUAL CME TO PROMOTE HEALTH AND VACCINE ACCESS, UPTAKE, AND CONFIDENCE FOR PATIENTS WITH I/DD Emily Hotez¹; Julianna Rava¹; Alice Kuo²

¹David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA; ²Medicine-Pediatrics, UCLA, Los Angeles, CA. (Control ID #3868135)

SETTING AND PARTICIPANTS: This presentation outlines our blueprint for a virtual CME targeting U.S. family medicine physicians, internal medicine and hospitalist physicians, and physicians in other internal medicine subspecialties. The course will be offered in 2023.

DESCRIPTION: People with I/DD, including individuals with ADHD, autism, developmental delays, and/or intellectual impairment, comprise between 1 and 2% of the U.S. population. During the pandemic, this population demonstrated more severe illness, greater risk of hospitalization, and almost twice the case fatality rates. There are opportunities in medical education to address health disparities for the I/DD population during and post-pandemic.

In the current presentation, we present our blueprint for a virtual CME course titled, “Promoting Vaccine Access, Uptake, and Confidence for Neurodivergent Patients,” funded by the Association of University Centers on Disabilities and the Centers for Disease Control and Prevention and supported by the UCLA Office of Continuing Medical Education and Medical Education Fellowship.

The course will include three modules: (1) The Experiences (addressing stigma and social determinants of the health through lived experience case studies); (2) The Facts (highlighting strategies for health-promotion and vaccine uptake for the I/DD population); and (3) Spreading the Word (enhancing public health communication).

EVALUATION: The learning obectives are: To gain knowledge and competence and improve performance and patient outcomes related to: (1) Factors that affect vaccine uptake/access/confidence, including the role of: a) stigma/bias and b) social determinants of health; (2) Strategies for: a) increasing adherence to virus mitigation strategies; b) promoting vaccine confidence / reducing vaccine hesitancy; and c) Creating a culture of neurodiversity; and (3) Becoming an effective inclusive public health communicator by a) improving the accessibility; and b) ensuring messages reflect the needs, experiences, and perspectives of the target population.

We will assess knowledge and competence for each learning objective pre- and post-CME. Participants will also participate in a 3-month follow-up survey to assess performance and patient outcomes. Participant feedback will be assessed throughout the full course to identify opportunities for improvement.

DISCUSSION / REFLECTION / LESSONS LEARNED: We will discuss the process of developing course content in collaboration with interdisciplinary healthcare providers and individuals with I/DD and their families. We will reflect on the acceptability and feasibility of the course, as well as the preliminary effectiveness of the course in addressing learning objectives. The course will be discussed in light of other educational and healthcare initiatives that seek to promote vaccine access, uptake, and confidence in the I/DD community.

MAKING FEEDBACK SMART AND LEARNER CENTERED: A WORKSHOP FOR CLINICAL SUPERVISORS

Kelly A. Kieffer^1,2; Brianna Ambrus³; David Haughey¹; Shane Greene¹

¹Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH; ²Medicine, Dartmouth College Geisel School of Medicine, Hanover, NH; ³White River Junction VA Medical Center, White River Junction, VT. (Control ID #3873376)

SETTING AND PARTICIPANTS: Hospital medicine and critical care faculty at an academic medical center.

DESCRIPTION: Residents are often dissatisfied with the quality of feedback they receive. We developed a two part interactive faculty workshop adapting the SMART (Specific, Measurable, Achievable, Realistic, Timely) mnemonic for goal setting to a tool for giving feedback.

In the first session (workshop A), we reviewed data on resident satisfaction with feedback, discussed evidence based tips for feedback delivery, and introduced the SMART tool. Facilitators enacted a bedside interaction between a faculty member and resident, and moderated a discussion regarding giving feedback to the resident. Participants role played a second scenario in small groups and debriefed with the full group.

The second session (workshop B) involved situations in which a learner’s emotional state made giving feedback challenging. After a brief didactic, participants role played scenarios in groups of three: one acting as a resident, one as a faculty member, and the third observing. Participants rotated roles in three scenarios, debriefing between role plays. Facilitators reviewed key take aways after the final debrief. We delivered the workshops during weekly faculty meetings of hospital medicine and critical care faculty.

EVALUATION: 18 hospitalists participated in workshop A and 11 in workshop B. We did not record attendance at the critical care sessions; a minimum of 11 critical care faculty participated in workshop A and 8 in workshop B based on pre- and post-workshop survey responses.

Participants were asked to anonymously submit responses to the prompts “I know how to give feedback” and “I feel confident in my ability to provide effective feedback to residents” at the beginning and end of each session. Response options were Strongly Disagree (1), Disagree (2), Agree (3), and Strongly Agree (4). For workshop A, the mean knowledge score increased from 2.6 prior to the workshop to 3.0 after (p=0.013), and the mean confidence score increased from 2.4 to 3.0 (p=0.0005). For workshop B, the mean knowledge score increased from 3.5 to 3.6 (p=0.35) and the mean confidence score increased from 2.6 to 3.2 (p=0.002). Aggregate evaluation scores of faculty feedback were not statistically different 4 months after the workshops compared to baseline, though this analysis is limited by temporal factors and insufficient power; assessment of this outcome over a longer time period is ongoing.

DISCUSSION / REFLECTION / LESSONS LEARNED: This two part workshop incorporating an easy to recall, outcomes oriented mnemonic and attention to learner factors led to increased self-assessed knowledge and confidence in providing feedback. The in-person, small group format allowed for authentic role playing and robust debriefing sessions that enhanced peer-to-peer teaching. Role play triads included a mixture of junior and senior faculty, providing opportunities for senior faculty to share experience and junior faculty to add the perspective of individuals more recently in the trainee role.

MINI-FELLOWSHIP FACULTY DEVELOPMENT TRAINING FOR PRIMARY CARE PROVIDERS

Yael Mauer¹; Amy Zack²; Kimberly Giuliano⁴; Andrea Sikon³

¹Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, OH; ²Family Medicine, Cleveland Clinic, Cleveland, OH; ³Dept. of Internal Medicine & Geriatrics, Cleveland Clinic, Cleveland, OH; ⁴Pediatrics, Cleveland Clinic, Cleveland, OH. (Control ID #3870741)

SETTING AND PARTICIPANTS: Primary care staff from Internal Medicine, Family Medicine, Pediatrics, and Geriatrics in an academic medical center in the Mid-West

DESCRIPTION: Primary care providers in our institution were surveyed regarding their interest in participating in a Mini-Fellowship faculty development program, as well as learning areas of interest. Topics of high interest and specialty access shortage (long waiting times) were selected. Three Mini Fellowships were offered, consecutively: Behavioral Health (pediatric and adult tracks), Caring for LGBTQ+ Population, and Dermatology. A Women’s Health Mini-Fellowship and an Endocrinology in Primary Care Mini- Fellowship are scheduled to take place in 2023. Primary care providers at our institution were invited to participate in each Mini-Fellowship program, a few months before it was offered. 15-20 participants were randomly selected from each applicant pool (considerations were taken to avoid selecting multiple providers from the same site and to extend invitations evenly throughout the different departments). Mini-Fellowships were conducted virtually for 2 hours a week, for a total of 10-16 sessions. Each session took place over 30 minutes of personal time (730-8 am) and 90 minutes of protected time (8-930 am, clinic was blocked). The dermatology Mini-Fellowship included a hands on workshop of procedural skills (suturing, biopsy, etc). Participants were allowed a maximum of 10-11 sessions of protected time. CME credits were offered. There were no participation fees and speakers were not monetarily compensated (schedules were also blocked to allow for teaching). Lecturers included specialists at our institution and 1 external specialist.

EVALUATION: Participants were asked to complete an anonymous survey for each session they attended, regarding knowledge, relevance, and value, as well as practice impact. Responses were highly positive, indicating participants perceived the lectures as informational, relevant, and impactful. A subsequent survey, several months after the completion of each fellowship, regarding utilization of knowledge gained, is planned.

DISCUSSION / REFLECTION / LESSONS LEARNED: Mini-Fellowships provide an opportunity for primary care staff members to expand their knowledge and skillset, as well as earn CME. They also improve patient access, for instance, by allowing primary providers to offer simple and moderately complex dermatology care to patients unable to see a dermatologist for several months due to access shortage. Mini- fellowships also promote physician satisfaction and wellbeing by allowing staff to take time off to develop professionally, improving their skill repertoire, and fostering professional connections and networking within our large institution. They also promote the satisfaction of the lecturers who are able to take time off to teach and network, while performing a scholarly activity. Mini-Fellowships also promote patient satisfaction by improving healthcare access and minimizing costs (obviating specialist co-pay fees and wait times).

NEW FRONTIERS IN DIGITAL MEDICAL EDUCATION: IMPACT OF THE CURBSIDERS TEACH PODCAST

Irina (Era) Kryzhanovskaya¹; Charlotte Chaiklin³; Andrew Delaat⁵; Frances V. Ue²; Molly Heublein⁴

¹Medicine, University of California San Francisco, San Francisco, CA; ²Internal Medicine, Cambridge Health Alliance, Cambridge, MA; ³University of Florida, Gainesville, FL; ⁴Department of General Internal Medicine, UCSF, San Francisco, CA; ⁵Liberty University College of Osteopathic Medicine, Lynchburg, VA. (Control ID #3877023)

SETTING AND PARTICIPANTS: Asynchronous learning in the digital medical education space for health professions educators

DESCRIPTION: Podcasts have become integral in medical education (Kelly 2022). As a result of the Covid-19 pandemic and the growth of social media, learners, clinician educators, and training programs have adopted podcasting into their arsenal of teaching modalities (Berk 2020). Few podcasts are aimed at continuing education for health professions educators; thus, the Curbsiders Teach podcast was developed as a free, open-access, digital resource.

EVALUATION: We analyzed descriptive data from media hosts Audioboom and Apple podcasts which included number of plays and downloads per episode and location. In a convenience sample of 11 episodes from season one (from 23 total episodes in two seasons), continuing medical education (CME) data was analyzed including: the professional role of listeners, perceived impact of the podcast, teaching quality, and real-world application of the content. 23 podcast episodes were created for the mini-series, and they were downloaded >82,000 times between 12/14/21-12/11/2022. All episodes offered free CME for listeners. Of the 38,221 plays from season one, 1,137 individuals completed CME questionnaires. Most individuals identified as practicing physicians (62%), and the remainder of listeners identified as NP/PAs (19%), or RN/LPN /Pharmacist/Student/Others (19%). The majority (70%) of listeners were either in internal medicine or family medicine specialties, followed by occupational therapy (14%), surgery (5%), and pediatrics (3% for both medicine-pediatrics and pediatrics). Listeners were from around the world and >18 countries represented, with most from the US, Canada, and Australia. Real-world application and impact was further analyzed for 5 episodes with 76% of listeners reporting that the content was relevant to their professional role, 97% noted the episodes’ teaching quality was “just right,” and 73% highlighted that the podcast affects their teamwork, clinical practice, and communication.

DISCUSSION / REFLECTION / LESSONS LEARNED: Curbsiders Teach podcast has developed a broad foundation of health professions education content with the mission of inspiring and improving the skills of educators worldwide. Descriptive and CME data support the far-reaching impact of Curbsiders Teach based on the location of listeners, the diverse roles and specialties, and high perceived impact and quality. Limitations may include bias related to self-reported data and unclear generalizability due to low percentage of listeners captured in the CME credit. Future directions include further quantifying and characterizing the impact on behaviors of educators and their clinical and instructional practices to determine the wide-ranging impact of the Curbsiders Teach podcast.

ONLINE RESOURCE URL: https://thecurbsiders.com/teach

References:

1) Kelly JM. PMID: 34935729.

2) Berk J. https://doi.org/10.1007/s11606-019-05606-2

TELEHEALTH SKILLS DEVELOPMENT COURSE FOR MEDICAL PROVIDERS: UPDATING SKILLS TODAY TO MEET THE PROMISE OF TOMORROW

Emily Cohen¹; Sarai Ambert-Pompey²; Shawn Braddock⁴; Janeen E. Smith³; Archana Sridhar

¹Clinical Resource Hub, Primary Care, Boise VA Medical Center, Boise, ID; ²Primary Care, Boise VA Medical Center, Boise, ID; ³Medicine, San Francisco VA Health Care System, San Francisco, CA; ⁴SimLEARN, VHA Central Office, Veterans Health Administration, Washington, DC, US, govt/health, Orlando, FL. (Control ID #3876644)

SETTING AND PARTICIPANTS: Primary care and urgent care providers may conduct virtual visits without formal and comprehensive telehealth training.

DESCRIPTION: We developed a facilitated virtual telehealth skills course for medical providers to conduct safe virtual patient encounters (for patients in non-clinic based settings) with non-inferior quality to an in- person visit. The 8 hour course consists of 3 modules. Each module is facilitated by a lead facilitator with additional facilitators in breakout rooms for smaller case discussions and hands-on practice. Simulated patient videos are used to demonstrate fundamental skills. Each participant practices a virtual assessment for a cardiopulmonary or upper respiratory, dermatology, gastrointestinal, genitourinary, and musculoskeletal concern. The course developers adapted the American Association of Medical Colleges (AAMC) telehealth competencies into a checklist that is used in the breakout rooms to guide the assessment of participants.

EVALUATION: The participants are required to complete a pre- and post-course survey with questions that address effective and safe engagement during virtual visits, adapting the in-person exam to the virtual setting, providing the same standard of care during a virtual visit as during an in-person visit, and time spent in hands-on practice during the course.

DISCUSSION / REFLECTION / LESSONS LEARNED: The course is taught by experienced telehealth providers representing the continuum of care: primary care, urgent care and hospital medicine. The course is offered jointly to beginner, intermediate and advanced telehealth providers, which may affect the flow of the breakout rooms. The survey data from the pilot course indicated that the participants’ self-perceived virtual care skills improved. Future evaluation data could include the percent of virtual visits as compared to in- person visits before and after the course. In addition, qualitative assessment of participant documentation of a virtual visit may reflect improved skills such as the use of patient generated data during a visit. Lastly, the AAMC telehealth competencies checklist was used to guide the assessment of each participant in the breakout rooms. With additional facilitators, this checklist could be used as a formal evaluation tool to provide each participant with individualized feedback on their performance during simulated virtual visits.

ONLINE RESOURCE URL: not applicable

TRANSFORMING THE MEDICAL EDUCATION JOURNAL CLUB TO INCREASE COLLABORATION AND ENGAGEMENT

Amy H. Farkas^1,2; Michael Braun²; Kristina Kaljo³; Lana M. Minshew²

¹General Internal Medicine, Medical College of Wiscponsin, Milwaukee, WI; ²Kern Institute, Medical College of Wisconsin, Milwaukee, WI; ³Ob/Gyn; Kern Institute, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3874417)

SETTING AND PARTICIPANTS: A monthly virtual medical education journal attended by faculty, trainees, and staff.

DESCRIPTION: Harnessing the accessibility of a now familiar online learning environment, we developed a virtual monthly medical education journal club to foster a community of practice. The goal of this new journal club was to address an institutional need for educators across professional ranks and expertise to collaboratively examine various research methodologies and means for scholarship. Like traditional journal clubs, we distributed the selected article in advance and encouraged registered participants to come prepared for discussion. One unique aspect of our virtual journal club is that we invite the author to facilitate the discussion. We ask the author to present 20 minutes of didactic content reviewing the article and lessons learned, then we spend the remaining time in discussion. We have covered a variety of topics including professional identify formation, EPAs, and medical education registries. The selected articles have highlighted diverse methodologies including the Delphi method, survey development, and qualitative analysis.

EVALUATION: For each monthly journal club we track attendance and ask participants to complete a brief electronic survey with both Likert-scale questions satisfaction and free text response questions to highlight strategies for application. Over the year, each journal club has attracted between 5-51 participants. As an indication of reach, we have attracted participants from other institutions. Satisfaction is high with 51.4% of participants rating it very effective and 43.2% rating it as effective. Participant insights can be grouped into two overarching themes: 1) community building, 2) application of knowledge. Statements drawn from the free text responses include the recognition to have “time to talk, interact”, “Being able to hear from the researcher about the project and ‘pick her brain’ about the implications”, and discovering “novel strategies to apply to medical education.”

DISCUSSION / REFLECTION / LESSONS LEARNED: Inviting authors to present their research and experiences in dissemination has resulted in critical discussions of educational scholarship and expanding an understanding of research methods. The virtual environment continues to be a benefit, allowing for author participation regardless of geographical location and inclusion of individuals across the medical education continuum, including trainees, staff and faculty. Participants are satisfied with journal club and the qualitative comments indicate the benefit of engagement with colleagues as well as the author. Notably, the free text comments highlight practical application of knowledge to research and the stimulation of new ideas. The next step includes an in-depth analysis of the longitudinal application of knowledge after participation and whether that stimulates increased scholarly dissemination.

Innovation in Medical Education (IME) - Curriculum Development- GME

AGENDA-SETTING IN THE PRIMARY CARE CLINIC: AN INTERACTIVE DIDACTIC SESSION FOR RESIDENTS

Nicholas S. Morgan

Internal Medicine, University of Colorado Health, Denver, CO. (Control ID #3876183)

SETTING AND PARTICIPANTS: Eleven internal medicine residents assigned to a common continuity clinic participated in an interactive didactic session during an outpatient rotation in a safety-net health system in the fall of 2022.

DESCRIPTION: The session focused on reviewing the definition, purpose, and process of agenda-setting and incorporated case-based simulations of outpatient visits allowing each resident to fill the role of physician and practice the skill. In addition, residents were surveyed at the end of clinic half-days both before and after participating in the didactic session to assess for a measurable reduction in frequency of last-minute concerns voiced by real patients.

EVALUATION: After completion of the session, residents rated their overall satisfaction with the session on a 5-point Liker scale. 100% of responding residents indicated they were satisfied or strongly satisfied with the session with 80% indicating they were strongly satisfied. In addition, the proportion of real patient visits with at least one patient concern identified by residents as "last-minute" decreased from 20% pre-session to 18% post-session.

DISCUSSION / REFLECTION / LESSONS LEARNED: Previous studies (1-3) have suggested that physicians' questions to elicit concerns not voiced by patients at the start of a clinic visit occur less than 40% of the time, so it is worthwhile to incorporate teaching of this skill into graduate medical education, and the satisfaction ratings in the present study suggest high overall buy-in from residents. The didactic session resulted in a modest decrease in the proportion of visits with at least one last-minute patient concern. A previous intervention (4) to increase use of agenda-setting by practicing physicians that featured multiple sessions over several weeks demonstrated a more robust decrease in the frequency of last-minute concerns. Further study could involve modeling this format in the context of graduate medical education.

1. Robinson JD, Tate A, Heritage J. Agenda-setting revisited: When and how do primary-care physicians solicit patients' additional concerns? Patient Educ Couns. 2016 May;99(5):718-23. doi:

10.1016/j.pec.2015.12.009. Epub 2015 Dec 21. PMID: 26733124.

2. Rey-Bellet S et al. Agenda Setting During Follow-Up Encounters in a University Primary Care Outpatient Clinic. Health Commun. 2017 Jun;32(6):714-720. doi: 10.1080/10410236.2016.1168003. Epub 2016 Jul 13. PMID: 27408954.

3. Singh Ospina N et al. Eliciting the Patient's Agenda- Secondary Analysis of Recorded Clinical Encounters.

J Gen Intern Med. 2019 Jan;34(1):36-40. doi: 10.1007/s11606-018-4540-5. Epub 2018 Jul 2. PMID:

29968051; PMCID: PMC6318197.

4. Brock DM et al. Effectiveness of intensive physician training in upfront agenda setting. J Gen Intern Med. 2011 Nov;26(11):1317-23. doi: 10.1007/s11606-011-1773-y. Epub 2011 Jul 7. PMID: 21735348; PMCID: PMC3208461.

A LONGITUDINAL COMMUNITY ORIENTED PRIMARY CARE CURRICULUM FOR INTERNAL MEDICINE TRAINEES

Gabriela Bernal, Ga Hee Kim, Tamara Goldberg

Internal Medicine, Mount Sinai Morningside Hospital, New York, NY. (Control ID #3876670)

SETTING AND PARTICIPANTS: Despite the importance of clinical-community partnerships in preventive healthcare, few internal medicine (IM) programs have integrated this topic into their curriculum. Our project aimed to facilitate a longitudinal community-based experience for our Primary Care Track residents by embedding dedicated service-learning sessions within their ambulatory schedule. Since our residents rotate at an urban Federally Qualified Health Center (FQHC) for their outpatient continuity practice, we collaborated with on-site community liaisons to build relationships with local community-based organizations (CBO’s).

DESCRIPTION: In July 2022, IM residency program leadership collaborated with FQHC site leadership to operationalize community-based opportunities for our residents. The outcome was a joint pilot initiative to incorporate one resident-led, CBO-based session during each two-week ambulatory block (6+ 2 schedule) between September 2022 and December 2022.

Each session included a PGY1, PGY2 and PGY3 resident and consisted of a 30 minute informational health topic review, followed by a 1 hour Q & A, and ending with real-time preventive service delivery (i.e. blood pressure checks, vaccine administration, etc.). Each resident team was assigned the topic 1-2 weeks in advance, and materials were reviewed by the Chief Resident and the Special Projects Coordinator.

EVALUATION: Pre-and post-intervention resident surveys were administered using a 5-point Likert agreement scale. Feedback from our CBO partners was also solicited. Over the study period, 100% (n=12) of the Primary Care Track residents participated in 13 community events across 5 CBO’s with an average number of 10 clients per session.

Survey response rate pre and post intervention was 100% (n= 12). To date, residents reported an increased understanding of how partnerships between healthcare organizations and CBO’s can address social needs (4.08 vs. 4.5. Additionally, residents felt more comfortable referring patients to local CBO’s ( 3.5 vs 4.41). Analysis of written feedback included common resident themes such as self- reported improvement in communication skills, improved sense of trust from the community, and increased patient access to health information. Additionally, common themes among CBO feedback were increased access to accurate medical information for clients and safe, non-judgemental space to discuss health concerns.

DISCUSSION / REFLECTION / LESSONS LEARNED: Results of this novel pilot curriculum suggest that a longitudinal community-based experience for Primary Care Track residents at an urban FQHC led to improved understanding of clinical-community partnerships and level of comfort referring patients to CBOs. Furthermore, CBOs benefited from having a space where their clients can freely and openly discuss their health concerns. Future steps to optimize the curriculum include an emphasis on physician training in use of plain language to optimize effective communication with clients.

AMBULATORY BOOTCAMP CURRICULUM DESIGNED FOR INTERNAL MEDICINE INTERNS

Purva Ranchal¹; Lindsay B. Demers²; Jennifer R. Siegel³

¹Internal Medicine, Boston University Medical Campus, Boston, MA; ²Medicine, Boston University, Boston, MA; ³Internal Medicine, Boston Medical Center, Boston, MA. (Control ID #3874877)

SETTING AND PARTICIPANTS: Primary care services contribute significantly to health equity, reduced healthcare costs, and healthier communities. However, medical schools provide inadequate exposure to ambulatory medicine leading to interns feeling unprepared as they step into the new role of primary care physicians. This study evaluates the role of a learner based ambulatory boot camp designed for Internal Medicine (IM) interns before they start ambulatory clinic. A total of 41 IM interns participated in bootcamp conducted during July 2021.

DESCRIPTION: At Boston University School of Medicine, we developed an IM ambulatory bootcamp curriculum for new interns using Kern's six step approach for curriculum development. Our curriculum covered a range of ambulatory workflow related topics with the goal of improving competency in primary care workflow, communication skills, professionalism, and time management skills. As a first step in developing the curriculum, we conducted a needs assessment by surveying current IM interns at Boston Medical Center (BMC) regarding the most relevant topics to include in the bootcamp curriculum. Using this approach, we were able to identify gaps in knowledge and competence that interns experienced during beginning of ambulatory clinic and develop an ambulatory bootcamp curriculum that is learner-focused and addresses the barriers and challenges interns experience at the beginning of a primary care rotation. At BUSM, there are four resident pods which rotate through clinic every 3 weeks (3+1 schedule). Bootcamp was conducted on day one of each clinic pod with the intention that interns get the opportunity to practice skills in the clinic for the rest of the week.

EVALUATION: We performed pre-bootcamp and post bootcamp survey to evaluate the curriculum using an anonymous, electronic survey sent to all participants through Qualtrics prior to the bootcamp and immediately after the bootcamp.

DISCUSSION / REFLECTION / LESSONS LEARNED: Overall response rate was 100%. We observed substantial improvement in both preparedness of working in clinic and competence in performing skills (p < 0.001). There was 100% improvement in understanding of clinic responsibilities and expectations. Studies have used residency preparatory courses to prepare interns for residency with complete focus on inpatient medicine. Our boot camp is focused on preparing IM interns for ambulatory medicine with most challenging workflow related topics. This study demonstrates that our learner focused ambulatory bootcamp is effective in training new interns and addressing most common workflow related challenges they face in beginning of ambulatory clinic.

AN AMBULATORY NOON REPORT SERIES: IMPROVING RESIDENT EXPOSURE, KNOWLEDGE, AND CONFIDENCE IN OUTPATIENT MEDICINE

Benjamin Depo¹; Halle G. Sobel¹; Emily Greenberger²

¹Internal Medicine, University of Vermont College of Medicine, Burlington, VT; ²Internal medicine, University of Vermont College of Medicine, Burlington, VT. (Control ID #3869127)

SETTING AND PARTICIPANTS: Academic Internal Medicine (IM) Residency Clinic at the University of Vermont (UVM). 33 residents participated

DESCRIPTION: The majority of IM training is focused on inpatient (IP) medicine, including service requirements and education. At the UVM IM residency program, noon report (NR) cases almost exclusively focused on IP cases before our curriculum and, thus, limited resident exposure to outpatient (OP) case discussions. Our goal was to develop an ambulatory NR to give residents and OP faculty opportunities to engage and discuss ambulatory cases. With this curriculum, we aim to improve resident knowledge and confidence in managing both common and complex OP medicine problems and increase exposure to our OP faculty. The curricular structure is as follows:

-PGY2 and PGY3 residents are assigned to present one ambulatory case per year during a clinic week, which they rotate through as firms every 5th week on a 4+1 block schedule.

-Residents select an OP case they experienced that illustrates a common or unusual diagnosis or a management dilemma.

-Residents work with a chief resident to identify and summarize teaching points to be presented during NR.

-Residents present the case to their firm and OP faculty, with dedicated pauses to build a broad differential diagnosis (DDx) and discuss key diagnostic and management aspects.

-Resident presenter summarizes their teaching points at the end of the case.

-At the start of the firm’s next NR (5 weeks later), the chief resident reviews a board prep multiple choice question related to the last case and summarizes the prior teaching points.

EVALUATION: The authors developed pre- and post-curriculum surveys in an iterative fashion. The surveys collected data using a 5-point Likert scale (1–strongly disagree, 5–strongly agree) on resident confidence, perceived medical knowledge, adequacy of training, clinical reasoning, DDx building, and healthcare systems issues, all in relation to OP medicine. The surveys were not validated. 33 residents were offered pre- and post-surveys. The pre-survey completion rate was 100%, the post-survey rate was 75.7%. Analysis of survey data revealed a statistically significant improvement in resident confidence (p= 0.003) and perceived medical knowledge (p=0.007) in the OP setting. Positive trends were noted in clinical reasoning, DDx building, and understanding of OP healthcare systems issues, but this data did not reach statistical significance. Qualitative feedback found that residents enjoyed the small group format, the blend of residents and faculty involved in case discussions, and the variety of cases.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our curriculum provides a structured approach to increase resident exposure to OP medicine case discussions. Our analysis indicates that the series has positively influenced residents perceived knowledge and confidence in providing ambulatory care. We aim to build on this first iteration to further improve our residency’s OP education experience and provide a framework for other IM programs to follow.

AN OPIOID USE DISORDER CONSULT SERVICE ELECTIVE FOR INTERNAL MEDICINE RESIDENTS

Mim Ari, John P. Murray, Sarah Dickson, George Weyer

Medicine, University of Chicago, Chicago, IL. (Control ID #3874016)

SETTING AND PARTICIPANTS: A 2-week inpatient Opioid Use Disorder (OUD) consult elective was developed for internal medicine (IM) residents. Eleven residents participated during the 2021-2022 academic year.

DESCRIPTION: Residents work in an apprentice model with an attending on the OUD consult service. The OUD consult service scope of practice includes comprehensive OUD assessments, recommendations on the use of medications for OUD and adjunctive medications for withdrawal management and long-term treatment, harm reduction interventions, and assisting in linkage to outpatient treatment. The OUD consult service sees 40-60 new consults monthly. An anonymous post-elective evaluation was created and distributed through REDCap at the end of the academic year, including questions assessing the degree to which learning objectives were met, clinical exposure to common consult scenarios, and attitudes towards patients with OUD.

EVALUATION: Nine of eleven (82% response rate) IM residents completed the evaluation. While all residents felt that they had received none or too little instruction in OUD prior to completing the elective, post-elective 78% (n=7) felt the level of instruction was just right and 89% (n=8) felt somewhat or very prepared to diagnose and treat OUD. All (n=9) residents agreed or strongly agreed they could take a substance use disorder (SUD) history, describe and use pharmacologic treatments for opioid withdrawal, describe harm reduction, and distinguish between stigmatizing and non-stigmatizing terms to discuss drug use. Almost all residents (n=8) felt comfortable using medications for OUD and distinguishing substance use from a SUD. Level of exposure to common clinical scenarios was deemed just right for evaluating and starting patients on MOUD (buprenorphine-100%, n=9; methadone-78%, n=7; buprenorphine through micro- induction-89%, n=8), and evaluating patients with acute pain and possible or confirmed OUD (78%, n=7). Questions aimed to capture attitudes towards patients with OUD revealed concern that patients with OUD are treated differently during hospitalization, but should receive treatment for opioid withdrawal and pain.

DISCUSSION / REFLECTION / LESSONS LEARNED: Developing effective clinical experiences for IM trainees is paramount to improve care for patients with SUDs. Aligned with the new ACGME requirement requiring all IM training programs to provide educational experiences in addiction medicine, this two-week elective experience on an OUD consult service was successful in meeting the elective’s learning objectives and providing clinical exposure to inpatient management of OUD. Elective refinements include facilitating non-hospital OUD experiences with community partners, a curriculum on stigma, more structured didactics and an expanded reading list, and offering this elective to other learners (psychiatry residents, medical students).

A NOVEL INPATIENT ROTATION IN HOSPITAL MEDICINE

Christopher Sankey^2,1; Anisha Advani¹

¹Yale New Haven Health System, New Haven, CT; ²Internal Medicine, Yale School of Medicine, New Haven, CT. (Control ID #3868852)

SETTING AND PARTICIPANTS: Hospital medicine (HM) is a frequently chosen career option for graduate medical trainees. Published data suggest residency graduates have knowledge and skill deficiencies upon arrival to HM positions. Additional data demonstrate that learners identify many challenges in transitioning from resident to attending roles. Apprenticeship models in which upper-level GME learners assume near-attending roles have been successful but are infrequently implemented. We developed a new inpatient rotation in inpatient medicine which is required for all PGY-3 learners in the Yale Traditional Internal Medicine Residency Program.

DESCRIPTION: The structure for this inpatient rotation is as follows. Day shift: 2 HM attendings paired with 2 PGY-3 learners without interns. Night shift: 1 PGY-3 and 1 PGY-1. All senior residents rotate through the day and/or night rotation. Patient handoffs between day and night teams occur via EMR (even for newly admitted patients overnight), and there are no formal walk rounds on daytime shift. The curriculum is informed by program-wide needs assessment based on published HM competencies, and housed via a centralized electronic platform (Microsoft Teams). There are weekly 60-90 minute interactive “skills labs” on POCUS, procedures, clinical deterioration simulation, and diagnostic reasoning. Attendings cover all floor patients during skills labs to protect learning. Education and support for use of EMR-based clinical pathways (CPs) are provided. Low-stakes feedback is obtained from unit nurses for both residents and attendings via a standardized tool.

EVALUATION: Subjective data being collected include resident experience, nursing experience, and resident self-assessments. Specific outcomes being tracked include the following patient-level metrics: 11 am discharge rate, length of stay, and readmissions. Learner-level metrics include EMR-based clinical pathway use, pre/post-rotation self-assessment regarding confidence in HM competencies, patient ownership scores using a validated tool, and written nursing feedback on resident interprofessional communication.

DISCUSSION / REFLECTION / LESSONS LEARNED: The strengths of this innovation include robust needs assessment data, real-time access to patient- and learner-level metrics, a well-defined group of learners, and a well-defined group of HM faculty supervisors. To date, collected data suggests that learners feel more comfortable dealing with uncertainty and leading an interdisciplinary team, and are more likely to use CPs on night shifts as compared to days. Limitations of the innovation include that at present it is restricted to a single nursing unit with impaired patient flow due to hospital volume and long-stay patients. While differences in institutions may not allow for en bloc transfer of this rotation structure, specific aspects of the rotation can be readily adopted as desired.

ONLINE RESOURCE URL: https://drive.google.com/drive/folders/1gPh550XXHSDOgONRPNtKD5tGFUl9nXR7?usp=sharing

A NOVEL OPPORTUNITY FOR URBAN-BASED IM RESIDENTS TO PRACTICE LONGITUDINAL RURAL PRIMARY CARE AT THE VA

Juliana Macri, Archana Sridhar

Department of General Internal Medicine, UCSF, San Francisco, CA. (Control ID #3875584)

SETTING AND PARTICIPANTS: A longitudinal rural primary care experience, using a blended model of telemedicine and periodic site visits, was created at a rural VA community-based outpatient clinic (CBOC) in the California/Hawaii region. The first year’s participants are two internal medicine residents at an urban academic medical center; supervising faculty are VA Clinical Resource Hub (CRH) PCPs with experience in rural care and telemedicine; and the patients are veterans at a rural VA CBOC.

DESCRIPTION: The well-documented crisis of rural primary care cannot be addressed without addressing the gap in rural medical education. Training experiences in rural primary care are positively correlated with future choice of rural practice, but few opportunities exist for this in urban GME programs. We sought to create a robust, immersive rural primary care training experience for trainees based at an urban academic medical center who otherwise may not be exposed firsthand to the growing crisis of rural healthcare access and widening health disparities between patients in rural and urban communities.

Trainees in our program become the PCP for a small panel of rural VA patients. One half day a week while on outpatient block they see their patients via telehealth modalities (video-to-clinic, video-to-home, or telephone). Quarterly, they make a two-day site visit to the rural CBOC to see their patients in person. Nursing and administrative staff in the CBOC provide on-site support for patient care, and faculty affiliated with the urban medical center provide resident teaching and supervision.

This blended approach allows trainees to have an immersive rural training experience within the often inflexible scheduling and geographical parameters of an urban academic training experience. The utilization of medical center resources and faculty to support this program reduces strain on chronically understaffed rural clinics.

EVALUATION: Participants complete a pre-survey, outlining their baseline interest and experience in primary care, rural medicine, and the VA. They are also asked about expectations and concerns for this elective. Upon completion, they will complete a post-survey. Other formative and evaluative activities may include: presentation of a case conference for peers, reflective writing exercises, and contributions to program sustainability.

DISCUSSION / REFLECTION / LESSONS LEARNED: The VA is a fertile launching ground for rural training opportunities given its strong telehealth infrastructure, experience serving as a training site, and geographical integration with rural CBOCs and the veterans those clinics serve. Success of this pilot longitudinal rural primary care experience has depended on utilization of telehealth, flexibility in the face of staffing challenges, and formative input from medical center and CBOC stakeholders. Our novel pilot program is a model that could be expanded within the VA nation-wide, thereby creating rural primary care training opportunities within urban academic centers where no such opportunities currently exist.

AN ULTRASOUND-GUIDED SIMULATION PROCEDURE CURRICULUM FOR INCOMING INTERNAL MEDICINE RESIDENTS WITH FOCUS ON THORACENTESIS, PARACENTESIS, CENTRAL VENOUS CATHETER PLACEMENT, AND LUMBAR PUNCTURE.

Enrique J. Rincon, Mark Terrell

Internal Medicine, Texas Health Resources, Arlington, TX. (Control ID #3875780)

SETTING AND PARTICIPANTS: During residents’ orientation, new residents take an ultrasound-guided procedure course in the simulation laboratory. The procedures are paracentesis, thoracentesis, central venous catheter placement, and lumbar puncture. The course consists of four-hour block for each procedure in two days. Every procedure has one hour of lecture learning, one hour for hands-on learning, one hour of hands-on practice/feedback, and one hour for final evaluation, including course evaluation.

DESCRIPTION: Goal 1. After a lecture and a demonstration video, the resident will illustrate basic ultrasound knobology. Goal 2. The residents will perform basic Internal Medicine (IM) procedures in the simulation laboratory under ultrasound guidance. Goal 3. The residents will be confident to apply simulation knowledge to live patients on basic IM procedures performance utilizing ultrasound guidance. Our curriculum teaches the simulation procedure skill, indication, contraindication, and consenting of the procedure. This the first time that an ultrasound guided procedure grades competency in the major procedures in Internal Medicine.

EVALUATION: In the simulation setting ,17 out of 20 residents feel confident or extremely confident to perform paracentesis, 18 out of 20 residents feel confident or extremely confident to perform lumbar puncture, 16 out of 20 residents feel confident or extremely confident to perform thoracentesis, and 17 out of 20 residents feel confident or extremely confident to perform central venous catheter placement. We create a Likert scale survey at the end of the course to identify if our objectives are achieved to residents' satisfaction. Our program evaluation data is collected after the course and input from the faculty focus group as well. In doing so, we create a new need assessment for subsequent planning.

DISCUSSION / REFLECTION / LESSONS LEARNED: Ultrasound-guided procedures simulation for incoming Internal Medicine residents is an innovative curriculum to teach novice residents new skills while preparing them to perform live procedures. Residents learn not only about the procedure skill, but they also learn the necessary ultrasound skills to identify anatomical parameters. The curriculum brings a golden opportunity to novice residents to master procedural skills with immediate faculty and peer feedback. The curriculum brings knowledge and confidence to residents who did not have previous ultrasound training. The curriculum aims to close the gap on ultrasound-guided procedures in the undergraduate medical education (US medical graduates and international medical graduates), and graduate medical education training. Our residents quickly adapt and embrace ultrasound-guided procedures at the bedside. Therefore, state-of-the-art technology is available to our residents preparing them to be the Internist of the future.

BATTLE IT OUT: A RESIDENT PANEL MANAGEMENT COMPETITION

Andrew D. Young, Eric Yudelevich, Stacey E. Jolly, Catherine Fleisher, Penali Noticewala. Internal Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #3874974)

SETTING AND PARTICIPANTS: Internal Medicine (IM) residents at a large academic medical center in the Midwest took part in this initiative starting in the 2020-2021 academic year. Over 100 residents participated in the project during their longitudinal continuity clinic (LCC) Y week. The residency program is divided into 5 groups called Frames and follows a 4+1 structure.

DESCRIPTION: Population health and quality improvement have become a priority for health systems over the last decade. With the aim of educating residents on the benefits of panel management in a fun experiential way, our ambulatory team began this engaging competition. While on their LCC week, residents received an hour-long interactive talk on population health including demonstration/instruction on how to review their individual patient panels with a primary focus on finding patients with uncontrolled hypertension (HTN) and Type 2 Diabetes Mellitus (T2DM).

PGY-1 residents were instructed to select one patient with uncontrolled T2DM and two patients with uncontrolled HTN while PGY-2 and PGY-3 residents selected two patients from each category to focus on throughout the upcoming months with the goal of having the patients’ chronic condition controlled. At the start of the project, residents were asked to send a confidential email to the project coordinators including the information for the patients they had selected.

Then over the next six months, residents received a variety of lectures during their LCC week on common chronic disease management. After the project concluded, residents completed a survey to provide the number of patients whose chronic condition was now controlled.

EVALUATION: Over 6 months, a group of 106 residents saw 90 and 108 patients gain control of their T2DM and HTN, respectively. The Frame that gained control over the greatest number of patients was highlighted and one resident randomly selected from that group won a prize. On a follow-up survey, 70% of residents found this project valuable, and wanted it to continue annually.

DISCUSSION / REFLECTION / LESSONS LEARNED: Quality metrics and panel management are changing the way that primary care physicians care for their patients. Our group found that many residents were unaware or unsure about strategies to manage their own patient panels and also not excited the topic or the prospect of doing so. However, with this fun experiential competition, residents were engaged with this activity and continued to utilize the panel management and clinical skills they learned during their LCC weeks. We just launched a third "season” for the current academic year.

BITE-SIZE PANEL MANAGEMENT PROJECTS TO ENGAGE RESIDENT LEARNERS

Mary C. Higgins-Chen¹; Christine Krueger²

¹Internal Medicine, Yale New Haven Health, New Haven, CT; ²General Internal Medicine, Yale School of Medicine, New Haven, CT. (Control ID #3877247)

SETTING AND PARTICIPANTS: This educational intervention was conducted with PGY3 residents at an academic medical center in New England where all residents have a continuity clinic and a 6+2 ambulatory schedule. Residents had received training in EMR-based analytic tools and the principles of QI work during their PGY2 year.

DESCRIPTION: Although panel management (PM) and quality improvement (QI) tools are readily available through the EMR, they have not consistently been used in our residency program. Engaging PGY3 residents in panel management work has presented a particular challenge as there is limited time for faculty oversight. Additionally, at this stage in training, residents have defined clinical interests and are planning diverse career paths, making a one-size fits all project challenging.

Thirteen PGY3 internal medicine residents had two 2-hour blocks of time during consecutive ambulatory weeks to conduct a small PM project of their choosing. The authors met with the residents on each ambulatory block for 30 minutes to discuss the project. Residents were instructed to use the remaining 1.5 hours to (1) use EMR-based analytic tools to identify a quality care gap and (2) begin a mini-PM project to try to close this gap. Residents were free to select any guideline-based care metric. After 1.5 hours, they were expected to email the authors the following: (1) Identification of a quality gap on their patient panel with current panel data, (2) Needs assessment, (3) AIM statement in SMART-goal format, and (4) Proposed intervention. The authors gave feedback via email.

The following week, residents had an additional 2-hour block to independently work on their intervention. Afterwards, they emailed the authors a summary of their progress in the project with next steps.

Four additional hours of time to work on their projects are planned for the spring.

EVALUATION: Of the 13 PGY3 residents given this assignment, all residents identified a quality gap and began work on QI intervention of their choosing on their patient panel.

Chosen quality metrics covered a diverse range of topics, such as improving lung cancer screening rates and discussing advanced care planning. Variable progress was made, with most residents using a combination of outreach to patients through MyChart, phone calls, and scheduling appointments. At this point, only anecdotal feedback has been collected, which has been mostly positive.

A brief survey to collect residents’ perceptions of the project is planned for the spring.

DISCUSSION / REFLECTION / LESSONS LEARNED: Although projects were small in scale, residents demonstrated their ability to independently use the EMR to identify care gaps and use a variety of outreach methods to improve patient care. Feedback has been positive thus far with one resident expressing that “it was actually kind of fun.” Other residents expressed frustration with additional workload during an already busy ambulatory block. It is unclear if all projects will reduce care gaps at this point.

BRINGING PRIMARY CARE TRAINING INTO THE HOME: A HOME VISIT CURRICULUM FOR INTERNAL MEDICINE RESIDENTS

Catherine R. Gordon²; Natalie C. Young¹; Radhika A. Ramanan³

¹Department of Medicine, Division of Palliative Medicine, University of California San Francisco School of Medicine, San Francisco, CA; ²Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA; ³Division of General Internal Medicine, University of California San Francisco School of Medicine, San

Francisco, CA. (Control ID #3874623)

SETTING AND PARTICIPANTS: A novel home visit curriculum was developed for primary care internal medicine residents at an academic training program in the California-Hawaii region.

DESCRIPTION: Many older adults have multimorbidity and functional limitations that make leaving the home challenging. A survey of this program’s residents found >90% of residents felt there was a need for geriatric-specific training, and 21% of residents felt their geriatric care skills were below average. In response, administrators developed a novel home visit curriculum for second- and third-year residents.

Learners participated in two half-day patient home visit sessions supervised by a geriatrician in a home-based care practice. During the first home visit, learners saw patients on the geriatrician’s panel and were guided through the process of conducting a home visit. Learners were encouraged to identify and schedule patients on their own panels for the second home visit. The curriculum included a mid-year didactic and reflection session that explored models of primary care delivery, reimbursement and sustainability of home-based care, patient characteristics suitable for home visits, and interprofessional communication with home-health agencies.

EVALUATION: A year-end learner survey was conducted. Qualitative exploration of learner attitudes towards home visits was conducted via thematic analysis of didactic session transcripts, in which learners reflected on their experience performing home visits.

DISCUSSION / REFLECTION / LESSONS LEARNED: The year-end survey indicated most learners found the home visit curriculum to be a valuable learning experience. Of learners who saw their own patients (8 of 15), 100% felt the home visit improved their understanding of the patient and how to partner in their care. During the mid-year small group, learners discussed social determinants of health, models of care and sustainability, home safety assessments, caregiving/social support, interprofessional collaboration, provider- patient relationships, care accessibility, medication review, care coordination, procedural training, and locations of care delivery. The educational value of this curriculum could be improved by increasing the percentage of learners completing home visits with their own patients. Learner-identified barriers to seeing their own patients included scheduling and administrative support, patient and provider discomfort, language discordance, and patients’ distance from clinic. Our goal is to expand on this work as this curriculum provides the valuable opportunity for patients not enrolled in a home-based care clinic to be seen by their primary care provider in their home, benefitting the patient and learner.

CALL FOR A FORMAL HOME VISIT RESIDENCY CURRICULUM TO ADDRESS COMPLEX SOCIAL DETERMINANTS OF HEALTH AND BARRIERS TO CARE: A PILOT

Yasmin Bains, Omair A. Syed, Leigh Ben-Zvy, Nicholas Nelson, Alejandro Díaz

Internal Medicine, Alameda Health System, Oakland, CA. (Control ID #3875235)

SETTING AND PARTICIPANTS: Home visits were conducted by residents at a community medical center in the California-Hawaii region.

DESCRIPTION: Home visits enhance resident learning about social determinants of health and build strong therapeutic alliances. Despite this, few home visit curriculums exist in internal medicine residency. Home visits at our residency program was founded in 2016 to provide direct patient-centered care for underserved communities. Currently, residents across all 3 years participate in the home visit program twice a year. Phase 2 focuses on creating a formal longitudinal home visit rotation for primary care residents in their second and third years.

EVALUATION: Currently, 56 residents select one or two patients for a home visit twice a year. Criteria for selection includes hospital discharge followup, clinic patients who have barriers to engaging in care and patients with complex chronic conditions. Residents are required to complete documentation which includes neighborhood walkability, transit and crime score and an “INHOMESSS” (Immobility, Nutrition, Home environment, Other people, Medications, Exam, Safety, Spirituality, Services) checklist. Residents submit a reflection after the visit.

For the phase 2 pilot, two residents in the primary care track dedicate time during ambulatory weeks for home visits and are supported by one medical assistant (MA). A template was built in the electronic health record system (Epic) for scheduling and to build a shared patient list. A workflow, including script, was developed for MAs. Residents identify patients for home visits based on selection criteria above and add them to the home visit list in Epic which the MA uses to schedule appointments. Residents complete documentation outlined above. Patients are staffed with attending and feedback is discussed with residents, MA and attendings to improve workflow.

In preparation for phase 2, we developed the workflow and Epic template build. In the trial period, we scheduled and completed 7 home visits using the new workflow. The primary reason for home visit included significant barriers to engaging in care (n=2), assessment of at least one INHOMESSS criteria in the setting of complex chronic conditions (n=3), post hospital follow-up (n=1) as well as a no show (n=1).

DISCUSSION / REFLECTION / LESSONS LEARNED: The pilot builds on our current home visit program. It helps identify/track patients who have home visit needs and provides robust longitudinal education for residents. Limitations include novelty of the program thus a small N, and time/resources for implementation. Future directions include refining workflow, quantitative/qualitative instruments for data and partnering with social workers, pharmacists and nurses to increase the number of visits and breadth of services provided in the home.

CAN A MULTIDISCIPLINARY VIRTUAL EDUCATIONAL SEMINAR CHANGE RESIDENT PHYSICIAN ATTITUDES AND REFERRAL PRACTICES TO COMPLEMENTARY AND INTEGRATIVE HEALTH?

Theresa H. Liao^1,2; Qian Leng^1,2; Alice S. Kehaya^1,2

¹Portland VA Medical Center, Portland, OR; ²Oregon Health & Science University, Portland, OR. (Control ID #3874064)

SETTING AND PARTICIPANTS: Oregon Health & Science University

All Internal Medicine (IM) residents

DESCRIPTION: Low back pain (LBP) is common, and its evidence-based management includes complementary and integrative health (CIH) approaches. Some patients, including diverse vulnerable populations, prefer CIH approaches. Considering CIH is necessary for evidence-informed, patient-centered, culturally responsive care. However, IM residents receive little training about CIH. A multi-disciplinary 105- minute virtual seminar was developed as part of the standing outpatient curriculum at a Northwest academic IM program, featuring multidisciplinary experts in yoga, acupuncture, mindfulness, chiropractic care and naturopathy. Evidence for CIH for LBP was reviewed, and multi-disciplinary CIH experts discussed practical considerations and answered questions. Residents completed brief, linked pre-and post-session surveys to help us assess their attitudes and consideration of CIH therapies.

EVALUATION: Nearly all IM residents attended the seminar (N=92), with 63 completing at least one survey and 27 completing both. The survey comprised 7 Likert scale questions (total range 7-35, higher indicates greater openness to CIH), and 3 qualitative questions soliciting opinions about barriers and facilitators to using CIH in practice. Responses were evaluated using the paired t-test and Cohen’s d effect size. Mean baseline score was 28 (N=38), increasing to 30 post- session (N=52). Among the 27 participants who completed both surveys, the mean increased by 2 points (95% CI 1.08-2.85, p=0.0001). Effect size was medium (Cohen’s d=0.5). Referrals to CIH therapies for each resident with VA continuity clinic were collected from the electronic health record for 3 months pre- and post-intervention. No change was seen when evaluating referral practices. 94% of respondents rated the activity as somewhat helpful to extremely helpful.

DISCUSSION / REFLECTION / LESSONS LEARNED: A virtual multi-disciplinary educational intervention introducing CIH for chronic LBP was well-received and demonstrated a statistically significant increase in residents’ openness to using CIH in clinical practice. Unsurprisingly, referral practices did not change, given additional factors such as complexity of referral process. This intervention is replicable, given growing availability of CIH subject matter experts at VA facilities now that several CIH approaches are covered as part of standard Veteran benefits. Limitations of our study included lack of a validated tool, lower survey response rates and occurring at a single center. Opportunities exist to streamline referral processes and further integrate CIH into IM education.

CAN YOU SEE MY SLIDES? A GUIDED FORMATIVE FEEDBACK PROGRAM FOR VIRTUAL TEACHING

Courtney E. Harris¹; Erik K. Alexander²; Jacob H. Johnson¹

¹Infectious Disease, Brigham and Women's Hospital, Boston, MA; ²Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA. (Control ID #3876056)

SETTING AND PARTICIPANTS: During the COVID-19 pandemic, virtual teaching was instrumental in preserving medical education of trainees. As a result, there is a growing need to help trainees improve their virtual presentations. To address this need, we designed a peer feedback program with infectious disease fellows using a formative feedback guide based on validated domains of virtual teaching.

DESCRIPTION: We previously designed an assessment tool for virtual teaching that predicted memorable lectures. In this study, we adapted this tool to a formative feedback guide. Fellows asked two peers to provide feedback, one “oral” (phone or in-person) or “written” (email), both using the guide. Post-feedback surveys were completed. Summary statistics were performed, and the Wilcoxon rank sum test was used to compare continuous variables.

EVALUATION: The formative feedback guide has 13 teaching domains, each with examples of optimal behaviors.

Sixteen fellows participated, and virtual feedback was given to 11 different infectious disease fellows who gave 30-minute presentations, with 91% of these getting feedback from 2 different peers. Baseline satisfaction (0-10) with prior feedback was low at 4.85 (IQR 3.3, 7.0). Self-assessed virtual teaching ability was also low at 4.95 (IQR 4, 6.7) compared to in-person at 6.05 (IQR 4.9, 7.0), p=0.2.

Presenters rated their session effectiveness, with a median score of 7.9 (IQR 6.45, 8.5). Peer's median score was 7.6 (IQR 6.8, 8.3), and their assessments did not differ significantly (p=0.82). Both presenters and peers rated the quality of the feedback received and given, with presenters perceiving higher quality feedback with a median score of 8.4 (IQR 7.5, 9.8) compared to peer's median score of their own feedback quality of 7.1 (6.3, 7.9), which was significantly different between groups (p=0.0048).

The presenter score of the quality of the feedback given by the peer was higher but did not differ significantly between those who gave written (median score 8.45, IQR 7.65, 9.95) versus oral (8.2, IQR 7.55, 9.1) feedback, p=0.62.

Nineteen of the 21 peer evaluators used the feedback guide and of those, 100% of participants rated “Strongly agree” or “Agree” when asked on a 4-point scale whether the guide was 1) easy to use, 2) improved their feedback, 3) would use the guide in the future, and 4) gave them ideas for future peer teaching strategies.

DISCUSSION / REFLECTION / LESSONS LEARNED: This study adds to the literature in 3 key areas: first, there is a clear need for feedback related explicitly to virtual teaching; second, a structured feedback guide can aid in highly perceived quality of feedback for virtual lectures; third, either written and oral feedback are useful mechanisms, and the easiest and timeliest method for feedback should be used to conduct peer feedback in graduate medical education.

CHALLENGING CONVERSATIONS 101: DEVELOPING AN INTRODUCTORY COMMUNICATION SKILLS WORKSHOP FOR FIRST-YEAR INTERNAL MEDICINE RESIDENTS

Sarah L. Floden, Andrew Coyle

Internal Medicine, University of Wisconsin System, Madison, WI. (Control ID #3875507)

SETTING AND PARTICIPANTS: A communication workshop was developed and delivered to 26 first- year internal medicine residents at an academic medical center in the Mid-West region.

DESCRIPTION: Our residency program received feedback from first-year residents stating they did not feel prepared to navigate challenging conversations with patients and their families, such as delivering difficult news or updating family members about the clinical status of their loved ones admitted to the intensive care unit. We assembled a multidisciplinary team including residents, chief residents, palliative care physicians, and general internists to create a workshop teaching foundational communication concepts, such as the "SPIKES" framework for delivering difficult news to patients and familes (set the scene, get patient's perspective, offer an invitation, share knowledge, summarize and strategize next steps). Concepts were reinforced via large group discussion, learner pair-and-share activities, and a demonstration between one of the course instructors and a trained simulated patient.

EVALUATION: Just prior to the workshop, residents completed an anonymous six-question survey regarding their previous exposure to communication strategies, familiarity with the SPIKES framework, and confidence in their ability to navigate difficult conversations with patients and their loved ones. Immediately following the workshop, residents completed a follow-up anonymous survey. This contained ten questions to reassess residents' confidence with navigating difficult conversations, as well as knowledge acquisition related to the SPIKES framework, whether residents felt the workshop should be continued in future years, and a free-text question inviting additional feedback.

DISCUSSION / REFLECTION / LESSONS LEARNED: Residents enjoyed the interactive components of the workshop and left the workshop with more confidence in their ability to engage in difficult conversations.

It was valuable to engage current residents, palliative care faculty, and general medicine faculty to create a session that is both engaging and clinically useful. Advanced communication skills are often considered a senior-resident level skill, however it was extremely meaningful to teach foundational communication concepts to first year residents. Not only can they use these skills when caring for patients, but they now have a foundation that can be built upon with future communication skill curricula as they progress throughout residency.

COMBATTING THE CRISIS: CREATION OF AN ADDICTION MEDICINE ELECTIVE FOR INTERNAL MEDICINE RESIDENTS

Kara M. Ryan, Alexis Vien

Weill Cornell Medicine, New York, NY. (Control ID #3848297)

SETTING AND PARTICIPANTS: Internal medicine residents at a Mid-Atlantic academic medical center DESCRIPTION: The addiction medicine elective is a voluntary two-week multimodal experience spanning inpatient, outpatient, and community settings to provide IM residents with a wide breadth of the care of patients with substance use disorders (SUDs). Two mornings per week are spent at the outpatient Medication for Addiction Treatment (MAT) Clinic. Learners also see patients at a hospital-associated methadone clinic. Additional community-based opportunities include visiting a syringe exchange and/or a local drug and alcohol rehabilitation. The rest of the learner’s time is spent on the inpatient addiction consult service with a multidisciplinary team of IM & psychiatry-trained attendings and addiction psychiatry fellows managing SUDs in inpatients. There are 4 in-person teaching sessions weekly and asynchronous learning via videos and podcasts.

EVALUATION: A 3-part survey assessing confidence, knowledge, and attitudes was administered immediately before and after the elective and at plus 3 months following completion of the elective.

DISCUSSION / REFLECTION / LESSONS LEARNED: In 2019, 20.4 million people aged 12+ had a SUD however, only 4.2 million received treatment. A survey of IM residents at Massachusetts General Hospital demonstrated that more than 60% felt unprepared to treat SUDs. Additionally, IM residents often have lower regard for patients with SUD than other diagnoses. The ACGME has begun responding to this gap recently. In July 2022, the ACGME specified addiction medicine as one of the subspecialities in which IM residents should demonstrate a level of expertise.

This multi-site and multimodal curriculum can be adopted by other IM programs who hope to enhance addiction medicine learning and provide residents the opportunity to engage with the community. Design of the elective is rooted in adult learning theory by creating a curriculum with flexible and diverse in-person clinical sites and asynchronous online experiences that allow residents to drive their learning. Based on similar research, we hypothesized that participation in this elective will provide an opportunity to gain knowledge and boost confidence treating SUDs, as well as improve attitudes toward individuals with SUDs.

Barriers to successful implementation include a lack of faculty with addiction experience and a lack of connections with community sites. However, addiction education is readily available through online resources to help train motivated faculty who can then teach trainees. Our experience has also been that community sites have also been eager to work with trainees and create partnerships for both teaching and referrals. There has been steady enrollment by IM residents since the elective's inception and initial informal feedback has been overwhelmingly positive, emphasizing its importance. After adequate enrollment of residents, we will analyze the pre and post surveys to formally evaluate the effect of the elective.

ONLINE RESOURCE URL: https://tinyurl.com/addictionmedicineelective

COMMUNITY HEALTH SEMINARS: ENHANCING RESIDENT HEALTH LITERACY EDUCATION THROUGH PUBLIC SPEAKING

Jayne Peterson. Medicine

The University of Arizona College of Medicine Phoenix, Phoenix, AZ. (Control ID #3847872)

SETTING AND PARTICIPANTS: Ambulatory Internal Medicine Resident PGY2

DESCRIPTION: Understanding community health needs is a key component of ACGME Milestone System Based Practice (SBP-2). Residents are taught to use teach back and to provide written materials at 6^th grade reading level to reinforce their one-on-one visit patient education, however, the literature shows that residents don’t always understand the extent of low health literacy in our communities. To enhance their medical education around community health literacy, curriculum was developed which provides our PGY2 residents the opportunity to present a medical topic to the patient community during their ambulatory rotation. These sessions educate our local community while assessing our Internal Medicine residents’ system-based practice, communication, and public-speaking skills. The learners choose the topic based on their own interests and previous audience topic ideas. Curriculum is provided on key public speaking skills and includes formative feedback on slides prior to the presentation. The health seminars were originally done in person but switched to virtual over the last few years. The audience often ask questions and provides immediate direct oral presenter feedback and a formal written evaluation.

EVALUATION: Curriculum assessment has been obtained through an end of rotation reflection on lessons learned. The qualitative data illustrates improvement in the following domains: 1. Presenting information in easily understandable, accessible patient centered manner 2. New techniques & public speaking presentation skills 3. Understanding the degree of community health literacy 4. Importance of providing time to clarify and answer patient questions

DISCUSSION / REFLECTION / LESSONS LEARNED: Community health seminars actively demonstrate health literacy in a meaningful way. Residents have provided over 30 monthly health seminars. Over time we have learned that patients want to hear information at a high physician level but presented in ways that they can understand and includes specific take home points. Residents often chose topics that correspond to their future career goals and can include the session in their curriculum vitae. Seminar topics range from "The Dangers & Benefits of Sun Exposure", "Medicinal teas", "Colorectal Cancer Screening", "Covid Vaccine FAQ", and "Importance of Physical Activity". Their assignment reflections indicate public speaking and community health literacy knowledge obtained from active participation in this activity. Originally these sessions when done in person were more highly attended but the virtual format allows for greater outreach into the community senior centers. We were also able to amplify the learning by incorporating first year medical students in the audience to observe the process as part of a capstone course. Main barriers has been widely advertising the health seminars and obtaining topics earlier than the start of the residents ambulatory month.

CURRICULUM DEVELOPMENT OF AN IMPROVISATION THEATER-BASED MOTIVATIONAL INTERVIEWING COURSE

Carolyn A. Chan¹; Kenneth L. Morford³; Steve Martino⁴; Donna Windish²; Peyton Cabaniss⁵; Andrés Martin⁶

¹General Internal Medicine, Yale School of Medicine, New Haven, CT; ²Internal Medicine, Yale University, Cheshire, CT; ³Internal Medicine, Yale University School of Medicine, New Haven, CT; ⁴Psychology, VA Connecticut Healthcare System, West Haven, CT; ⁵Yale University, New Haven, CT; ⁶Child Study Center, Yale University School of Medicine, New Haven, CT. (Control ID #3853594)

SETTING AND PARTICIPANTS: Internal medicine residents participated in a 6-hour course (3 sessions, 2 hours) using improvisational theater techniques to learn motivational interviewing (MI). Four resident cohorts participated. Thirty-nine residents completed at least two of the sessions.

DESCRIPTION: MI is a critical skill for internists to learn as they care for individuals with chronic diseases. Medical improv is the use of improv theater exercises to teach communication in healthcare. This is the first reported medical improv-based MI curriculum. The first 10 minutes of each session involved an overview of the session, while the other 110 minutes were spent performing improv exercises including instructions, experiential application with side coaching, and a debrief.

EVALUATION: A mixed-methods evaluation was used to assess the curriculum and included a post- curriculum survey, pre/post role-plays, and focus groups. The response rate for the post-curriculum survey was 58.3%. Individuals reported they were fairly or completely confident in applying the following MI skills pre vs. post the curriculum: respond to a patient’s argument against change (28.6% vs. 72.1%, p < 0.001), negotiate a plan for change (28.6% vs. 79.3%, p < 0.001), elicit change talk (21.4% vs. 85.7%, p < 0.001), provide information in an MI centric way (39.3% vs. 85.7%, p < 0.001) and apply at least 1 or more MI skill (35.7% vs. 92.9%, p < 0.001). Seven individuals (14.3%) participated in pre- and post-role plays. Post- intervention there was an increase in the number of individuals who met at least beginning proficiency in the global summary scores on the Motivational Interviewing Treatment Integrity score (MITI) (42.9% vs. 100%; p = 0.125). The percent of MI adherent behavior increased from 0%-62.5% to 50-100% post-course; p = 0.018, while the percent of MI non-adherent behavior decreased from 37.5%-100% pre-course to 0%-50% post-course; p = 0.018 in the post-course role plays.

Themes from focus groups to assess learning through improv included: deliberate practice and skill building, creates a zone of proximal development, non-medical scenarios reduce fear of peer judgment and frees residents from medical knowledge burden while learning new skills, builds relationships with colleagues, and a patient point of view enhances learning.

DISCUSSION / REFLECTION / LESSONS LEARNED: Medical improv is a novel teaching pedagogy that can be used to increase learner confidence in applying MI skills and achieving MI proficiency.

Qualitative data supports that improv provides deliberate practice, skill building, and non-medical improv scenarios contribute to the learning environment. We learned that a medical improv-based MI course is feasible, acceptable, and effective for teaching residents MI. Participants preferred smaller class sizes of 6-10 for optimal learning. Future studies should compare the effectiveness of a medical improv-based MI curriculum to other teaching strategies.

DEVELOPING A FORMALIZED INTERN-ATTENDING FEEDBACK PROCESS TO IMPROVE EDUCATION DURING CROSS COVER SHIFTS

Dorothy E. Loy¹; Kaitlyn McLeod¹; Natalie Longino¹; Kinnear Theobald²; Joshua Raines²; Christine D. Jones¹; Lauren McBeth³; Sarah Mann³; Julia Limes¹

¹Internal Medicine, University of Colorado, Denver, CO; ²Internal Medicine, VA Eastern Colorado Health Care System, Aurora, CO; ³Medicine/Hospital Medicine, University of Colorado, Aurora, CO. (Control ID #3877206)

SETTING AND PARTICIPANTS: In response to duty hour restrictions, night float schedules have become more common in graduate medical education. This has resulted in increased cross cover burden, decreased feedback, and less traditional formal education. At our institution, onsite nocturnists are available during cross cover shifts for decision making support but education remains a secondary focus. We sought to enhance education on cross cover shifts for interns in the University of Colorado Internal Medicine Residency Program (CU-IMRP) by creating a formalized feedback process. CU-IMRP interns cross cover internal medicine ward services at the Rocky Mountain Regional Veterans Affairs Medical Center and the University of Colorado Hospital. Interns at both sites were randomized by rotation block to control or intervention groups with the same number of shifts and interns in each group.

DESCRIPTION: Interns in the intervention group were asked to utilize a one-page form to guide discussion of three medical decisions with an attending nocturnist and to document the impact of the discussion on their clinical reasoning, systems knowledge, and medical knowledge. The control group had access to nocturnists as needed but not the structured form. Both groups were sent a post-survey to assess their perception of their clinical skills, confidence, and educational experience. Descriptive statistics were used in our preliminary analysis of the data.

EVALUATION: In total, 62 cross cover forms and 28 post-surveys were collected and analyzed from August through December 2022. After discussion with a nocturnist utilizing the standardized form, interns indicated that they changed their differential diagnosis and clinical management in 31% and 61% of cases, respectively. On the post-survey, 41% of interns in the intervention group felt the educational experience of cross cover shifts was very valuable compared to 18% in the control group. More interns in the intervention group reported they were very or somewhat confident in their cross cover skills after the week of cross cover (94% vs 64% in the intervention and control group respectively). There was no difference in the perceived level of autonomy between the intervention and control groups (82% of respondents in both groups felt it was “just the right amount of autonomy”) and 47% of interns in the intervention group versus 55% in the control group reported interacting with a nocturnist several times a week.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our data suggests that a structured feedback process for reviewing cross cover decisions with an attending nocturnist changes patient care, increases perceived educational value, and improves confidence on cross cover shifts without decreasing interns’ perceived autonomy.

DEVELOPMENT AND EVALUATION OF AN INTERACTIVE, CASE BASED LEARNING CURRICULUM ON ADDICTION MEDICINE FOR INTERNAL MEDICINE-PRIMARY CARE RESIDENTS

Eric Kutscher^2,1; Marco Barber Grossi^2,1; Melissa Chiang^2,1; Mat Kladney^2,1; Kathleen Hanley^2,1

¹Internal Medicine, NYU Langone Health, New York, NY; ²Internal Medicine, Bellevue Hospital Center, New York, NY. (Control ID #3874335)

SETTING AND PARTICIPANTS: Internal medicine-primary care interns (PGY1) at NYU Langone Health/Bellevue Hospital Center participated in an updated curriculum during a dedicated 2-week outpatient block focusing on addiction medicine training. A total of 8 interns completed the curriculum. DESCRIPTION: We reviewed qualitative and quantitative feedback from 2019-2021 on prior curricula and sessions during the Block on Addiction Medicine (last substantially updated in 2017) and noted a desire for more interactive learning, fewer traditional didactics, and coverage of a wider scope of addiction medicine beyond opioid and alcohol use. Using this feedback, we developed interactive sessions on harm reduction and bias, wrote clinical cases to cover essential topics in opioid use disorder and alcohol use disorder, and established an independent learning project for residents to teach each other about other drug classes. We prioritized community engagement with a site visit to a newly opened overdose prevention center and a patient conversation. Residents were provided with clinical experiences in addiction medicine, including participating in patient care during an addiction medicine clinic session, and integrating addiction skills into primary care visits.

EVALUATION: Residents were assessed for changes in attitudes and beliefs using the Medical Condition Regards Scale (MCRS). We also collected data related to resident satisfaction on each session and the overall curriculum.

DISCUSSION / REFLECTION / LESSONS LEARNED: All resident learners (N = 8) completed MCRS and satisfaction surveys. Overall attitudes towards individuals with substance use disorder improved among trainees, with total MCRS scores increasing from 37.5 to 53.3 (p <0.001) with largest changes around how “difficult” it is to work with patients with a substance use disorder, the satisfaction in providing care for this population, and the ability to help these individuals feel better. Resident learners rated the overall block as either “excellent” (7) or “above average” (1), with all residents rating each new aspect of the curriculum either excellent or above average. This pilot curriculum shows the feasibility and efficacy of interactive and case-based addiction medicine curricula for graduate medical education level trainees. Next steps including knowledge assessments of residents, assessing trainee skills with observed standardized clinical evaluations, and expanding the curriculum to the broader residency program to assess efficacy in a non-primary care cohort.

DEVELOPMENT OF AN INTERNAL MEDICINE RESIDENT CONTINUITY CLINIC AT A FEDERALLY QUALIFIED HEALTH CENTER SERVING A MAJORITY LATINO POPULATION FOCUSED ON UNDERSERVED MEDICINE AND HIV CARE.

Brian C. Hilgeman¹; Theodore MacKinney²; Amalia Lyons¹; Kathlyn E. Fletcher³

¹General medicine, Medical College of Wisconsin, Milwaukee, WI; ²GIM, Medical College of Wisconsin, Milwaukee, WI; ³Internal Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #3857398)

SETTING AND PARTICIPANTS: Providing opportunities for internal medicine residents to work within community health centers (CHC) serving Latinx and/or people living with HIV in a focused way is needed, but opportunities are not reported.

The Medical College of Wisconsin Internal Medicine Residency hosts 120 residents annually with a primary care track. Options to complete continuity clinic outside of the academic health system and Veterans Affairs clinic are limited.

The Sixteenth Street Community Health Centers (SSCHC) is a large CHC with 5 clinical sites around the greater Milwaukee area with 85% of the clinic population identifying as Hispanic, 70% best served in a language other than English, and 74% living under the federal poverty level. Two hundred and forty-one patients are part of the Ryan White HIV AIDS Program.

DESCRIPTION: A faculty member was contracted with SSCHC to serve half of their clinical time at SSCHC. Operational details were developed including templates, empanelment, EHR access, clinical space, and clinical support staff. Didactic and quality improvement experiences were developed to focus on areas unique to the SSCHC continuity clinic experience including discussions of caring for Latinx patients, community health centers, cultural humility and health equity.

Starting in July 2022, the MCW Internal Medicine Program chose 6 internal medicine residents to complete their weekly continuity clinic at SSCHC. Demand for the experience was greater than the program could support. Five of the 6 residents identify as Latino/a.

EVALUATION: Analysis of the intervention is planned. The impact upon the residency program in the recruitment of underrepresented in medicine (URM) students will be measured by pre/post enrollment of URM students into the program and self-reported interest in the program by URM students. Impact upon resident education will be assessed by comparing SSCHC vs. non-SSCHC resident interest and comfort in primary care, caring for non-English speaking, vulnerable and HIV populations as well as comparative responses on the Cultural Competency in Care Questionnaire. The impact on SSCHC will be measured via monitoring of empanelment and productivity of the faculty member and understanding satisfaction of medical and nursing leadership with the program.

DISCUSSION / REFLECTION / LESSONS LEARNED: This expansion serves an important need for the internal medicine GME community given significant gaps in educational opportunities that exist. This type of clinic is feasible through a strong collaborative relationship and has been found to have high interest among residents. Research is planned to understand the impact of this opportunity on recruitment of URM students, impact on resident education, and impact upon the community health center.

DEVELOPMENT OF A STRUCTURAL COMPETENCY, QUALITY IMPROVEMENT MORBIDITY AND MORTALITY

Maeve E. Ward¹; Lauren Shapiro²

¹Internal Medicine, Montefiore Medical Center, Bronx, NY; ²Medicine, Montefiore Medical Center, Bronx, NY, NY. (Control ID #3872127)

SETTING AND PARTICIPANTS: -Montefiore Medical Center; Bronx, New York

-Internal medicine residency morbidity and mortality (M&M) conference

-Attendees included internal medicine residents, interprofessional, and interdisciplinary colleagues DESCRIPTION: Traditional M&Ms focus on one provider’s cognitive error and can promote a culture of blame. In comparison, Quality Improvement (QI) M&Ms analyze the impact of systems on adverse patient outcomes. Consideration of structural competency in such an M&M has not been described. To address the need for resident curriculum in QI and structural competency, we developed a recurring, resident led, structural competency QI M&M. Our goal was to promote structural competency among conference attendees by explicitly examining structures and barriers that shape clinical interactions.

Each M&M analyzed one internal medicine adverse patient outcome resulting from systems errors. The conference was led by two internal medicine residents, and cases were selected from resident submissions. Conference attendees included internal medicine residents and relevant interdisciplinary and interprofessional colleagues, depending on the case.

The conference included a case presentation, large group completion of a fishbone diagram, and breakout groups who brainstormed then presented proposed solutions to the large group. The fishbone diagram separated root causes into the following categories: structural barriers, communication, teams, environment, and policies. Each root cause was examined by a separate breakout group focused on solution generation. The structural barriers group focused on factors such as provider/patient language discordance or insurance status.

EVALUATION: Attendees completed a pre (n=34) and post-M&M (n=21) survey designed to assess impact.

95% of survey completers were confident in their ability to identify how structural barriers contribute to adverse patient outcomes after the M&M, compared to 43% in pre-M&M surveys. After attending the conference, the percent of responders who were likely to identify and address a structural barrier in their care increased from 77% to 95% and 38% to 76%, respectively.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our results suggest that a QI M&M is an effective curriculum tool to educate healthcare providers on the interplay between structural barriers and adverse patient outcomes, thus improving their structural competency. If utilized by other residencies, this conference will help train the next generation of providers to address structural barriers, a skill critical to promoting health equity. In future conferences we plan to utilize a modified fishbone diagram that moves structural barriers to the “tail” of the fish, upstream of all other root cause categories. This diagram modification is designed to represent visually that structural barriers are upstream contributors to all other factors that contribute to adverse patient outcomes.

DIAGNOSTIC TIME-OUT: A CLINICAL REASONING HUDDLE TO IMPROVE DIAGNOSTIC SAFETY

Daniel A. Motta Calderon, Maureen Fausone, Peter Paik, Eduard E. Vasilevskis, Derek Pae, Chase J. Webber

Internal Medicine, Vanderbilt University Medical Center, Nashville, TN. (Control ID #3877098)

SETTING AND PARTICIPANTS: Hospitalists and internal medicine residents at an academic medical center in the southern United States.

DESCRIPTION: Based on literature review and expert discussion, we adapted a diagnostic time-out (DTO) initially developed by Garber et al to reflect the principles of problem representation and prioritization of a differential diagnosis. We discussed with residents and hospitalists, situations where reconsidering the diagnosis would be most helpful and compiled a list of trigger events to take a DTO. Using simulation and group thinking strategies, we developed an educational curriculum that we implemented during the night float rotation at a large internal medicine residency program. During the first night of a two-week rotation, residents and the night hospitalist are introduced to the DTO through an online video showcasing a simulated case [see video]. On the following nights, the hospitalist on call and residents meet to take a DTO for one patient admitted that night. The hospitalist provides direct, in-person feedback on clinical reasoning and the proposed plan. Following each rotation block, we surveyed participants’ perceptions of diagnostic uncertainty and intention to change practice after using the DTO using an electronic data capture tool. Survey questions were structured on a Likert scale. We calculated Cohen’s D effect size to compare perceptions before and after using the DTO. We are presenting preliminary data as of December 2022. We are continuing to collect data through June 2022.

EVALUATION: A total of 21 residents completed the DTO experience during a 4-month period. Survey response rate was 85%. Our preliminary data suggest that after learning and using the DTO during their night float rotation, residents were more likely to communicate diagnostic uncertainty to their patients (Cohen's D 0.63) and reach out to their supervising physicians when feeling uncertain of the diagnosis (Cohen's D 0.99).

The majority of residents (88%) expressed their intent to take a DTO in future high-risk situations for diagnostic error or high levels of uncertainty. Some reported limitations in using the DTO included time constraints when teams have a high workload burden and perceived lack of utility in low-complexity cases.

DISCUSSION / REFLECTION / LESSONS LEARNED: The DTO was found to be a useful tool to address diagnostic uncertainty and to potentially optimize clinical reasoning among house staff in situations at high-risk for diagnostic error. Additionally, we are developing a digital tool to prompt clinicians to take a DTO and then to document the outcome in the electronic health record.

ONLINE RESOURCE URL: Link to the simulation video used to train participants: https://youtu.be/3LuuxcvSkOU

END OF LIFE CONVERSATIONS IN THE ICU: IMPROVING RESIDENT COMFORT

Beret Fitzgerald¹; Yaa Asare¹; Kerry E. O'Connor²; Sarah Slaven¹; Mary Gay J. Marangola¹; Allison Wolfe²

¹Internal Medicine, University of Colorado, Denver, CO; ²Palliative Care, University of Colorado, Denver, CO. (Control ID #3872749)

SETTING AND PARTICIPANTS: Based on a needs assessment of internal medicine residents at the University of Colorado we found that most residents lead end-of-life (EOL) conversations in the intensive care unit (ICU) during their first year of training. However, less than half of residents had ever received training in EOL conversations, and only a third were comfortable leading them. Our novel curriculum is targeted EOL training for interns at the beginning of their ICU rotation. Palliative Care physicians lead 45- minute sessions where they teach structured approaches to EOL conversations, then provide real-time feedback to interns as they practice these techniques.

DESCRIPTION: End-of-life (EOL) care is an essential skill for physicians. Their approach to EOL conversations shapes how patients and families engage, process, and cope with making EOL care decisions. This is especially apparent when patients and families navigate complex decisions in the ICU, including transitions from life-prolonging interventions to comfort-focused care. Medicine residents play a key role in these conversations. However, there is significant variability in the education they receive on these important communication skills and our needs assessment identified that a significant proportion of residents are not prepared to lead these important conversations.

Our curriculum provides structured training on how to lead EOL conversations, with an approach to EOL care in the setting where interns are most likely to need those skills. On a rotation that is typically very time intensive, our curriculum proves that it is possible to implement additional teaching that has real-time application for interns in the ICU. Our early data suggests that a targeted approach to teaching EOL care is possible, with ongoing research to track how much focused intervention can shift resident skill and comfort level.

EVALUATION: We are tracking anonymous surveys regarding intern experience and comfort level leading EOL conversations and guiding EOL care. Initial pre-intervention data is similar to the results of our needs assessment. We are tracking post-intervention outcomes both immediately after the sessions and one month after our intervention to evaluate the short term and sustained impact of targeted teaching. Next steps include utilizing pre-and post-surveys to gather data that aids in refining our intervention and to determine how our curriculum improves intern comfort level when discussing EOL care.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our project demonstrates that it is feasible to create a curriculum that trains interns to lead EOL conversations and confirms that integration of targeted teaching into busy rotations is possible. This project also showed us the importance of buy-in from everyone involved in this training - residents, palliative care physicians, and ICU physicians.

ESCAPING TRADITIONAL DIDACTICS: IMPLEMENTING MEDICAL ESCAPE ROOMS FOR TEACHING, SKILLS-DEVELOPMENT, AND TEAM-BUILDING

Abhinav J. Appukutty, Anuj K. Chokshi, Marion Stanley, Debi Mitra

Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #3871906)

SETTING AND PARTICIPANTS: 65 PGY-1 Internal Medicine residents completed a medical escape room in two successive groups in Fall 2022 at an academic medical institution.

DESCRIPTION: Medical escape rooms involve completing a series of timed, medical- and puzzle-based challenges to obtain clues to ultimately solve, or “escape”, the room. It provides an exciting opportunity to step away from traditional didactics and instead deliver educational content by utilizing simulation, collaborative learning, and gamification. We created four parallel team-based, time-limited escape rooms in which groups of interns competed to finish 14 simulated activities involving diagnostic reasoning, procedural knowledge, lab interpretation, and workflow training. We utilized a before-after survey study to evaluate the activity and its effectiveness in promoting medical knowledge, teamwork skills, and team environment.

EVALUATION: Pre- and post-activity surveys were completed by 91% (59/65) of participants. 98% (58/59) agreed the activity was both fun and educational and would recommend this activity to other residents. 78% (28/36) of those who have done prior escape rooms rated this medical version as a better experience. Moreover, 93% (55/59) and 91% (52/57) rated this as very or extremely effective at promoting team-building and communication, respectively. In regard to medical knowledge, 98% (56/57) agreed they learned from their peers during the activity, while 95% (54/57) and 98% (56/57) recommended this curriculum as a way to acquire new and reinforce prior medical knowledge, respectively. In response to six questions that assessed the team environment (i.e., trust, understanding, cooperation, dependence, support, and attitude) of those in a single escape room, the average positive response of “strongly agree” improved from 61% pre-activity to 86% post-activity. Narrative feedback from participants was excellent. Multiple individuals suggested this curriculum was a highlight of their educational content and felt it would be a benefit for future learners in various settings.

DISCUSSION / REFLECTION / LESSONS LEARNED: Escape rooms as medical educational activities allow for simulation-based application and reinforcement of clinical knowledge while promoting interpersonal development and communication in a fun and engaging manner with relatively low cost. Our escape room was well received with survey data showing a potential impact on learning, team-building, and team environment. Given this positive feedback, we plan to leverage our escape room building experience towards creation of easily adaptable and scalable escape room templates. To-date, we have developed an implementation guide with a flow chart of established puzzles that could be translatable to a diverse range of medical knowledge learning points. We hope to study the utility and adaptability of this templated escape room in different educational settings and plan to assess if these escape rooms can improve medical knowledge acquisition and application.

ONLINE RESOURCE URL: bit.ly/escaperesources

EVALUATION OF AN INTERNAL MEDICINE RESIDENT CONTINUITY CLINIC TRANSFORMATION

Katherine Allen, Karen Kimel-Scott, Marcella Boynton, Darren DeWalt

Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC. (Control ID #3875076)

SETTING AND PARTICIPANTS: Internal medicine residents completed serial questionnaires about their continuity clinic experience.

DESCRIPTION: A core experience of internal medicine residency is the outpatient continuity clinic. Many programs have shifted to separate inpatient and outpatient experiences or an X+Y model which has disrupted continuity clinic schedules. The shift to X+Y has been beneficial to the well-being of resident physicians but has had negative effects on continuity with patients. During July of 2021, continuity clinic was transformed to improve the patient and resident experience. This involved creating 10 clinical teams where residents worked with the same attending and clinical staff on a consistent day of the week during their outpatient time.

EVALUATION: To study the changes made to continuity clinic, internal medicine residents were surveyed regarding their experience in continuity clinic. We conducted 3 waves of data collection: May 2021 (baseline), November 2021, and June 2022. There were approximately 90 residents in the program during the times that the survey was administered with an average response rate of 54%. Each item was scored on a 5-point Likert scale where 0 was the most negative response and 4 was the most positive response. We used multilevel modeling because of data non-independence and used time as a varying predictor.

Each of the following domains had statistically significant improvement from wave 1 to wave 3 with most improvement from wave 1 to wave 2: satisfaction with continuity clinic experience improved by 0.89 (p<0.001); satisfaction with continuity with attending preceptor improved by 1.81 (p<0.001); satisfaction with feedback on outpatient care improved by 0.44 (p=0.011); support with managing asynchronous care improved by 0.64 (p=0.013); and satisfaction with patients’ continuity improved by 0.68 (p<0.001).

A few domains improved mostly from wave 2 to wave 3: management of asynchronous care improved by 0.36 (p=0.036); comfort with workflow and processes in clinic improved by 0.50 (p=0.013); participation in QI for patient panels improved by 0.45 (p=0.019). We did not see improvement in ability to access interprofessional colleagues nor likelihood to pursue primary care.

DISCUSSION / REFLECTION / LESSONS LEARNED: Transformation of the continuity clinic successfully adapted to the X + Y schedule and substantially improved resident experience in our program. Clinic teams showed positive and statistically significant improvement in resident perceptions in the first 6 months of the change, and these changes were sustained or further improved at the 12-month mark. Some metrics improved later in the process reflecting ongoing maturity of the program.

EXPANDING SOCIAL DETERMINANTS OF HEALTH TRAINING IN RESIDENCY: A NOVEL RESIDENT-DESIGNED ACADEMIC ELECTIVE

Griffin Plattner, Ran Xu, Kevin Heaton, Jessica Zeidman, Rashmi Jasrasaria

Internal Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #3875200)

SETTING AND PARTICIPANTS: This curriculum was offered to Internal Medicine (IM) residents at an academic medical center in New England and took place in surrounding communities.

DESCRIPTION: This program was developed by IM residents in collaboration with clinical education faculty, physician leaders, and community partners. It provides two weeks of protected academic time and structured experiences to enhance individual education on Social Determinants of Health (SDH), promote community engagement, and foster peer-to-peer teaching that enhances SDH education in the larger residency curriculum. In the academic year 2022-2023, 12 total residents will participate over the course of six two-week blocks. The curriculum offers three key components:

- A modular schedule of community-based clinical and volunteer engagement based on specific resident

interest; options include participation with a mobile clinic, community partner programming, and patient home visits.

- Enhanced coordination with clinic-based integrated care management and community health workers.

- Development of an SDH or health equity focused academic deliverable that is presented at a residency-wide conference

EVALUATION: Evaluation of the elective includes qualitative feedback provided by participants at the end of each block and quantitative feedback collected through program-wide elective evaluation. Feedback on conferences produced during the elective is collected by structured focus groups for noon conferences. In addition to providing an immersive educational experience for participating residents, the elective serves as a source of educational content for the residency conference curriculum. Therefore the impact of the SDH elective will additionally be assessed through health equity focused questions that track the effectiveness of the larger Social Medicine Curriculum which are included in the intern orientation surveys and the residency- wide end-of-year survey.

DISCUSSION / REFLECTION / LESSONS LEARNED: Education on how SDH impacts health outcomes, the programs and resources available to promote health equity, and how to leverage these resources to reduce health disparities is a crucial element of residency training. This is reflected in ACGME guidelines and emphasized by resident sentiment.

Resident-led development of this initiative included collaboration with academic leadership and community partners, creation of a curriculum outline and learning objectives, and a pilot during flexible outpatient blocks during the 2021-2022 academic year. All available slots were filled for the 2022-2023 academic year. This elective represents a practical and reproducible model to promote community engagement and enhance SDH education. Furthermore, it represents a sustainable approach to promote scholarly work by residents in the field of health equity and incorporate these into a larger residency curriculum.

FEASIBILITY OF A PROCEDURE CLINIC-WITHIN-CLINIC FOR GENERAL INTERNAL MEDICINE TRAINEES

Alexis Tressor^2,1; Mindy Sobota^1,3

¹Division of General Internal Medicine, Brown, Providence, RI; ²Medicine, Rhode Island Hospital, Providence, RI; ³Medicine, Rhode Island Hospital, Providence, RI. (Control ID #3876586)

SETTING AND PARTICIPANTS: A large, urban resident/faculty primary care practice in New England. Patients are predominantly low-income, non-native English speakers, and insured by Medicaid and/or Medicare (10% uninsured), making referrals to orthopedics and gynecology challenging.

DESCRIPTION: Starting in 2015, we integrated a weekly half-day “procedures clinic” into our primary care practice to address unmet orthopedic and gynecologic clinical and educational needs. All providers at the clinic can refer patients, who typically obtain appointments within 2 weeks. Participants include all general internal medicine trainees (30 total PGY1-3), with session scheduling prioritized based on interest.

Additional trainees have included attending MDs, NPs, MS3s, and categorical track residents with particular interest.

EVALUATION: To understand the numbers and types of visits we provide for our trainees, we tabulated the number of sessions, residents and procedures and here report the data since January 2021 (there was a hiatus during the pandemic), with 80% of all session data tabulated. During this timeframe, a total of 40 trainees rotated through the procedure clinic. Participation by trainee ranged from 1-6 sessions over the studied time frame, with an average of 2 sessions/trainee (mode of 1). On average, 3 procedures were performed per session. Among the 181 procedures performed, the majority were musculoskeletal corticosteroid injections, with knee being most common (39%) followed by shoulder (33%) and trigger finger (12%). Gynecologic procedures performed or assisted by residents included IUD insertion/removal and contraceptive arm implant insertion/removal, comprising approximately 13% of procedures. There were a significant number of appointments which yielded evaluations of musculoskeletal issues without resulting injections, including shoulder, knee, back, elbow, wrist, and foot evaluations in addition to pelvic exams and PAP smears. Additional procedures included skin tag removal, de Quervain’s tenosynovitis corticosteroid injections, incision & drainage, and buprenorphine XL injections. Of note, 17% of all tabulated procedures were performed by 3 residents who participated most (in 4-6 sessions), indicating an appropriate increase in training towards those with greater interest.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our study shows that a dedicated procedure clinic built within a resident clinic is feasible and can expose residents to a variety of common primary care musculoskeletal and gynecologic procedures. Next steps include optimizing longitudinal trainee scheduling based on resident interest, ensuring appropriate logging of procedures by residents, and tracking to drill down into non-procedural and procedural competencies by resident.

ONLINE RESOURCE URL: https://docs.google.com/document/d/1VTdvxPKM31JlQmfdgm5cpJ1W9cZje_xg/edit?usp=sharing&ouid=110069894854190383412&rtpof=true&sd=true

FEASIBILITY OF FACILITATED CONVERSATIONS WITH COMMUNITY-BASED ORGANIZATIONS IN A PRIMARY CARE RESIDENCY CURRICULUM

Rex Tai, Erin Goss, Mary Gover

Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #3876799)

SETTING AND PARTICIPANTS: We held facilitated conversations among 2 community-based organizations (CBO), 2 design school partners, 10 residents and 2 faculty members in the Primary Care/Social Internal Medicine residency program at Montefiore Medical Center in the Bronx, NY.

DESCRIPTION: Gaps in trust and fractured engagement between physicians and the local communities they serve are widely reported. Structured opportunities for improving these relationships are difficult to develop and sustain, with physician-cited barriers of limited time and relevant expertise and community- expressed pereptions of medical paternalism. Collaboration between CBOs and healthcare is a means by which physicians can address local structural determinants of health. Open dialogue that allows each party to understand the other’s needs, priorities, and skills is essential to successful collaboration.

We studied the feasibility of including facilitated conversations between medical residents and CBOs in a primary care residency curriculum with the goal of sharing transdisciplinary perspectives. We reached out to 2 Bronx-based CBOs focused on environmental health and economic development, respectively. We also sought collaboration with a local graduate social design program to serve as a neutral 3rd-party facilitator with skills in promoting inter-community dialogue.

EVALUATION: We examined process measures around the feasibility of holding facilitated conversations between residents and CBOs. We began by identifying 2 suitable Bronx-based CBOs already engaged in health advocacy work for partnering in our residency curriculum. 1 CBO focused on environmental health, and 1 other focused on community economic development. Our 2 faculty members, 1 resident, and 2 design school partners prepared visual aids to assist in facilitation of community conversations initially around individual perspectives and approaches and in later meetings on identification of shared transdisciplinary goals. We held 3 facilitated discussions in the span of 7 weeks involving 10 residents and the 2 CBOs. After these conversations, all meeting participants provided feedback on the impact of the facilitated conversations on trust, enthusiasm, and reservations about the partnership and proposed projects.

DISCUSSION / REFLECTION / LESSONS LEARNED: The facilitated community conversations brought together resident physicians and CBOs with different skills and priorities toward identifying areas of common interest and opportunities for partnership. Each group expressed initial doubt in understanding the other’s perspective and finding time to design collaborative opportunities, but the facilitated conversation model provided an efficacious and concise framework to realizing these objectives in 3 brief sessions. These findings suggest that a community engagement curriculum in residency designed around structured community conversations has didactic benefit to residents and can bridge trust with CBOs. Future work should revolve around understanding the outcomes of resident and CBO partnerships.

HEALTH EQUITY AND TOMORROW'S PHYSICIANS: DEVELOPMENT OF HEALTH EQUITY CURRICULUM FOR A RESIDENCY PROGRAM

Jennifer H. Towbin²; Octavio A. Vega¹

¹Internal Medicine, Rush University Medical Center, Chicago, IL; ²Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #3875984)

SETTING AND PARTICIPANTS: Internal medicine residency program in an urban academic medical center. Each intake includes 5-8 medicine and med/peds residents per year.

DESCRIPTION: Education in Health Equity is a vital component in training tomorrow's physicians. In 2019, we created a track dedicated to understanding and addressing education in health equity. The objectives of the curriculum are to educate residents on system-based approaches to address health inequities and optimize patient care. We developed multimodal learning experiences including self-study and group didactics, journal clubs, and experiential learning, culminating in a research project. Participants are awarded one 2-week block of dedicated time in the 1st year and two, 2-week blocks in 2nd and 3rd years. Examples of curricular topics include Advocacy, Food insecuity, and LGBTQ+ gender affirming care. Group sessions are used to create conversation between presenter and learner to increase awareness and knowledge.

EVALUATION: Feedback via post-curricular session surveys and informal discussion has assisted in identifying opportunities for improvement. Pre and post track surveys are now being completed to quantify residents' understanding and comfort with health inequities.

DISCUSSION / REFLECTION / LESSONS LEARNED: Transitioning from hour-long group sessions run by track leaders to 3-hour sessions led by outside experts proved successful. It strengthened and enhanced residents' understanding of issues affecting our patients and community. Formalization of the 2-week experiential learning with community and global partners has augmented track participants' understanding of systems-based approaches through direct exposure and participation. Maintaining resident engagement across a 3-year span has been a challenge. Barriers have been competing demands on residents. Demands include clinical duties, personal responsibilities affecting evening meeting attendance, and work towards acceptance into fellowship taking priority. Additionally navigating return to in-person meetings, rather than virtual, in this post-COVID state has been challenging. Another difficulty identified has been the ability to take a research project from development of clinical question through to publication during a short 3-year residency.

Protected time from clinical duties from the residency program for track participants has proved to be essential for meaningful engagement and completion of track objectives. It would allow for deeper understanding of and experience in addressing the health inequities that affect our patients and clinical practice today and moving forward. We are currently partnering with the residency to optimize the balance between clinical duties and track participation. We are also working on identifying ongoing research questions/projects that are topically relevant so that completion of projects and number of publications will be higher.

ONLINE RESOURCE URL: www.rushu.rush.edu/education-and-training/graduate-medical-education/residency-programs/internal-medicine-residency/health-equity-track

IMPLEMENTATION AND ASSESSMENT OF AN INNOVATIVE AMBULATORY BOOTCAMP FOR INTERNAL MEDICINE INTERNS

Tanya Nikiforova¹; Jillian Kyle¹; Elizabeth Oczypok^2,1; Scott D. Rothenberger³; Christina M. Lalama³; Deborah DiNardo^2,1

¹Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ²Department of Medicine, VA Pittsburgh Healthcare System, Pittsburgh, PA; ³Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #3868128)

SETTING AND PARTICIPANTS: We developed, implemented, and evaluated an interactive case-based ambulatory medicine bootcamp for early year interns at a large, academic internal medicine (IM) residency program.

DESCRIPTION: Training in ambulatory medicine within IM residency is underemphasized and inadequate. There is some precedent for the use of an “ambulatory bootcamp” during intern year to introduce key outpatient topics, but whether this kind of training can have durable impact remains unknown. After conducting a literature review and needs assessment survey, we identified topics for inclusion in the bootcamp: COPD/asthma, cardiovascular disease prevention, hypertension, diabetes, and obesity. Thirty-six of 51 invited interns participated in the full-day bootcamp in fall 2021. We employed a multimodal educational approach to deliver the curriculum. Topics were presented as a 10-minute lecture followed by 40 minutes of case-based, small group discussions that were facilitated by faculty and utilized partially completed handouts.

EVALUATION: Four months after the bootcamp, interns completed a knowledge assessment containing 16 Medical Knowledge Self-Assessment Program (MKSAP) questions corresponding to topics covered in the bootcamp. We compared intervention intern knowledge scores with those of a historical control group of interns at the same timepoint during the prior academic year who participated in standard ambulatory education. Twenty-eight of 51 (55%) interns in the intervention group attended the bootcamp and completed the knowledge assessment. Thirty-six of 53 (68%) of control group interns completed the knowledge assessment. The mean assessment score was significantly higher in the intervention group than the control group (72.3% vs 65.6% correct, p<0.05), and significant knowledge improvements were seen in diabetes, hypertension, and obesity-specific questions (p<0.05). The training was well received with 100% of those completing post-training surveys rating the quality as very good to excellent.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our findings suggest that bootcamp training early during intern year can lead to durable improvements in knowledge regarding core ambulatory topics and that such trainings are well-received by residents. The bootcamp was easy to implement without supplemental funding but required protected time for faculty and residents. Our multimodal educational approach included active learning principles. By using a historical control, our findings suggest that an ambulatory bootcamp can complement and improve on standard ambulatory education. Future investigations should explore impact of such trainings on higher order trainee and patient-centered outcomes. This model can be easily adapted at other institutions seeking to improve residents’ knowledge of ambulatory medicine.

IMPLEMENTATION OF A CLINICAL RESEARCH CURRICULUM IN A COMMUNITY-BASED INTERNAL MEDICINE RESIDENCY PROGRAM

Katia El Jurdi, Khalil Choucair, K. J. Kallail, William J. Salyers Jr

Internal Medicine, University of Kansas School of Medicine Wichita, Wichita, KS. (Control ID #3871852)

SETTING AND PARTICIPANTS: Categorical internal medicine residents at a community medical center in the Midwest region participated in an optional 3-year clinical research curriculum (CRC).

DESCRIPTION: A pre-implementation survey reflected a high level of interest in clinical research in our residency program. We thus developed a structured CRC, to equip residents with the knowledge and skills required for clinical research.

The CRC was divided into 3 phases for each year of training. In the preparatory phase, interns identified a mentor and a research project, partook in carefully designed series of didactic lectures and workshops, and submitted a research proposal. The investigatory phase was designed for data collection and analysis. During the synthesis phase, residents finalize their research projects, present their findings to a committee, and submit a manuscript.

Didactic lectures involved: developing a research question, study design, populations and sampling methods, systematic literature review, the IRB process, meta-analysis, clinical trials and drug development, and biostatistics.

Residents filled out a pre-initiation survey upon signing up to the CRC, and a post-completion evaluation survey (post-survey) after completing year 1. In those, residents reported their confidence in tackling different elements of clinical research. Here, we present data from the preparatory phase.

EVALUATION: Ten residents enrolled in the CRC (80% male, mean age 28.5 years), and 9 completed the first year and the post-survey.

At the end of year 1, there was a 60%, 69%, 36%, and 28% increase in confidence in formulating a research question, conducting a literature review to answer clinical questions, designing a research plan, and interpreting results and drawing clinically relevant conclusions from a study, respectively. Compared to the pre-initiation survey, there was a12% increased confidence in performing biostatistical analyses of clinical data. Following the dedicated lecture, 59% more residents reported familiarity with the process of clinical trials and drug development. Overall, there was a 41% increase in confidence level across the different clinical research elements (p<0.001) by the end of year 1.

Overall, 89% of residents reported that the CRC has allowed them to conceive and design their research project and had a positive impact on their career development, and 77% would recommend the CRC to other residents. At the end of the preparatory phase, all residents had ≥1 publication (13 new publications).

DISCUSSION / REFLECTION / LESSONS LEARNED: Our results demonstrate the feasibility and impact of establishing a CRC in a community-based program. One year into the CRC, residents had a higher scholarly output and reported more confidence in different elements of research. The skills developed will provide them with the tools to conduct clinical research in their future careers, and to better understand and appraise scientific evidence to improve patient care during their training and beyond.

IMPLEMENTATION OF A HYBRID ONLINE AND SIMULATION EXPERIENCE CURRICULUM FOR MOTIVATIONAL INTERVIEWING

Jared P. Walsh²; Andrea Garroway³; Catherine Gracey¹

¹Medicine, University of Rochester Medical Center Department of Medicine, Rochester, NY; ²Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ; ³Psychiatry and Medicine, University of Rochester Medical Center, Rochester, NY. (Control ID #3875104)

SETTING AND PARTICIPANTS: The internal medicine (IM) resident ambulatory experience provides a half day of dedicated education time once a week during the ambulatory block for 76 residents at the University of Rochester School of Medicine and Dentistry. All IM residents completed the curriculum in 4 cohorts.

DESCRIPTION: Despite a national increase in support for training IM physicians in addiction medicine, the time dedicated to this lags behind other core topics. IM residents (IMR) and physicians report they feel unprepared in the pathophysiology and communication skills needed to treat addiction. To address this we provided communication skill training in motivational interviewing (MI) through online modules, which synthesized material from the MIA:STEP training tool with additional SAMHSA training matierals. The modules covered the Definition of MI, Spirit of MI, 4 Processes of MI, OARS, Sustain Talk v Change Talk, and Change Planning. Application of MI in an OUD patient encounter was evaluated utilizing a standardized patient (SP) experience observed live by 3 co-residents and a primary-care embedded behavioral health (BH) provider. IMR received feedback from co-residents and the BH provider. After feedback the next resident in the group would repeat the SP interview in a round-robin style, which allowed IMRs to learn from each other and respond to feedback. BH providers met to debrief the evaluations following the sessions.

EVALUATION: All IMR were evaluated by 4 BH team members via the MIA:STEP MI Rating Worksheet which evaluated competence in 16 MI domains. The BH provider debriefing session was then evaluated via a qualitative analysis utilizing Nvivo software. Themes identified: (1) IMR who completed the modules demonstrated true empathy and excellent reflections, (2) Almost no IMR felt comfortable addressing substance misuse (and most did not bring it up), (3) IMRs struggled to break out of the “I’m being evaluated” mentality, (4) IMRs felt uncomfortable engaging in counseling without developing a medical management plan, and (5) IMRs struggled with periods of silence. A resident self-assessment survey was administered after the session (N=38; 50% response rate). All participants reported the module was a worthwhile learning experience, content was delivered at an appropriate level of understanding, and the content will change the way they practice.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our evaluation shows that while IMRs can learn MI skills through a web module, there remain challenges to IMRs utilizing these skills in practice. Residents struggled to break out of the “fix the problem” mentality and instead adopt a longitudinal mindset for behavior change despite explicit permission to do so. IMRs exhibited concern for appearing inadequate if they presented “I just did counseling” to faculty preceptors. This finding suggests a strong need for faculty development to support this type of intervention in resident clinic. In addition, training is needed to achieve IMR comfort with addressing OUD during new patient visits.

IMPLEMENTATION OF AN ONLINE LEARNING MODULE CURRICULUM FOR OPIOID USE DISORDER

Jared P. Walsh²; Catherine Gracey¹

¹Medicine, University of Rochester Medical Center Department of Medicine, Rochester, NY; ²Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ. (Control ID #3875087)

SETTING AND PARTICIPANTS: The internal medicine (IM) resident ambulatory experience provides a half day of dedicated in-person education time once a week while on the ambulatory block for 76 residents at the University of Rochester School of Medicine and Dentistry. Here we report the results of a pilot trial with 7 IM residents.

DESCRIPTION: The elimination of waiver training for the buprenorphine X-license (30 patients), while highly beneficial for patient care, exacerbated a gap in training of IM physicians in the management of opioid use disorder (OUD). There is a need for an efficient, practical evidence-based training module for IM physicians on the management of OUD. To address this need, we developed interactive web modules in the practical management of buprenorphine. The modules synthesized information from a comprehensive literature review, training materials from a NIDA sponsored addiction training couse, and the SAMSHA Buprenorphine Quick Start Guide. IM physicians then applied this comprehensive foundation to interactive, online patient case scenarios that tested their ability to diagnose OUD and manage buprenorphine. This was combined with webmodule training in motivational interviewing (MI). Seven IM residents completed the training followed by a standardized patient interview to demonstrate application of skills to a patient encounter. Module topics: Disease of Addiction, Overview of OUD, Stigma, Pharmacology of Buprenorphine, Urine Toxicology Testing, OUD in Primary Care, Brief Training in MI, and Interactive Cases.

EVALUATION: We administered pre- and post-assessment surveys to assess learner knowledge of the management of OUD. This included 13 questions covering knowledge recall and application. The post- assessment included 3 Likert-scale questions (score 1-5, Strongly Disagree-Strongly Agree) to obtain feedback on the learning modules. All 7 IM residents in the pilot test completed the survey (100% response rate), which were analyzed utilizing paired t-test. Results: Pre-assessment survey: Mean 5.98/13 SD 1.95 and Post-Assessment Survey: Mean 9.41/13 SD 1.95 (p=0.0007). A 100% affirmative response was received for the feedback questions: “This activity was a worthwhile learning experience,” “The content was delivered at an appropriate level of understanding,” “This content will change the way I practice." All learners demonstrated competancy during standrdized patient interviews on both the OUD standardized patient checklist and the MI skill assessment (MIA-STEP rating tool).

DISCUSSION / REFLECTION / LESSONS LEARNED: The synthesis of data from multiple sources into online learning modules allowed residents to obtain a comprehensive foundation of knowledge for the management of OUD and the application of MI skills as demonstrated through a multiple choice test and a standardized patient interview. The next step is to deploy this to the full residency program followed by local practicing primary care physicians.

IMPLEMENTING A LONGITUDINAL CLINICAL REASONING CURRICULUM AND CASE CONFERENCE SERIES

Kirollos Roman¹; Carlie Stein²; Ryan Kraemer³

¹Internal Medicine-Pediatrics, UAB Hospital, Birmingham, AL; ²Medicine, UAB Hospital, Birmingham, AL; ³Medicine, UAB Hospital, Birmingham, AL. (Control ID #3874598)

SETTING AND PARTICIPANTS: Fifteen Internal Medicine-Pediatric residents and numerous clinical faculty participate in a longitudinal noon conference curriculum consisting of monthly one-hour sessions, both didactic and interactive, in addition to a resident-led case conference series.

DESCRIPTION: The didactic curriculum is comprised of four one-hour long sessions – the first two sessions provide a foundational familiarity with heuristics and the components of clinical reasoning, whereas the latter two introduce the role of cognitive bias in diagnostic errors and provide a debiasing framework. These skills are then applied in a monthly resident-led case conference series. Every 4-6 weeks, a PGY-2 or PGY-3 resident is tasked with presenting a clinical case in one of two proposed formats – a clinical problem- solving exercise demonstrating navigation and troubleshooting of the clinical reasoning process, or a “Cognitive M&M (morbidity and mortality)” exercise illustrating a cognitive error relating to the clinical reasoning process. Depending on the format selected by the resident, they are encouraged to generate their own diagnostic schemas and illness scripts, or analyze the variables and biases contributing to the cognitive error via a fishbone diagram.

EVALUATION: The evaluation process consists of a pre and post intervention survey comprised of 6 brief questions assessing resident confidence in the clinical reasoning process and its practical implications, as well as comfort in identifying and confronting cognitive biases. These questions utilize a likert scale of 1-5, with 1 indicating "strongly disagree" and 5 indicating "strongly agree". Tentatively, mid-curricular survey results have demonstrated an increase in each of the measured responses, with an average increase of 0.66 (a roughly 23% increase). Qualitatively, anonymous feedback has indicated that the curriculum "fills a gap in knowledge" and "has opened a space to talk about reasoning deficits in a safe space".

DISCUSSION / REFLECTION / LESSONS LEARNED: Implementation of a case conference series with intrinsic autonomy and creative freedom – in the form of multiple proposed formats – as well as incorporation of frequent breakout sessions and a distinct focus on cognitive skills has subjectively increased resident participation and qualitatively improved resident satisfaction. By empowering residents to process the foundational knowledge above and apply it in a case-based peer-teaching format, this serves to solidify their knowledge as well as grow their skills as clinician-educators. Finally, promoting vocalization of real- time clinical reasoning, with an explicit emphasis on the reasoning process more so than the diagnosis, in addition to implementation of a Cognitive M&M has fostered a culture of self-examination, intellectual vulnerability and cognitive feedback.

IMPLEMENTING AN AMBULATORY ADDICTION MEDICINE ROTATION TO MEET ACGME REQUIREMENTS: TRAINING TOMORROW'S INTERNISTS TO PROVIDE EQUITABLE CARE FOR THOSE WITH SUBSTANCE USE DISORDERS

Frances Norlock^1,2; Sarah Messmer³; Elisabeth A. Poorman⁵; Ena Mahapatra^4,2

¹Dept. of Medicine, Stroger Hospital of Cook County, Chicago, IL; ²Rush University Rush Medical College, Chicago, IL; ³Internal Medicine-Pediatrics, University of Illinois at Chicago, Chicago, IL; ⁴Internal Medicine, Stroger J Hosp of Cook County, Chicago, IL; ⁵Medicine, University of Illinois Chicago, Chicago, IL. (Control ID #3836837)

SETTING AND PARTICIPANTS: Starting July 2022, the Accreditation Council for Graduate Medical Education (ACGME) required internal medicine (IM) programs to provide structured clinical experiences in addiction medicine; and at least 10 months of outpatient training while minimizing conflicting inpatient and outpatient responsibilities. A 2-week Addiction Medicine rotation was developed with a focus of satisfying these 3 ACGME requirements for 45 residents per year. Each week residents were assigned 8 half-days of on- campus clinical and off-campus field experiences; 1 half-day working on a quality improvement project and self-study assignments; and 1 half-day of interactive workshops. Additional faculty included a multidisciplinary team of physicians, recovery coaches, harm reduction specialists, pharmacists, care coordinators, social workers, and mental health workers with expertise in caring for those with substance use disorders.

DESCRIPTION: Presenters will discuss the importance of building relationships with community organizations, allowing residents to learn about how to provide equitable substance use treatment in the communities they serve. The rotation emphasizes a harm reduction philosophy and reducing stigma for patients with substance use disorders, and help develop medical professionals to improve equity in caring for this vulnerable population of patients. Residents are exposed to different levels of care in substance use disorder treatment, including low barrier outpatient programs, intensive outpatient, street outreach harm reduction initiatives, medically supervised withdrawal management, peer support groups and residential treatment. Barriers in curriculum development and resolutions to those barriers will be reviewed. The health system’s safe-opioid prescribing guidelines, including how to safely taper opioids if indicated, as well as a variety of self-study assignments, are also part of the rotation’s curriculum. A required quality improvement project focused on decreasing the risk of opioid overdose among continuity clinic patients, by increasing the rate of naloxone availability will be discussed.

EVALUATION: Common themes based on 35 residents’ experiences during the Addiction Medicine rotation will be made available by the time of the meeting through qualitative analysis of rotation evaluations completed by the residents. To date residents have overwhelmingly given positive feedback regarding acquiring new skills of communication and patient care, as well as medical knowlege learned about SUD and harm reduction.

DISCUSSION / REFLECTION / LESSONS LEARNED: Caring for patients with SUD is complex, requiring a harm reduction approach, low barrier outpatient programs and collaboration with interdisciplinary colleagues to provide high-quality treatment for vulnerable populations. Teaching residents the skills to provide equitable, stigma-free care not only provides immediate benefits for patients seen during the rotation, and may create a cascade effect in how trainees approach patient care in subsequent rotations.

IMPLEMENTING AN AMBULATORY POPULATION HEALTH ROTATION TO MEET ACGME REQUIREMENTS: TRAINING TOMORROW'S INTERNISTS TO PROVIDE EQUITABLE CARE FOR VULNERABLE POPULATIONS

Frances Norlock^2,1; Ena Mahapatra^2,1; Axi Patel²; Hafeez Shaka²; Marie Jennifer Seares²; Kimberly Dixon²

¹Medicine, Rush University Medical Center, Chicago, IL; ²Medicine, Cook County Health, Chicago, IL. (Control ID #3858919)

SETTING AND PARTICIPANTS: Starting July 2022, the Accreditation Council for Graduate Medical Education (ACGME) required internal medicine (IM) programs to provide training in population health, and at least 10 months of clinical training in the outpatient setting while minimizing conflicting inpatient and outpatient responsibilities. A Population Health rotation was developed to satisfy these requirements for 45 residents per year. Each week residents were assigned 8 half-days of on-campus clinical experiences; 1 half- day working on a quality improvement project; and 1 half-day of interactive workshops and self-study assignments. Additional faculty included a multidisciplinary team of physicians, a registered dietician, registered nurses, a healthy lungs specialist, care coordinators, doctors of nurse practice, clinic leadership and mental health workers with expertise in caring for vulnerable populations.

DESCRIPTION: The process of developing an ambulatory Population Health rotation within a safety-net health care system, including clinic experiences, case-based teaching sessions, clinic-based quality improvement initiatives, and faculty development around population health will be delineated. Faculty distribution of resources, resident use of population health data, quality improvement (QI) projects developed, as well as barriers in implementation and their resolutions will be discussed. Clinic experiences housed within the general medicine clinic practice included Smoking Cessation, Weight Loss, Diabetes Prevention, Dietician Individual and Group Visits, Diabetic Group Visits, Cervical Cancer Screening, Hypertension/Diabetes Care Management with RNs, Care Coordination meetings with clinic management, and Safe Event Reporting Team meetings with health system management. Case-based teaching sessions employed the online Caring with Compassion modules and workshops on weight management. During each 2 week rotation, 1 resident each is assigned to ongoing diabetic and hypertension QI projects.

EVALUATION: Common themes based on 35 residents’ experiences during the Population Health rotation will be made available by the time of the meeting through qualitative analysis of rotation evaluations completed by the residents. Results of the diabetic and hypertension resident quality improvement projects will also be available.

DISCUSSION / REFLECTION / LESSONS LEARNED: By using population health initiatives already established in the general medicine clinic, one was able to integrate the role of the resident in a variety of multi-disciplinary initiatives. Faculty development focused on teaching population health skills to the residents. Teaching residents the skills needed to provide equitable patient care between routine clinic visits not only provides benefits for patients seen during the rotation but may create a cascade effect in how trainees approach patient care in subsequent rotations. Engaging physicians, mid-level providers, nurses, a dietician and clinic management resulted in a holistic approach needed to care for vulnerable adults.

IMPLEMENTING A TRAUMA-INFORMED CURRICULUM ON CERVICAL CANCER SCREENING

Kayo Robinson, Amy Weil, Shana Ratner

Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC. (Control ID #3875062)

SETTING AND PARTICIPANTS: A 30-minute outpatient curriculum, “Trauma-Informed Approach to Cervical Cancer Screening,” was created. The curriculum will be delivered by 18 faculty team leads in small groups to reach 86 Internal Medicine categorical resident physicians in their first, second, and third years of training at the University of North Carolina (UNC). The curriculum will be implemented in January 2023.

DESCRIPTION: About 5 out of every 10 women (or 50%) experience at least one trauma in their lifetime. Physicians must keep this information in mind, especially when completing cervical cancer screenings. Utilizing a trauma-informed approach can result in patients feeling safer and more supported during the exam. Many resident physicians do not receive training in trauma-informed approach to care during their medical student years or time in residency training. Prior to creating this curriculum, residents also expressed discomfort with the steps and technique of completing a pap smear. A trauma-informed outpatient curriculum was created under the guidance of UNC Internal Medicine clinician educators utilizing various resources including the American College of Physicians (ACP), American Family Physicians (AFP), National Health Care for the Homeless Council (NHCHC), Center for Disease Control and Prevention (CDC), and Substance Abuse and Mental Health Services Administration (SAMHSA). Learning objectives included 1. Provide trauma-informed care in terms of language and techniques used when completing pap smears, 2. Discuss SAMHSA’S 6 guiding principles to a trauma-informed approach, 3. Review techniques for effective cervical cancer screening. The curriculum included a Medical Knowledge Self Assessment Program (MKSAP) question related to cervical cancer screening, a patient case with follow-up questions to encourage discussion and cover learning objectives, review points, references, and resources on trauma-informed care.

EVALUATION: Evaluation data is pending. Proposed methods to collect and analyze data include 1. Creating a pre and post-curriculum survey to assess resident comfort and attitudes in completing pap smears 2. Assess for improvement in cervical cancer screening rates in resident clinic utilizing the Primary Care Improvement Collaborative (PCIC) performance measure.

DISCUSSION / REFLECTION / LESSONS LEARNED: It is important to take a trauma-informed approach when caring for all patients, especially when completing cervical cancer screenings. An outpatient curriculum was created to educate resident physicians on cervical cancer screening technique that applied the CDC and SAMHSA’s 6 guiding principles to a trauma-informed approach (safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment voice and choice, cultural historical gender issues) and applied these principles to cervical cancer screening techniques. The curriculum also emphasized best practices for effective cervical cancer screening.

ONLINE RESOURCE URL: https://drive.google.com/drive/folders/11Y-H7yXv35AU2ubeYUP1cWEkcex9pat9?usp=share_link

IMPROVING SHARED DECISION MAKING FOR COLORECTAL CANCER SCREENING IN A RESIDENT PRACTICE THROUGH AN ASYNCHRONOUS LEARNING MODULE

Rosemary Farahmand¹; Nicole Kwan¹; Katherine Wrenn²; Maelys Amat¹

¹Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ²Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #3876720)

SETTING AND PARTICIPANTS: Large, urban, academic hospital-based primary care clinic with 60 attending and 110 resident primary care physicians (PCPs) who care for approximately 52,000 patients. All resident PCPs in the practice in Fall 2021 and Fall 2022 were asked to participate in the study. We focused on the resident patient population as colorectal cancer (CRC) screening rates have historically been 16-21% lower in the resident versus attending practice.

DESCRIPTION: We developed an asynchronous learning module consisting of a 33-slide presentation to address previously identified deficits in residents’ skills and knowledge around shared decision making (SDM) and CRC screening. The presentation was sent via email to all resident PCPs in the practice. It utilized a CRC screening patient decision aid that was created as part of an initiative within the clinic’s affiliated performance network. The learning module reviewed USPSTF recommendations for CRC screening, the definition and steps of SDM, and how the patient decision aid may facilitate SDM discussions. It then reviewed the steps required of a patient to complete a stool-DNA test or colonoscopy. The module ended with four case-based self-assessment questions. After completing the module, the residents were asked to complete a brief survey.

EVALUATION: Identical pre- and post-surveys were sent in Fall 2021 and post-module in Fall 2022, allowing for direct comparison of results. The 51 resident PCPs who completed the survey in Fall 2021 are referred to as “pre-module residents” and the 31 resident PCPs who completed the survey after reviewing the module are referred to as “post-module residents." The surveys utilized a 5-point Likert scale (1=strongly disagree, 5=strongly agree) and had questions pertaining to CRC screening knowledge, SDM skills, and system processes. On average, post-module residents were more confident in their abilities to explain the steps (4.3 vs. 2.8, p<0.0001), pros (4.5 vs. 3.6, p<0.0001) and cons (4.4 vs. 3.6, p<0.0001) of stool-based testing as compared to pre-module residents. Post-module residents were also more confident in their ability to perform a key aspect of the SDM process, forming a recommendation taking into account patient goals and preferences (4.3 vs. 3.9, p<0.02). We plan to further evaluate the impact of the module by comparing CRC screening rates for resident patients in specified time periods pre- and post-module release.

DISCUSSION / REFLECTION / LESSONS LEARNED: Previously identified barriers to SDM around CRC screening in our resident practice included lower confidence in SDM abilities and knowledge gaps around stool-based testing. We therefore created an asynchronous learning module aimed at addressing these barriers. Post-module survey results demonstrated improved resident confidence in their SDM abilities and knowledge around the different CRC screening options. As residents at our practice tend to serve more psychosocially complex patients, we hope this module will help improve the care of our more vulnerable patients.

INCORPORATING WEIGHT MANAGEMENT IN INTERNAL MEDICINE RESIDENCY TRAINING

Taha Ahmed^1,2; Adrianna Wegrecki⁵; mehrshid kiazand^4,3; Noor Khan³

¹Medicine, UPMC, Pittsburgh, PA; ²UPMC Mercy, Pittsburgh, PA; ³Medicine, UPMC Mercy, Moon Township, PA; ⁴Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ⁵Internal Medicine, UPMC Mercy, Pittsburgh, PA. (Control ID #3875180)

SETTING AND PARTICIPANTS: PGY1, PGY2 and PGY3 internal medicine trainees in 4-week ambulatory rotation.

DESCRIPTION: Overweight and obesity affect up to 74 % (CDC 2018) of the US Adult population. When we treat overweight and obesity, we are also treating many of the most common conditions that afflict our patients. In 2015, EMR data showed that 85% of our Residency Clinic patients had overweight or obesity with an average BMI of 37. To address knowledge and practice gaps, we have implemented a longitudinal obesity medicine curriculum at our institution. Trainees at each PGY level assigned to their 4-week Ambulatory Rotation develop incremental weight management skills. Educational strategies include an interactive teaching session on anti-obesity medications (all trainees) and a half-day dedicated weight management clinic at the PGY2 and PGY3 level.

PGY1 residents do a structured reflection exploring weight stigma and implicit bias. Tools used to prompt reflection include the online Harvard Implicit Association Test and patient perspectives. PGY2 residents work with designated faculty to develop SMART (specific, measurable, achievable, realistic, temporal) exercise goals for themselves. They use these skills to counsel patients on designing SMART goals to enhance behavior change. PGY2 and PGY3 residents spend a half-day session seeing weight management patients with an emphasis on taking a weight specific history and exam and using lifestyle and anti-obesity medications to improve overall health and co-morbid conditions.

EVALUATION: We send a post-rotation knowledge and attitude survey to all residents in the ambulatory rotation. This survey is distributed electronically with one reminder after the due date. Our goal is to have 80% of PGY3s score 80% or higher in the knowledge questions. We are now planning on sending out a pre- rotation survey in week 1 to allow us to assess improvement.

PGY1 residents submit narrative comments reflecting on bias and/or implicit association test results. PGY2 residents submit a written personal SMART exercise goal. PGY 3 Residents implement an obesity treatment plan using lifestyle and medications and surgical interventions if appropriate in their half day weight management clinic.

DISCUSSION / REFLECTION / LESSONS LEARNED: We implemented this curriculum this academic year starting in June 2022. So far we have data from seven 4-week Ambulatory blocks. The interactive session on anti-obesity medications is rated highly by trainees. All trainees at PGY 1 level except one have submitted narrative comments on bias and stigma. All trainees at PGY2 level have participated in SMART goal setting and all PGY3s have documented a weight management plan for patients seen in their half-day sessions.

Participation in the Microsoft Forms electronic survey remains low. 7/11 PGY3s have completed the post rotation survey. 4/7 residents scored 80% or higher in the post rotation knowledge survey (below our target). Based on knowledge survey, we have modified the didactics.

INDIVIDUALIZING THE RESIDENT EXPERIENCE THROUGH CONTENT MAPPING

Jeremy Lin¹; Patrick Li^2,1; Daniel Sartori¹

¹Internal Medicine, NYU Langone Health, New York, NY; ²Internal Medicine, NYU Langone, Brooklyn, NY. (Control ID #3874542)

SETTING AND PARTICIPANTS: Designing curricula that meet the specific learning needs of Internal Medicine trainees is challenging. Despite efforts to build curricula around core topics, individual trainees are nevertheless exposed to variable content throughout residency. There remains a need for residency programs to characterize and measure the specific content individual residents experience. Doing so would allow residents and programs to identify and supplement underrepresented content areas to ensure adequate breadth of study. We implemented a pilot program to characterize all inpatient didactic experiences for residents in our Mid-Atlantic Academic Residency program from July2022 - present; we have coupled this characterization with a flexible small group conference series to tailor didactic content to resident needs.

DESCRIPTION: We have manually mapped topics covered during residents’ inpatient didactic conferences to core medical content areas as defined by the American Board of Internal Medicine (ABIM). Mapping decisions have been performed based on presenter specialty and chief resident judgment. For example, a conference on heart failure would be mapped to ‘Cardiology.’ Our program’s management platform ‘New Innovations’ (Uniontown, OH) serves as a repository for conference information and attendance. Each individual resident’s conference attendance stratified by didactic content area can be downloaded and plotted as a frequency distribution. During our small group afternoon teaching sessions, we have targeted topics that are underrepresented in specific resident’s didactic experiences to align their cumulative content distribution with the ABIM Blueprint distribution.

EVALUATION: While our large group noon conference series is intended to cover a variety of core ABIM topics, a representative resident in our program has had nearly two-thirds of their noon conference experience cover just four of the ABIM categories (Cardiology, Infectious Disease, Neurology, and Pulmonary Disease), with no exposure to eight of the other ABIM categories. We have been able to supplement this experience in our flexible small group afternoon conference with five of the ABIM categories that are underrepresented in their conference experience to date (Endocrinology, Gastroenterology, Nephrology/Urology, Hematology, and Rheumatology). Similar data have been collected for all residents in our program.

DISCUSSION / REFLECTION / LESSONS LEARNED: Through this pilot to date, we have mapped resident conference experience and utilized these data to shape small group conference exposure to represent the ABIM blueprint distribution. We believe that this lays an important foundation for a fully individualized resident experience in the future. The next steps include evaluating whether creation of a well-rounded conference experience aligned with ABIM blueprint impacts educational outcomes.

IN IT TOGETHER: TEACHING A TEAM-BASED APPROACH TO PATIENT-INITIATED MISTREATMENT

Luke Fraley, Virginia Sheffield, Nathan Houchens

Internal Medicine, University of Michigan, Ann Arbor, MI. (Control ID #3877037)

SETTING AND PARTICIPANTS: Previous studies have demonstrated that medical trainees and faculty commonly experience harassment or discrimination on the job or in training, and patients are a commonly cited source. Our objective was to implement a curriculum for faculty and trainees in an academic hospital setting that expands upon published strategies and equips medical providers with techniques to manage patient-initiated mistreatment. Participants in the curriculum included medical students, house officers, and faculty. Individual sessions were facilitated by trained faculty and house officers.

DESCRIPTION: The curriculum consists of 90-minute virtual sessions, each of which includes three parts: 1) an overview of literature, 2) a framework for preparing for, addressing, and debriefing after patient- initiated mistreatment, and 3) skills practice using patient-actors to simulate instances of mistreatment while maintaining psychological safety. A laminated “badge backer” featuring the framework and example response phrases is provided for reference during moments of mistreatment. Pre- and post-session surveys using 5-point Likert scales were administered.

EVALUATION: A total of 322 and 228 participants completed pre- and post-session surveys, respectively. Respondents comprised 40% medical students, 40% house officers, and 20% faculty. Regarding gender, 61% self-identified as female, 38% male, and 1% non-binary. Regarding ethnicity, 63% self-identified as White, 22% Asian, 6% Hispanic, Latino or Latina, or Spanish origin, 4% Black or African American, and 4% Middle Eastern or Northern African.

On pre-session surveys, 275/316 (87%) reported experiencing harassment or discrimination, and 290/312 (93%) reported witnessing these behaviors directed at another team member. Most (70%) reported that their teams never discussed mistreatment at the start of a rotation, and many (53%) reported never or rarely debriefing after mistreatment.

Post-session surveys revealed significant increases in confidence recognizing mistreatment (4.13 to 4.61, p<0.0001); addressing behaviors on behalf of the self (2.93 to 4.23, p<0.0001) and as bystanders (3.17 to 4.29, p<0.0001); and belief that their institution takes mistreatment seriously (4.01 to 4.51, p<0.0001). Among 211 respondents, 210 (100%) agreed they see themselves using the skills, 206 (98%) planned to address mistreatment with their future teams, and 206 (98%) would recommend the curriculum to others. DISCUSSION / REFLECTION / LESSONS LEARNED: Our data corroborate high rates of patient- initiated mistreatment and lack of clarity and confidence in responding to the behaviors at all levels. Our curriculum increased participant confidence in both recognizing mistreatment and intervening for themselves and as bystanders. Nearly all participants found the curriculum valuable and planned to use the skills.

Medical school and healthcare leaders may consider this brief education for all trainees and faculty.

INTERN REPORT: AN INPATIENT INTERNAL MEDICINE PROGRAM NEEDS ASSESSMENT Justin Q. Wang, Dennis T. Roarke, Ava-Dawn Gabbidon

Internal Medicine, Northwell Health, New Hyde Park, NY. (Control ID #3874826)

SETTING AND PARTICIPANTS: A needs assessment was conducted in a northeastern academic center with internal medicine residents and chief resident or faculty facilitators using qualitative and quantitative measures via Likert scales. Seventeen questions were made for residents across three levels (PGY) and sixteen for facilitators concerning the format and efficacy of Intern Report (IR). The survey was in February and asked for past experiences so questions about the overall second half of the academic year excluded interns. Qualitative data were compiled by two coders with a third coder for discrepancies.

DESCRIPTION: Intern Report is a widespread and varied educational exercise across the United States, yet has limited literature. Initially used to monitor all resident growth via overnight admissions, IR shifted towards rare cases and developing case-based intern critical thinking. Our program’s format is an intern presents a case in a dedicated afternoon hour inpatient session (held twice a week) that is explored via audience questions led by a facilitator to develop history gathering, differential diagnosis (ddx), and workup skills. The success of this construct remains unclear. This study employs a needs assessment regarding our current Intern Report curriculum.

EVALUATION: Fifty-seven participants responded (21 PGY1, 15 PGY2, 8 PGY3, and 13 facilitators). Average length was 43 minutes. 66% of residents enjoy IR. 32% of residents and 41.7% of facilitators said audience engagement was less than 60% of the time. Reasons to engage were interesting cases, facilitator questions, and take-home points. 34.6% of residents and 33.4% of facilitators said distraction occurred at least 40% of the time. Reasons included IR length, clinical work, level of presenter preparation, and inconsistent formats. 56.8% of residents knew differentials considered during questioning. 50% of residents and 41.7% of facilitators said IR develops ddx skills. 47.7% of residents and 75% of facilitators believe IR develops workup skills. In the first six months, 29.5% of all residents and 8.33% of facilitators were quite confident in intern ddx skills versus 78.3% of PGY2s and PGY3s and 58.3% of facilitators in the latter six months. 20.5% of all residents and no facilitators were at least quite confident in intern workup skills versus 69.6% of PGY2s and PGY3s and 41.7% of facilitators in the latter six months. Improvement suggestions included standardization, shorter length, take-home points, curriculum based on ddx frameworks for the first six months then workup frameworks for the next six, and more facilitator probing questions.

DISCUSSION / REFLECTION / LESSONS LEARNED: The Intern Report needs assessment supports a call to modify the construct with a curriculum adjusted to intern growth given overall differences in confidence regarding ddx and workup skills in the first versus second half of the year. It should also develop ddx and workup frameworks with a more standardized format. These results provide insight for programs seeking to re-evaluate Intern Report.

LESSONS LEARNED FROM A PILOT STUDY OF POCUS NEAR-PEER MENTORED SCANNING IN A LARGE ACADEMIC SETTING

Cristina Fischer¹; Julia Limes²; Michelle Fleshner¹

¹Internal Medicine, University of Colorado, Denver, CO; ²Medicine, University of Colorado, Denver, CO. (Control ID #3875397)

SETTING AND PARTICIPANTS: First year internal medicine residents at an academic, VA, and community hospital setting in the Mountain West Region

DESCRIPTION: Point-of-care Ultrasound (POCUS) use is rapidly increasing within Internal Medicine (IM), necessitating the development of formal training during residency. Major obstacles to effective training include lack of trained supervisors, time for mentored scanning, and longitudinal training experiences.1,2,3

We developed a novel POCUS training curriculum within a large multi-site IM residency program that consists of didactics and mentored scanning, self-guided scanning with a required image portfolio and quality assurance, and a final skills assessment.

Feedback received from interns emphasized a need for increased support during self-guided scanning. To address this, we piloted a month-long near-peer mentorship program that utilized senior residents who had completed an advanced POCUS elective to serve as mentors to interns. During this pilot, inpatient interns at three training sites were approached through e-mail and direct secure messaging to set up a training session. Resident interviews were performed to determine what barriers exist preventing learners from engaging in hands-on POCUS training in the inpatient setting.

EVALUATION: During the pilot, six teams were secure messaged within the electronic health record to coordinate a POCUS session. Of these, four interns responded with interest in a scheduled session, and two sessions were completed performing scans of 2-3 organ systems each. In addition, 13 teams consisting of 1-2 interns were approached via a weekly e-mail over two weeks. No e-mail responses were received.

Positive feedback was received during the training sessions that were performed. Barriers identified were challenges with identifying the most efficient form of communication and coordination of appropriate timing for a dedicated POCUS session during a busy inpatient day. Recommendations included involving senior residents to support the team during POCUS scanning sessions and having mentors be available all throughout the day.

DISCUSSION / REFLECTION / LESSONS LEARNED: This pilot revealed the challenges of incorporating longitudinal POCUS learning into inpatient care. While there was interest in and positive feedback regarding near-peer mentorship from interns, finding time to scan during a busy inpatient day was difficult. This highlights that the approach to implementing a successful longitudinal near-peer mentoring program must be multi-faceted and focus on communication and resident availability. Recommendations for the next iteration include having a POCUS resident available for both morning and afternoon shifts, focusing mentoring on outpatient settings or low volume inpatient teams, and engaging senior residents and faculty on inpatient teams to help support their intern while they engage in POCUS sessions. Through these steps we hope to continue to develop a sustainable, longitudinal learning environment that supports the development of POCUS skills.

LET’S TALK ABOUT MEDS: AN EDUCATIONAL INTERPROFESSIONAL EXPERIENCE FOR INTERNS WITH OUTPATIENT CLINICAL PHARMACISTS

Andrew D. Young¹; Stacey E. Jolly¹; Giavanna Russo-Alvarez²; Katie Kish²; Anna Bondar²

¹Internal Medicine, Cleveland Clinic, Cleveland, OH; ²Pharmacy, Cleveland Clinic, Cleveland, OH. (Control ID #3871800)

SETTING AND PARTICIPANTS: Educational interprofessional experience for all Internal Medicine (IM) interns at a large academic medical center in the Midwest with outpatient clinical pharmacists who are part of the continuity clinic sites medical home started in the 2020-2021 academic year.

DESCRIPTION: Managing chronic diseases in an outpatient clinic can be challenging for interns as most medical education experiences occur in an acute hospital care setting. The purpose of this educational interprofessional experience is to guide interns through the role a clinical pharmacist plays in the outpatient setting through a half-day experience with core and tailored instructive content. During the one-to-one session, the pharmacist covers topics such as medication procurement, medication device teaching, and an overview of continuous glucose monitors. Interns observe the pharmacist-led visits to gain insights into medication reconciliation, instruction on use of medications, and chronic disease management.

Approximately 45 interns have completed the experience with one of nine clinical pharmacist educators during the 2020-2021 and 2021-2022 academic years. This educational interprofessional experience is placed at the mid-way point of the academic year when interns have had at least three weeks of their continuity clinic and after the ambulatory intern curriculum presentation has been given by the clinical pharmacists.

EVALUATION: Pre-and post-intervention surveys were sent to interns to voluntarily complete during the project's first year. The surveys assessed their planned career choice, clinical site, and perceived knowledge of the role of the clinical pharmacist. Post-intervention surveys gauged satisfaction with the half-day curriculum and gathered suggestions for improvement. To date, 44 participants have completed at least one survey and 26 completed both. This intervention was favored by the residents with 96% (n=25) of respondents noting that it should continue for future residents. Their perceived comfort in consulting the pharmacy team increased from 41% to 81% (n=21) and the percentage of residents strongly agreeing that pharmacists are helpful in co-managing patients in clinic increased from 68 to 85% (n=22).

DISCUSSION / REFLECTION / LESSONS LEARNED: This initiative began after an ambulatory chief resident noticed that many residents were unaware of the pharmacists' role and their abilities in the co- management of patients with chronic conditions. It has since grown into a yearly interprofessional educational experience for interns. While not all parts of the program may be generalizable, having residents learn about medications and chronic disease management from a pharmacist's perspective is feasible for many programs and important for professional development and understanding of system-based practice in the form of an outpatient medical home for interns. The educational interprofessional experience is ongoing in this academic year and discussions are underway regarding how to re-visit this for residents in their 2nd/3rd years.

LEVERAGING ASYNCHRONOUS CARE FOR RESIDENT E-LEARNING: RESIDENT AND FACULTY EXPERIENCES WITH SUBSPECIALTY E-CONSULTATION ROTATIONS AT AN ACADEMIC SAFETY-NET HOSPITAL SYSTEM

Rebecca Rogers²; Hsiang Huang¹; Zhiheng He²; Alison Rapoport²; Richard Pels²

¹Cambridge Health Alliance Department of Psychiatry, Cambridge, MA; ²Medicine, Cambridge Health Alliance, Cambridge, MA. (Control ID #3874648)

SETTING AND PARTICIPANTS: Internal medicine/primary care residents (PGY 1-3) in a community safety-net academic medical center in the North East. Faculty educators included those from Divisions of Infectious Diseases (ID), Endocrinology, and Department of Psychiatry.

DESCRIPTION: Residents in the training program have 2-week ambulatory blocks that include time in subspecialty clinics in addition to continuity clinics. After covid restrictions there were fewer specialty clinics available for residents to attend. In 2017, the department developed “e-consults” as a way for PCPs to obtain expedited specialist input on a case based on chart review. In 2020, we piloted partnering residents with faculty who were doing e-consults as a way for residents to obtain exposure to specialist learning. Up to this point, this rotation has been established for psychiatry, endocrinology, and ID.

See URL for detailed workflow.

EVALUATION: 58% of residents responded to a survey about their experience. In terms of medical knowledge, 78% reported they saw a good range of cases via e-consults, and 70% felt better prepared to care for patients independently in the future. 78% also agreed that the experience increased their confidence in knowing how to utilize e-consults as a PCP and how to craft consult questions. On the faculty side, three out of five faculty members respond to a survey. All of them agreed that they were able to teach residents on a good range of topics and communicate important learning points via e-consults, and that fitting time for e-consutls with residents into their schedule was straightforward.

On qualitative comments, residents and faculty agreed that having dedicated time to review a few pre- selected cases, rather than squeezing in teaching during a busy clinic session, were key advantages of e-consults vs traditional specialty clinic experiences. Limitations of e-consults for education were lack of ability to practice taking a history targeted to that specialty, and lack of ability to practice physical exam skills.

DISCUSSION / REFLECTION / LESSONS LEARNED: With demand for appointments and wait times increasing, institutions may find e-consults to be a way of meeting the promise of timely and effective care. We have capilaized on this model for education and demonstrated that resident e-learning through e-consults is feasible to implement and improves resident self-reported medical knowledge. Residents also enhance their understanding of how to better utilize e-consults, which reflects improvement in systems-based practice.

One limitation of our study is we have not yet confirmed whether the self-reported improvements in medical knowledge correspond to improvement in subject-area score improvement, or resident-reported comfort in that specialty on end of year surveys. Still, there is enough evidence of educational value that we plan to continue these e-consult experiences mixed with in-person clinic to practice the hands-on patient care skills.

ONLINE RESOURCE URL: https://docs.google.com/document/d/1YIl5f0CzK3WHM2vt4avyBzdrvwdizHGf1MVXFBmFCAg/edit?usp=sharing

LIFESTYLE MEDICINE CURRICULUM: A POWERFUL TOOL FOR CLOSING THE KNOWLEDGE GAP AND IMPROVING PATIENT CARE

Jasmin Hundal¹; Erica C. Becker¹; Zoe Possick¹; Narinder Maheshwari³; Varalakshmi Niranjan²

¹Internal Medicine , University of Connecticut, Hartford, CT; ²Medicine, University of Connecticut, West Hartford , CT; ³Internal Medicine, UConn Health, Farmington, CT. (Control ID #3875368)

SETTING AND PARTICIPANTS: Chronic medical diseases preventable with lifestyle modifications are the leading causes of morbidity and mortality in the United States. Clinical guidelines suggest lifestyle changes as the primary intervention, but clinicians report insufficient counseling and training skills. To close the gap, the Lifestyle Medicine Educational Pathway curriculum by the American College of Lifestyle Medicine (ACLM) was introduced to internal, family medicine residents and attending physicians at the University of Connecticut. After 13 months of intervention, what percent of residents report understanding the 6 pillars, and by what percent does it change management? 22 residents signed up for the lifestyle medicine track.

DESCRIPTION: The comprehensive Lifestyle Medicine Curriculum (LMC) was implemented and offered to trainees and attending physicians. This consisted of monthly, one-hour virtual didactic meetings and community activities. Residents also have a patient log tracker to document encounters where they discussed lifestyle medicine interventions.

EVALUATION: Overall, positive feedback was received which is reflected by our preliminary results. 14 participants completed a survey assessing the impact of LMC in clinical practice. 64.2% agreed that LMC is well integrated into the residency while only 7.1% disagreed. Additionally, 92.9% of participants report understanding the six pillars of lifestyle medicine and appliance to patient care. 78.5 % report that LMC has allowed them to change their management of patients with chronic medical conditions to improve patient outcomes and 12.5% neither agreed or disagreed. Participants also applied the knowledge to improve personal quality of life and well-being and feel confident being an advocate.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our preliminary data indicate that the Lifestyle Medicine Curriculum has improved patient care when applied in a clinical setting. Data suggest that LMC has facilitated a collaborative environment among residents and physicians. While our preliminary data indicates promising results, further analyses will provide more insight into the benefits of LMC. This project is the initial step toward encouraging physicians to embrace therapeutic lifestyle intervention in clinical practice and everyday life to improve patient care and overall well-being, respectively. The following steps include pre- and post-quizzes biannually to evaluate whether trainees are actively incorporating lifestyle medicine into clinical practice. Many of our patients have a high burden of preventable chronic diseases and this educational opportunity equips clinicians with skills to educate patients on cost-effective, evidence-based behaviors that can help them prevent and treat many of the common conditions from which they suffer.

ON THE ELECTRONIC MEDICAL RECORD: UTILIZING A FLIPPED-CLASSROOM TO EDUCATE NEW RESIDENTS

Devorah Edelman¹; Ga Hee Kim¹; Gabriela Bernal². ¹Internal Medicine, Mount Sinai School of Medicine, New Rochelle, NY; ²Internal Medicine, Mount Sinai Morningside Hospital, New York, NY. (Control ID #3852076)

SETTING AND PARTICIPANTS: PGY-1 residents in an Internal Medicine residency program. These sessions are part of the “Arts and Practice” educational series, a curriculum devoted to mastering the practice of medicine outside of medical knowledge and clinical reasoning. In particular, we focus on the ACGME competencies of communication and systems-based practice. Chief residents facilitate small group sessions with 10-12 residents for this topic.

DESCRIPTION: For this initiative, we piloted a “nuts and bolts of EMR” session. Each resident self- selected a topic before the session. Sample topics included communicating with non-clinical staff members using telephone encounters, problem list management, reconciling medication, and creating appropriate referrals. Each subject had a two to three-minute video tutorial attached, which residents watched for reference before the session. Using a flipped classroom model, each resident spent 2-3 minutes teaching the rest of their peers what they had learned.

EVALUATION: We used a post-lecture feedback form to assess the session’s effectiveness. After two sessions, 83% of residents (n=12) gave the session a 4 out of 4 rating on the following parameters: relevance to practice, practicality, effectiveness, and recommendation to keep the session for next year’s interns. The average rating was 3.75.

DISCUSSION / REFLECTION / LESSONS LEARNED: Introducing new residents to an Electronic Medical Record (EMR) is vital in teaching them to navigate a medical system. Mastering this systems-based practice enables residents to effectively manage their individual patient’s health and entire patient panels. However, learning the intricacies of an EMR can be dry and seem out of context to new residents, making effective teaching difficult. Residents can use a flipped classroom model to reinforce their learning by teaching their peers. This intervention is simple and easily replicated. It requires little facilitation, making it a practical intervention when designing a longitudinal curriculum. The flipped classroom model is an innovative strategy that can help overcome the challenges of traditional teaching methods, shifting the students' passive position to a student-centered learning strategy.

OUTPATIENT MATTERS: AMBULATORY INFECTIOUS DISEASE TRAINING IN INTERNAL MEDICINE

Beret Amundson¹; Emily Moore¹; Jacob H. Johnson²

¹Internal Medicine, Brigham and Women's Hospital, Boston, MA; ²Infectious Diseases, Brigham and Women's Hospital, Boston, MA. (Control ID #3873640)

SETTING AND PARTICIPANTS: Given the new ACGME emphasis on outpatient training for internal medicine (IM) residents, innovations in ambulatory training are needed. Traditionally, most outpatient subspecialty exposure is centered around shadowing of clinicians and often misses the breadth and depth of a given field. We designed a two week multifaceted ambulatory subspecialty elective (ASE) in the field of infectious disease (ID) at a large urban academic hospital highlighting the diverse field of ID. Faculty members, clinical and microbiology ID fellows, and social workers in the ID department were paired 1:1 or 1:2 with residents.

DESCRIPTION: This innovation was designed in collaboration with an ID faculty member and two senior IM residents. The elective featured the breadth of ID as residents were assigned 5-6 half days of clinic per week in HIV medicine, pre and post-transplant ID, and general ID. Residents were expected to see at least one new patient independently each clinic. Residents were also trained in prescribing practices for PrEP/PEP through a half day interactive session. The depth of the field was accentuated in the microbiology laboratory where residents worked alongside a microbiology fellow, with the goal of better understanding the process of culture maturation, identification, and antimicrobial resistance. Given the importance of motivational interviewing (MI) in the field of ID, residents attended an interactive session with a social worker skilled in MI. They practiced MI techniques in concept areas such as safe sex practices, safe injection techniques, and ART adherence. Accompanying educational materials for each subject area were designed and provided to participating residents.

EVALUATION: Evaluation data will be collected from residents, fellows, and faculty who participate in the ID ASE over a one year period beginning in November 2022 via semi-structured 1:1 interviews. Qualitative metrics will include positive and negative aspects of the ASE with regard to bidirectional investment in learning, expectations of residents, perceived knowledge in concept areas of HIV, transplant ID, microbiology, MI techniques, and PrEP/PEP. Qualitative data will be utilized iteratively to make changes for new cohorts of participants. Perceived likelihood to apply to ID fellowship will also be assessed.

DISCUSSION / REFLECTION / LESSONS LEARNED: Innovations in ambulatory education are necessary given the expanded requirement for outpatient training in IM residency programs, and the ID elective we developed may serve as a model for ambulatory experiences in other fields. We created a rotation that allowed for 1:1 learning sessions between residents and ID fellows/faculty, as well as hands on training in core ambulatory skills. Thus far, we have learned that iterative feedback from residents and faculty will be essential to ensure that the ASE is meeting the goals of participants. Lastly, in an era of low ID fellowship applicants, we hope to explore if highlighting the richness of ID may be beneficial as a recruitment strategy.

PODCASTING, MEET THE FLIPPED CLASSROOM: UNIFYING TWO COMPLIMENTARY EDUCATIONAL MODALITIES INTO A NOVEL GME CURRICULUM ON LIPID MANAGEMENT IN PRIMARY CARE.

Cary J. Blum. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3873175)

SETTING AND PARTICIPANTS: Internal Medicine residents participating in regularly scheduled didactic sessions at a large, urban, academic medical center.

DESCRIPTION: I created a 45-minute podcast and a one-page companion reference guide with information on lipid testing, interpretation, and management. All internal medicine residents in our program (n = 151) were asked to download and consume these materials. The material in the podcast ranged from basic material on lipid panel interpretation and statin guidelines, to more advanced topics such as ApoB and Lp(a) testing, as well as non-statin lipid therapies. Within one week of listening to the recording, residents then participated in a one-hour in-person didactic session. The in-person session for PGY1 residents consisted of a typical case of lipid management in a primary prevention patient, building on the topics in the recording. The in-person session for PGY2’s and 3’s was an open discussion in which residents were encouraged to bring clinical cases from their practice.

EVALUATION: Of 76 residents asked to complete an anonymous survey after the in-person session, 60 responses were received (response rate = 78%). Of the respondents, only 36 (60%) actually listened to the podcast prior to the session. Residents who listened had a self-reported improvement in comfort with lipid management of 2.25 points on a 10 point scale, while non-listeners improved by a self-reported 1.875 points (T-test: p = 0.34). Residents who listened to the recording were far more likely to report having an increased, as opposed to neutral or decreased, propensity to consume podcasts in the future (53% vs 20%). Surprisingly, the majority of listeners and non-listeners both reported enjoying this session more than the average passive didactic session at approximately equal frequencies (64% vs. 63%). 55% of participants agreed that more audio didactic material should be incorporated into GME curricula, while 33% were unsure, and 12% disagreed.

DISCUSSION / REFLECTION / LESSONS LEARNED: Merging podcast-style didactic material with a discussion-based flipped classroom session was well-received by most internal medicine residents, whether they engaged with the assigned materials ahead of time or not. The biggest challenge was getting residents to actually consume the audio material prior to the in person session. Among listeners, most reported being more likely to consume other medical podcasts independently going forward. Therefore, perhaps one of the most important impacts of such a curriculum is the introduction of a new modailty for life-long learning in a subset of learners. Residents enjoyed the conversational, case-based style of the session, and appreciated the multimedia materials. To improve the session, several residents suggested shortening the podcast and/or allowing playback at a faster speed.

ONLINE RESOURCE URL: Recording: https://drive.google.com/file/d/10m1eQs9Ay1LLlI9O0GGSGuYaeBAS9PD0/view?usp=share_link

Companion reference guide: https://drive.google.com/file/d/1-rBDzVfcoQAY9O4zEOy1JIaTtjPSt_cQ/view?usp=share_link

RE-DESIGNING COMPETENCIES IN A HEALTH EQUITY-FOCUSED RURAL HEALTH LEADERSHIP FELLOWSHIP

Stephanie Sun, Matthew Tobey

Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #3873899)

SETTING AND PARTICIPANTS: A two-year academic New England fellowship in rural health leadership aims to develop early-career generalist physicians into leaders in rural health equity with the knowledge, skills, and attitudes to catalyze system change in partnership with resource-denied communities. The fellowship's community partners are a rural Mid-West American Indian community and Indian Health

Service Unit.

In 2022, competencies in rural health leadership were revised based on surveys and exit interviews from four cohorts of fellows (7 responses), and a survey of leadership challenges faced by global and rural health fellows across three leading GME-level training programs in the U.S (22 responses).

Fellows desired a clearer set of fellowship learning goals with a plan to achieve them, better connecting their clinical work with the broader education of fellows, and a greater sense of connection to the home academic institution.

Leadership challenge themes named by fellows were finding support and mentorship, utilizing influence over authority to generate change, conflict resolution, tactfully challenging the status quo, organization skills, building trust, and amplifying the voices of stakeholders that are typically overlooked.

DESCRIPTION: Four overarching fellowship competencies were named:

1. Analyze the interpersonal, structural and systemic forces contributing to disease.

2. Create and execute collaborative solutions to provide more equitable health care.

3. Communicate effectively and persuasively across lines of difference.

4. Practice leadership that uses influence over authority to inspire positive, incremental change and agency.

From these competencies, five areas of focus were identified:

1. Excellent rural patient care

2. Implementing processes to improve health systems

3. Effective communication and advocacy

4. Leadership practice

5. Project management

All fellowship objectives and activities were mapped to one of these areas of focus.

EVALUATION: Qualitative data from 6-month follow-up fellow interviews shows the revised fellowship competencies have contributed to earlier identification of project focus, connection to mentors, and a stronger sense of how fellows’ clinical work connects to their health equity career development. The revision of competencies also identified areas for further program development, leading to a major revision of the mentorship structure.

Annual GME surveys and bi-annual follow-up interviews are planned to continue evaluating the impact of the revised competencies.

DISCUSSION / REFLECTION / LESSONS LEARNED: Learners face common leadership challenges regardless of their practice location. Defining the skills, knowledge, and attitudes that are essential to health equity leadership practice is essential to developing a roadmap for how fellows can develop these tools. Leadership practice is an ongoing process that requires a multi-faceted mentorship model, community, and a new set of skills in health systems change.

ONLINE RESOURCE URL: https://docs.google.com/document/d/1RekL80P9FySUhVGU5lXFlcW-QwDQ0QL3ucdkFK4V6yU/edit?usp=sharing

REVAMPING PEER-TO-PEER FEEDBACK: A WORKSHOP FOR INTERNAL MEDICINE RESIDENTS

Claire Drolen¹; Rachel P. Sarnoff¹; Joshua S. Li²; Nicholas Jackson²; Jodi Friedman¹; Lisa J. Skinner¹; Rachel Brook¹

¹Internal Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ²Department of Medicine Statistics Core, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #3873983)

SETTING AND PARTICIPANTS: Internal medicine residents at an academic medical center in the California-Hawaii region during the 2021-2022 academic year.

DESCRIPTION: Feedback is important for the professional growth of medical trainees. Studies show that peer feedback (feedback received from colleagues at the same training level) can be especially valuable. However, peer feedback can be limited by interpersonal concerns, perceived inexperience, and lack of training in delivering feedback. Among the models for delivering feedback in the medical education literature is the Ask Discuss Ask Plan Together (ADAPT) framework, proposed by Fainstad et al. in 2018. We describe a resident-led curriculum for delivering peer feedback using ADAPT. Participants attended a one-hour peer feedback workshop in small groups in late 2021. A recorded video lecture with background information and an introduction to ADAPT was assigned prior to the workshop (URL below). During the workshop, residents engaged in pre-set roleplay feedback scenarios using ADAPT. After the session, residents participated in a reflection and debriefing session. Residents were surveyed before and after the workshop to assess attitudes towards, and competencies in, peer feedback. A final survey was administered 6 months later to assess the long-term impact of the curriculum.

EVALUATION: The workshop was delivered to five resident cohorts (total n = 178) over two months. Among residents who completed the pre-workshop survey (n = 135), 94.8% thought peer feedback was unique compared to other types of inpatient feedback, and 91.8% though it was important to professional growth. Only 39.3% felt they had a structure for delivering effective feedback.

Comfort with delivering and receiving peer feedback was measured on a 5-point Likert scale in each of the surveys. From pre-workshop to post-workshop survey (n = 87), residents reported increased comfort giving feedback about things peers were doing well (mean 4.43 to 4.65) and about areas for growth (3.15 to 3.79). Residents also reported increased comfort receiving feedback about things they were doing well (3.98 to 4.36) and in areas for growth (4.14 vs 4.27). These comfort measures remained elevated above the pre- workshop baseline for residents who completed the final survey (n = 35). 89.6% of residents had a structure for delivering feedback when evaluated on the post-workshop survey, compared to 39.3% prior.

DISCUSSION/REFLECTION/LESSONS LEARNED: Residents believe that peer feedback is valuable for their professional growth, but are often uncomfortable and lack training in how to give and receive feedback effectively. In this preliminary study, a 1-hour, virtual workshop increased resident comfort in giving and receiving peer feedback in short- and long-term assessments. As we continue this workshop in the future, we aim to examine its effect on resident behavior with increased focus on change in frequency and quality of peer feedback, as well as the sustainability of this effect over time.

ONLINE RESOURCE URL: https://tinyurl.com/mry896wd

SENIOR REPORT: AN INPATIENT INTERNAL MEDICINE PROGRAM NEEDS ASSESSMENT

Justin Q. Wang, Ava-Dawn Gabbidon, Jared Honigman

Internal Medicine, Northwell Health, New Hyde Park, NY. (Control ID #3874817)

SETTING AND PARTICIPANTS: A needs assessment was conducted in a northeastern academic center with internal medicine residents and chief resident or faculty facilitators using qualitative and quantitative measures via Likert scales. Twenty-eight questions for second year (PGY2) and third year (PGY3) residents and seventeen questions for facilitators were generated concerning board review, landmark studies, and the current format and effectiveness of Senior Report (SR). Qualitative data were compiled by two coders with a third coder for discrepancies.

DESCRIPTION: Senior Report is a widespread and varied educational exercise across the United States but with limited literature. Originally used to assess all resident growth via overnight admissions, SR developed to be directed towards PGY2 and PGY3s covering treatment management and literature appraisal. Our program’s current SR format is that a PGY2 or PGY3 presents a case in a dedicated hour afternoon inpatient session (held twice a week) led by a facilitator to develop clinical management and evidence-based medicine skills. Treatment and management are explored using literature via a population, intervention, control, and outcomes (PICO) question. The success of this construct remains unclear. This study employs a needs assessment regarding our current SR curriculum.

EVALUATION: Twenty-four participants responded (11 PGY2, 8 PGY3, and 5 facilitators). Average SR

length was 33.8 minutes. 31.8% of residents enjoy SR. The audience was engaged 59.7% (residents) and 43% (facilitators) of the time. Reasons include case management focus, interesting discussions, appropriate PICO question, and literature choice. The audience was deemed distracted 49.3% (residents) and 42% (facilitators) of the time. Reasons include clinical work, lack of perceived relevance, and PICO or literature choice. Topics were at most somewhat relevant to clinical practice 79% of the time but more than 58% of the time did not help guide future management. 78.9% enjoy board review and 94.7% of residents want it as SR weekly with 78.95% agreeing that it correlate with the monthly lecture-series theme. 94.7% of residents are unlikely to access our program generated landmark study database even though 100% acknowledge clinical practice relevance. 100% of facilitators agree about landmark study daily practice relevance and are receptive to incorporate them into SR. Improvement suggestions include format flexibility choosing a PICO or a landmark study-based case presentation, take home points, and incorporating board questions, landmark studies, and guideline changes.

DISCUSSION / REFLECTION / LESSONS LEARNED: The Senior Report needs assessment supports the call to modify the construct as less than half of residents enjoy the current SR model due to lack of perceived relevance and inconsistent literature quality. Improvements include providing more standardization to SR and incorporating both board review and landmark studies to increase engagement. These results provide insight for programs seeking to re-evaluate Senior Report.

STARTING OUR PRIMARY CARE TRACK: BUILDING FOUNDATIONS, GROWING PAINS, AND SWEET SUCCESSES

Elizabeth A. Murphy, Elizabeth Ferzacca, Jeevarathna Subramanian

General Internal Medicine, University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #3853102)

SETTING AND PARTICIPANTS: Primary Care Track Faculty and Residents for AY20-21, AY21-22, and AY22-23.

DESCRIPTION: Our Medical School has always been known as a leader in Primary Care education, but did not have an Internal Medicine Primary Care residency until 2019 when our Department of Medicine and clinical system united to provide funding for a new Internal Medicine Primary Care Track. Support was granted for 4 residents each year, with a full complement of 12 residents. Using best practices from respected and established programs across the country and such resources as the AAIM Primary Care Toolkit, we have been able to be innovative with our delivery and intentional with our teaching and mentoring. We have our first full complement of 12 residents in AY2022-23. Over the past 3 years, we have built our clinical rotations (continuity clinic, Primary Care Specialty Clinics, medical specialty clinics, and electives), Primary Care Core Curriculum sessions, career mentoring, community outreach, and primary care residency community. Thanks to robust collaboration with our residents, DOM, and across our institution, we have been able to celebrate our successes and address areas in need of improvement or development.

EVALUATION: An End of Year Survey was sent electronically to 4 PGY1s for AY20-21 and 4 PGY1s and 4 PGY2s for AY21-22, and as well as 8 faculty members. Monthly feedback sessions with all residents and at least quarterly feedback sessions with individual residents allowed for amble qualitative data.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our residents highly rated their Primary Continuity Clinics, Primary Care Core Curriculum sessions, Primary Care Specialty Clinics, Weekend Urgent Care, Primary Care Second Clinic Sites, and 3+2 schedule format. For medical specialty clinics, they most valued Obesity, Rheumatology and Dermatology clinics, followed by Diabetes and Geriatrics. Our Benedict Leaders Clinic, where each intern was paired up with an institutional/educational leader, who is a GIM faculty member, was found to be a valuable experience for both residents and faculty. With two and a half years into our new program, we are pleasantly surprised with our primary care recruitment efforts. In addition to two of our current PGY3 Primary Care residents joining our practice for the upcoming academic year, we have had seven additional new faculty recruits to our GIM division for AY2022-23 and AY2023-24. As these recruits are not from our Primary Care Track, we feel the Track has made our division and clinic more appealing to junior faculty members starting out their careers. Based on additional resident feedback, we plan to use our upcoming academic year to develop more community service activities and incorporate the medical humanities into our teaching.

TEACHING PRIMARY CARE: A LIFESPAN APPROACH

Laura Desrochers, Kelly Graham

Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #3875906)

SETTING AND PARTICIPANTS: This curriculum consists of three teaching sessions during ambulatory didactics spread across the academic year and involves internal medicine interns at a large, urban academic medical center. Each session is 60-90 minutes and involves shared discussion and skill building portions. All 67 interns will receive this new curriculum and are invited to voluntarily participate in evaluation.

DESCRIPTION: Teaching primary care skills to residents occurs throughout residency. However, much of this teaching is focused on individual disease states and pathologies, screening guidelines, or broad topics including high value care and social determinants of health. Though some medical schools provide training on the skills of becoming a physician, internal medicine residents may benefit from further development of these skills. This curriculum focuses on how primary care physicians build relationships with patients in a longitudinal fashion, teaching communication and counseling skills, as well as strategies for interacting with patients at different time points rooted in common needs across the lifespan; with specific emphasis and attention to the outpatient setting. Each of the three sessions focus on different points in life: young adulthood, middle age, and older adulthood. Sessions are paired with a skill building component focused on communication and relational skills via an introduction to foundational motivational interviewing techniques as a basis for discussing behavior change, engaging in complex shared decision-making, and navigating end of life decisions in the outpatient setting.

EVALUATION: This is a quality improvement study based in the intern ambulatory curriculum delivered in three separate intern didactic sessions each offered 6 times across the PGY1 year to capture all interns.

Anonymous pre-and post session surveys will be administered in addition to a cumulative survey and focus group. To account for natural growth that occurs with time in internship, PGY2 residents will also be surveyed.

DISCUSSION / REFLECTION / LESSONS LEARNED: Baseline data from 18 participants who participated in the first session shows >90% of participants endorse having formal training in motivational interviewing as a communication tool but 66% fail to endorse any training in reflective listening as a key component in motivational interviewing. Most respondents are only somewhat likely to use motivational interviewing techniques when discussing behavior change with patients. Further, 76% of respondents are unlikely or very unlikely to explore end of life decision-making (beyond end-of-life preferences and code status) with their outpatients. Only 30% of participants endorse any formal training in undertaking shared- decision-making conversations. This early data suggests trainees will benefit from curricula designed to provide a framework for approaching primary care across life. Lastly, it highlights need for training in shared-decision-making given the complex nature of medicine and importance of such discussions in primary care.

THE DEVELOPMENT AND EVALUATION OF A WEIGHT MANAGEMENT CURRICULUM FOR INTERNAL MEDICINE RESIDENTS

Elizabeth Oczypok¹; Tanya Nikiforova²; Sarah Jones³; Anita Ganti⁴; Jonathan Lin⁶; Scott D. Rothenberger⁵; Deborah DiNardo⁷

¹Department of Medicine, VA Pittsburgh Healthcare System, Pittsburgh, PA; ²Internal Medicine, University Of Pittsburgh Medical Center, Pittsburgh, PA; ³General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ⁴Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ⁵Medicine, University of Pittsburgh, Pittsburgh, PA; ⁶Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA; ⁷Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #3874594)

SETTING AND PARTICIPANTS: Ambulatory faculty delivered the curriculum to categorical internal medicine (IM) residents during three 30-minute pre-clinic conferences at resident continuity clinics at a large academic medical center.

DESCRIPTION: Though the prevalence of obesity is increasing, weight management is under-addressed by healthcare providers, who cite knowledge gaps and lack of comfort with the topic as reasons they do not regularly counsel patients about weight. The few existing obesity medicine curricula focus on motivational interviewing and include little to no discussion of weight loss pharmacotherapy or use of multidisciplinary teams. To address this gap in education, we created and implemented a three-part, interactive, case-based, weight management curriculum for PGY1-3 IM residents with practical instruction on (1) setting expectations, goal-setting, and weight bias, (2) diet, exercise, and behavioral change, and (3) weight loss medications and clinic-based resources for weight management.

EVALUATION: The curriculum was delivered in the fall of 2022 to 159 IM residents, of which 112 (70%) completed the pre-test survey and 98 (62%) completed the post-test survey. Surveys included 14 multiple choice knowledge questions and 11 questions about comfort with weight management. Most of the residents felt that education about weight management was important to their IM training and to their future career (91% and 65%, respectively, ranked it 4-5 on a 5-point Likert scale). Mean resident knowledge scores

improved from 55.5% ± 15.2 correct before the curriculum to 74.6% ± 15.0 correct after the curriculum (p<0.001), with the largest gains in questions related to pharmacotherapy. Resident comfort with weight management (measured on a 5-point Likert scale) also significantly increased after the curriculum (3.2 ± 0.6 vs. 4.0 ± 0.5, p<0.001). The significance of the pre-post improvement persisted even after adjusting for potential confounders. The educational program was well-received by the residents, with 80% ranking it 4-5/5 for enjoyability. A majority of residents (73%) noted that they used information from the curriculum in at least one patient encounter.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our weight management curriculum for graduate medical trainees addresses an important gap in current IM training and was well-received by participating residents. Our findings show that just ninety-minutes of dedicated instruction on weight management can lead to significant gains in residents’ knowledge of and comfort with the topic. Further clinical data is being collected to see if this curriculum affected referrals to clinic-specific weight loss programs or prescriptions for weight loss medications for patients seen in the residents’ clinics. Since diverse faculty at multiple clinical sites utilized our preceptor guides to successfully lead the workshops at our institution, we believe that this curriculum could be readily shared, adapted, and implemented at other medical training programs.

THE INVERTED PYRAMID - A FRAMEWORK TO TEACH DIAGNOSTIC AND MANAGEMENT REASONING

Daniel A. Motta Calderon, Maureen Fausone, Chase J. Webber

Internal Medicine, Vanderbilt University Medical Center, Nashville, TN. (Control ID #3875427)

SETTING AND PARTICIPANTS: Internal Medicine residents in a VA hospital in southern United States. DESCRIPTION: The inverted pyramid is a framework developed to systematically integrate diagnostic and therapeutic reasoning when admitting patients to the general medicine service. We hypothesized that patients’ chief concern is frequently not addressed during a hospitalization and there is a disconnect between diagnostic and therapeutic reasoning. We conducted informal interviews with residents and performed direct observation of teaching teams during the admission process. We found three common themes in our analysis (1) therapeutic plans did not always address the patient’s chief concern, (2) most diagnoses lack etiologic specificity, and (3) the pathophysiology of the underlying disease state was often not discussed in detail. We designed an inverted pyramid that is patient-centered and breaks down the most likely primary working diagnosis at three levels (a) clinical syndrome, (b) undifferentiated diagnosis, and (c) etiologic diagnosis. For each level of specificity, the pyramid prompts clinicians to propose a management plan. The structure of the pyramid encourages the clinician to ensure that the treatment plan considers the symptoms, disease state, and etiology in the management reasoning process.

EVALUATION: We will pilot our framework during our weekly clinical reasoning conference at the VA during February and March of 2023. At the end of each session, we will survey residents on their intent to use the framework in future admissions, intent to teach the framework to medical students and interns, and we will conduct a focus group to assess perceptions on usability for an iterative version.

DISCUSSION / REFLECTION / LESSONS LEARNED: Few tools exist to promote the practice and teaching of the intersection between patient-centered diagnostic and management reasoning in the GME setting. Furthermore, tools like management scripts are not explicitly tied to diagnostic reasoning tools with which residents may be more familiar. This cognitive tool gives residents a framework to practice and teach both diagnostic and management reasoning during clinical practice.

ONLINE RESOURCE URL: Look the following video to see the inverted pyramid in action. https://youtu.be/zWKBi7fEWAU

THE RURAL HEALTH EQUITY TRAINING COLLABORATIVE : PROVIDING ENHANCED ADDICTION MEDICINE TRAINING IN A COMMUNITY-BASED PRIMARY CARE INTERNAL MEDICINE RESIDENCY PROGRAM

Judith Griffin

Internal Medicine, Cayuga Health System, Ithaca, NY. (Control ID #3876312)

SETTING AND PARTICIPANTS: This primary care internal medicine (IM) residency program is located in rural, upstate New York (Ithaca) at the community-based Cayuga Medical Center (CMC). Since starting in 2019 with with an initial cohort of 3 residents, the program has grown to 10 residents per year, the program includes up to 30 residents. The majority of the residents are international medical graduates and 60% are male.

DESCRIPTION: The Rural Health Equity Training Collaborative (RHETC) is HRSA-funded Primary Care Enhancement and Training program with a focus on opioid use disorder (OUD) in rural settings. RHETC is a partnership between CMC, REACH Medical and Tompkins-Cortland Community College Nursing program. RHETC focuses on providing clinical and didactic training on harm reduction and overdose prevention, medications for OUD, trauma-informed and non-stigmatizing care through a harm reduction and health equity lens. Residents participate in longitudinal outpatient clinical rotations, including at REACH Medical, a community-based medical practice offering lower barrier medications for OUD (MOUD), primary care and related services.

EVALUATION: To date, 24 IM residents have completed a 6-month, longitudinal clinical rotation at REACH Medical. The first three graduates of the IM program (June 2022) all completed their waiver training to prescribe buprenorphine. Twenty-eight residents received a 6-hour Addiction Medicine curriculum day (December 2022) with lectures on harm reduction and overdose prevention, OUD/MOUD, and other SUDs (stimulants, alcohol, sedative-hypnotics, tobacco), as well as case-based discussions on SUD. An anonymous post-lecture survey was completed by 13 residents (46% 3rd year, 31% 2nd year, 23% first year). After these lectures, 62% strongly agreed and 38% agreed with having a better understanding of harm reduction principles; 54% strongly agreed and 46% that they felt more confident in my ability to manage cases involving substance use disorder; 62% were very likely and 38% were likely to prescribe medications for opioid use disorder in your practice when it is appropriate; 85% very likely and 15% likely to to prescribe and counsel patients on the use of naloxone to prevent opioid overdose; 23% very comfortable, 70% comfortable and 7 % neutral on their ability to counsel patients in harm reduction for ongoing substance use; 39% strongly agreed, 46% agreed and 15% were neutral that the lectures increased their interest in providing addiction medicine services in the community.

DISCUSSION/REFLECTION/LESSONS LEARNED: Our experience developing and implementing a harm reduction, equity-focused clinical and didactic Addiction Medicine training program for primary care IM residents indicates a high level of interest and impact. To date, all 3 graduating residents completed their x-waiver training, and residents reported that an addiction medicine curriculum day increased their interest in high levels of confidence in their ability and likelihood of providing MOUD, naloxone prescribing and counseling in the future.

TRAINING THE NEXT GENERATION OF INTERNISTS FOR HIGH-FUNCTIONING PRIMARY CARE: AN INTEGRATED PANEL MANAGEMENT AND QUALITY IMPROVEMENT CURRICULUM

Christine Krueger¹; Mary C. Higgins-Chen²

¹General Internal Medicine, Yale School of Medicine, New Haven, CT; ²Internal Medicine, Yale New Haven Health, New Haven, CT. (Control ID #3877269)

SETTING AND PARTICIPANTS: Fifty-four internal medicine primary care residents participated in an ambulatory-based curriculum which took place once a week during ambulatory blocks for a total of 15 hours over 9 months.

DESCRIPTION: Managing chronic diseases and providing preventive services are the backbone of primary care. Less than 10% of Americans receive all high-priority, appropriate clinical preventive services. Chronic diseases are the leading cause of death and disability in the US. Value-based care strategies can improve chronic disease outcomes and delivery of preventative services.

Training the primary care doctors of tomorrow requires teaching principles to provide high-value primary care. In this novel 9-month longitudinal curriculum, residents first learned the basics of quality improvement (QI) methodology. Then, they learned how to use software tools to perform panel management (PM), including examining, tracking, and reporting patient outcomes. Through an equity lens, they identified patient populations that were receiving sub-par care. They worked with the care team to identify and understand processes that contributed to patient care deficiencies. They used PDSA cycles to pilot methods to address the care gaps.

EVALUATION: The curriculum was evaluated qualitatively (focus groups) and quantitatively (pre- and post-questionnaires).

DISCUSSION / REFLECTION / LESSONS LEARNED: The inaugural year of the curriculum was a success. All residents used PM skills to identify gaps in the rates of cancer screening. Several PDSA cycles were completed to streamline processes, perform in-reach and out-reach, and engage patients in care to close care gaps.

The curriculum filled a need: 44% of residents had never had a formal QI course and 46% felt uncomfortable designing or implementing a QI project. However, most (90%) thought that QI was important to improve patient care. Most (80%) residents had no training in PM tools but 100% thought it was important for improving patient care.

The curriculum improved resident comfort in both QI and PM skills. Residents who felt comfortable designing a QI project improved from 38% to 70%. Residents who were “not at all confident” in their PM skills decreased from 38% to 3%; residents who felt moderately, very, or extremely confident in their PM skills increased from 30% to 70%. Residents liked focusing on their outpatient clinic and learning aspects of QI within the framework of an experiential project. They enjoyed learning how to use PM to better understand their patient panels. They thought that it was a powerful tool that felt relevant to their future practice.

There were many lessons learned that were incorporated into the second year of the curriculum. The 6+2 schedule led to a disjointed experience for some. Residents preferred more autonomy over choosing individualized projects.

USING CASE COMPETITIONS TO DEVELOP SKILLS FOR SYSTEMS LEVEL CHANGE

Shub Agrawal, Mackenzie L. Garcia

Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #3877143)

SETTING AND PARTICIPANTS: Our Health Equity Day Case Competition engages learners across our academic center; participants included undergraduate students, medical students, medical residents, and pharmacy residents who are reached via university wide email. In the first year our prompt asked participants to articulate a solution to social death in the hospital. Our second year, the prompt asked participants to create an intervention to address equity in access to the COVID-19 vaccine.

DESCRIPTION: Case competitions are competitive pitch events where teams propose a solution to a real- world problem. They are used in the business world to foster innovation and develop skills required to lead interdisciplinary teams. Though they are rare in medical education, case competitions provide unique opportunities to assess communication and leadership skills. Creating a case competition starts by identifying competitoin hosts, identifying a prompt, and recruiting diverse stakeholders to act as judges. Additional steps include recruiting and coaching participants.

EVALUATION: We gather data in the following areas: 1) the quality of the submitted solutions, 2) the impact of the competition on the participants, and 3) how often the winning solution results in the creation of the proposed solution. Using a 5-point Likert scale, submissions were rated on the clarity of the problem statement, the feasibility of the potential intervention, the articulation of the goals and the persuasiveness of the presentation. For future competitions, we plan to evaluate the perceived impact of the competition on participants via survey and structured interviews.

DISCUSSION / REFLECTION / LESSONS LEARNED: We have found case competitions to be an effective tool for engaging a wide array of learners in solving complex, and often overwhelming problems. Advantages of using a case competition format include allowing residents to problem-solve diverse topics without formal research, providing skills to reframe problems as an opportunity for advocacy and innovation, and encouraging participants to reframe themselves as more than researchers or reporters, but as change agents. Our initial feedback from learners is consistent with this, with a resident stating, “I feel like I could actually make a difference again.” Additionally, those that participated in judging found the competition engaging, and “the most fun I’ve had while judging.” Though the participants we have worked with have found the experience meaningful, our biggest challenge has been building awareness and recruiting a diverse set of participants. We’ve also found participants’ lack of familiarity with the case competition format has been a barrier to entry. To address this barrier, we plan to offer a coaching service to those who are interested in participating. In the future, we hope to use the case competitions to provide an opportunity to partner with local community organizations, both by collaborating on an initial case prompt and using community stakeholders as judges.

Innovation in Medical Education (IME) - Curriculum Development- UME

A NOVEL EDUCATIONAL SESSION FOR PRIMARY PALLIATIVE EDUCATION IN UNDERGRADUATE MEDICAL EDUCATION

Emily Chan¹; Simon Wallace²; Miguel A. Paniagua¹; Jennifer Olenik¹; Alana Sagin¹

¹Department of General Internal Medicine, University of Pennsylvania, Philadelphia, PA; ²VA Medical Center Corporal Michael J Crescenz, Philadelphia, PA. (Control ID #3870600)

SETTING AND PARTICIPANTS: Students in the class of 2024 in their clerkship stage of training from one large medical school in the Mid-Atlantic US were included. The session was piloted July 2022.

DESCRIPTION: A novel flipped and multimodal educational session designed to introduce primary palliative care skills including pain management in serious illness was piloted. This session takes place within a comprehensive and longitudinal primary palliative care curriculum. Students independently watched a pre-recorded 45-minute didactic lecture on pain management in serious illness, including an introduction to prescribing opioids. This was followed by a one-day in-person small-group interactive session that utilized an evolving case recorded with actor portrayal and interspersed discussion facilitated by practitioners from various disciplines within palliative care using a facilitator’s guide. In addition to pain management, participants also learned introductory skills in managing other symptoms like nausea and constipation.

EVALUATION: Students completed a six-item test before and after the session evaluating their knowledge of pain management. Pre- and post-test results were compared using a two-tailed t-test. 108 students completed the pre-test and 109 students completed the post-test. There was a statistically significant improvement in mean score out of a total of 6 points (3.787 vs 4.303, p=0.005). Subjective comments were collected from students in a focus group after the educational session

DISCUSSION / REFLECTION / LESSONS LEARNED: Education on the primary palliative care skills of pain and symptom management in serious illness can be effectively delivered with a flipped and multimodal session in undergraduate medical education. Generally, students found this session to be valuable and commented that they wished there was more opportunity to practice opioid dosing and management. They also enjoyed using a video-based case to practice applying pain and symptom management strategies. The pre- and post-test results will be used to further refine the didactic lecture. This approach could be replicated at other medical schools to improve the foundation of primary palliative care skills in undergraduate medical education.

A NOVEL TWITTER-BASED CURRICULUM FOR THIRD-YEAR MEDICAL STUDENTS ON THE INTERNAL MEDICINE CLERKSHIP

Maxwell Hart¹; Nathaniel Long²; Susan Veldheer³

¹Internal Medicine, Banner University Medical Center Tucson, Tucson, AZ; ²Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ³Family and Community Medicine and Public Health Sciences, Penn State College of Medicine, Hershey, PA. (Control ID #3873826)

SETTING AND PARTICIPANTS: Implementation of this curriculum took place at an academic medical center with an associated medical school in the Mid-Atlantic region. Target learners for this curriculum were third-year medical students on an internal medicine (IM) or medicine subspecialty rotation.

DESCRIPTION: The goal of our Twitter-based curriculum was that medical students in the IM clerkship would explore and utilize Twitter during their IM clerkship to supplement their medical knowledge, actively engage in dialogue, and develop more meaningful connections with other members of their communities of practice (other students, residents, and attending physicians). This course was comprised of a series of 18 Twitter threads that were published over the course of 10 weeks from a Twitter account run by this project’s authors. Each thread covered high-yield clinical "pearls," small pieces of medical information that are pertinent to a third-year medical student's experience throughout an IM clerkship. Tweets utilized a variety of media including combinations of polls, pictures, videos, diagrams, flowcharts, and links to relevant literature. Prior to the clerkship, a short lecture was given to students to make them aware of the curriculum and encourage them to participate. Each Twitter thread encouraged students to interact in the online space, share ideas, and develop their own learning points.

EVALUATION: Using Twitter Analytics, data was obtained including Tweet impressions (number of times that Tweet was seen on Twitter) as well as Tweet engagements (total number of times a user had interacted with a Tweet including retweets, replies, follows, and likes). The first Tweet of a series (the poll/quiz) had much higher impressions than the last Tweet of the series. Number of votes in the poll/quiz ranged from 9 to 69. Some of the Tweets with the highest number of impressions covered content related to residency application and general tips for success on the wards. Topics with the highest impressions included urinary tract infections (69 poll votes and 2826 impressions), congestive heart failure (62 poll votes and 1217 impressions), and shock (42 poll votes and 1296 impressions). Using Twitter Analytics alone, the authors were unable to discern how many clerkship students were engaging with the content and how many other Twitter users engaging with the content, given that the account is public and available to all who follow the Twitter account.

DISCUSSION / REFLECTION / LESSONS LEARNED: The authors present this work as part of an ongoing project. As a pilot program, it was decided to make student participation voluntary in this project. In this sense, the curriculum served as a “para-curricular” resource for students on their IM clerkship. Future iterations of this curriculum will include student focus groups and pre/post-clerkship surveys aimed at better defining the utility of a Twitter-based curriculum. Future work will also include assessing knowledge that students gained from this intervention.

ONLINE RESOURCE URL: https://twitter.com/PSUIMReport

BUILDING BRIDGES: THE STATE HEALTH POLICY SCHOLARS PROGRAM- LEGISLATIVE ADVOCACY TRAINING FOR MEDICAL STUDENTS

Vineeth Amba^1,2; Taylor Glassman^1,2; Anthony Gallo³; Shilpa Pai¹; Kristen Coppola⁵; Joshua Bengal²; Alejandra Casillas⁴

¹Robert Wood Johnson Medical School, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ; ²Medical Society of New Jersey, Lawrenceville, NJ; ³Cleveland Clinic, Cleveland, OH; ⁴Medicine, David Geffen School of Medicine @ UCLA, Los Angeles, CA; ⁵Psychiatry, Rutgers, RWJMS, Piscataway, NJ. (Control ID #3875861)

SETTING AND PARTICIPANTS: Health policy and advocacy training is rare in medical school curriculums, partly due to a focus on the basic and clinical sciences in medical education, and a lack of faculty expertise. However, such initiatives will be necessary as the locus of medical care shifts towards addressing the social determinants of health. We describe the new State Health Policy Scholars Program (SHPSP), a collaboration between students from Mid-Atlantic Region academic medical centers and medical society lobbyists. Through a health policy curriculum and immersive opportunities in the state legislative process, the SHPSP aims to build foundational skills for student engagement in health policy action at the local, state, and federal levels.

DESCRIPTION: SHPSP is a free, virtual program that runs annually from September to April offered both real-time and asynchronously. Advertising strategies involve faculty leadership and student leaders in advocacy-related groups. The overarching goals of this program are to help students acquire the foundations to engage in state health policy action (ex. lobbying and testifying), discover personal interests in policy or advocacy, and develop as physician-leaders. Specific topics include Organized Medicine, Building Relationships with State Officials in Advocacy, Understanding Health Policy Literature, Communicating Across the Aisle, and Strategies for Effective Physician Lobbying. Students also participate in the SHPSP culminating experience- a coordinated lobbying day with state legislators annually in March.

EVALUATION: SHPSP has maintained an average of 85 medical students for each workshop this year, with balanced representation from all five partner medical schools. Students will work with five lobbyists, two physician-advocates, a director for state policy research, and a variety of legislative officials. Post-workshop evaluation comments by students have pointed to the following themes: appreciation for the intersection of medicine and politics, understanding of the importance of integrating personal experience with scientific evidence to persuasively advocate a position, and ability to create opportunities for future political action.

One student wrote, “I learned that to become physician leaders, we must engage in the field in health policy. This program fills that need, with its broad application it will empower us to advocate for endless causes moving forward”.

DISCUSSION / REFLECTION / LESSONS LEARNED: A novel collaborative of academic medical centers and a state medical society brought new and unique perspectives to medical students. SHPSP worked to eliminate barriers to participation by ensuring curricula was inclusive to individuals without prior knowledge of health policy or advocacy, and via the provision of asynchronous workshop virtual options.

Our model is on track to be a sustainable initiative in our region, and we anticipate that other medical institutions may successfully adopt it as a solution to the national education gap in health policy and advocacy.

CLERKSHIP TRANSITIONS: ALLEVIATING STRESSORS OF THE TRANSITION TO THE CLINICAL CLERKSHIPS

Stacy Rubin, Lisa C. Martinez, Jennifer Foster, Allison Ferris, Michael Mamone

Medicine, Florida Atlantic University, Boca Raton, FL. (Control ID #3870704)

SETTING AND PARTICIPANTS: Simulation activity involving students transitioning from second to third year.

DESCRIPTION: Plenty has been published around the transition to residency, but there are limited data on the move to clinical clerkships for medical students. The anticipation of this transition leads to increased stress in students. There are limited opportunities for pre-clerkship students to develop their clinical skills in settings that mirror their future clerkships and provide formative feedback from faculty and peer coaches on the knowledge, skills and attitudes necessary for success thus, alleviating stress. Transition courses that bring students into settings that mirror future clerkship experiences have shown to be helpful. We created an Introduction to Hospital Medicine course that provides students with both real and simulated experiences in hospital settings. One highlight of the course is "Roundsmanship" where students participate in simulated rounds, including resident pre-rounds, nursing communication and attending rounds.

EVALUATION: All students completed an evaluation of the course and the preparation for the inpatient experience. 98% felt that it improved their understanding of the organization of inpatient care and 89% stated it improved their understanding of their role as a third year student.

DISCUSSION / REFLECTION / LESSONS LEARNED: This session has been successful in allowing students to better understand their role as a third year student. It also introduces them to the more acute inpatient setting. The incorporation of residents into the session also allows for further mentorship in a low stakes environment. Residents also gain insight into how students are trained to participate on rounds, and can more clearly guide them once they arrive on their clerkship rotations. One issue that we did encounter is the timing of this session. Placing it before the students take Step 1 lead to some disinterest, but placement immediately at the start of third year was better positioned.

COACHING IN HUMANISM: A PILOT PROGRAM FOR MEDICAL STUDENTS

Meagan Matuska¹; Diane Rogers²; Deanna Frings²; Nicola Orlov¹

¹Pritzker School of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; ²The hArt of Medicine, Phoenix, AZ. (Control ID #3875853)

SETTING AND PARTICIPANTS:

Setting: The setting for this medical education pilot project was the pediatric clerkship rotation of a medical school with a traditional curriculum.

Participants: Data collection for this project is ongoing. Participants in this project will be the 88 members of the medical school's Class of 2024; to date, 40 of those students have completed the intervention.

DESCRIPTION:

Objective: The objective of this innovation was to (1) pilot an academic coaching program within a traditional medical school’s clinical curriculum and (2) assess the program’s impact on medical students’ confidence in demonstrating [empathy, humanism, patient-centeredness] at the patient bedside.

Coaching Program: The academic coaching program employed in this project was adapted from the hArt of Medicine – a pre-existing, evidence-based coaching framework – to directly address the skills of empathy, humanism, and patient-centeredness within medical students.

Innovation: Each third-year medical student participant completed one academic coaching experience while on their pediatric clerkship rotation. The experience consisted of (1) a 15-minute patient encounter in which the student was virtually observed by their academic coach, and (2) a 45-minute coaching conversation in which the coach provided focused feedback on the student’s demonstration of empathy, humanism, and patient-centeredness at the patient bedside.

EVALUATION:

Assessment: Using a pre-post survey design, medical student participants were surveyed before and after their coaching session. To provide evidence for instrument validity, the pre- and post-surveys were developed through an iterative process over the course of 2 months following guidelines from Academic Medicine. Survey results were collected in REDCap and analyzed in Excel.

Outcomes: To date, 40 third-year medical students have completed the coaching intervention and associated surveys. Paired t-tests showed that medical student confidence in demonstrating empathy, humanism, and patient-centeredness at the bedside significantly increased following a coaching experience. Further, the large majority of students identified the coaching experience as a valuable part of their clerkship rotation (97.5%) and expressed a desire for more coaching in the future (92.5%).

DISCUSSION / REFLECTION / LESSONS LEARNED: With empathy, humanism, and patient- centeredness linked to important patient outcomes, it is crucial that medical school curricula place a formal emphasis on their development. The results from this pilot project show that academic coaching is a potential avenue through which medical schools can formally address these skills, and thus should be explored broadly as a means to cultivate the communication skills of our future physicians.

ONLINE RESOURCE URL: The hArt of Medicine coaching framework: https://hartofmedicine.com/

CONFRONTING SACRED “TRUTHS” – A NEW APPROACH TO COMMUNICATIONS SKILLS TRAINING

Paul Haidet¹; Amanda B. Cooper²; Katharine Dalke³; David Richard⁴; J. Andy Probolus⁵; Stephen Henderson⁵; Richard L. Street⁶

¹Medicine, Humanities, Public Health Sciences, Penn State College of Medicine, Hershey, PA; ²surgery, Penn State College of Medicine, Hershey, PA; ³psychiatry, Penn State College of Medicine, Hershey, PA; ⁴family and community medicine, Penn State College of Medicine, Hershey, PA; ⁵medicine, and family and community medicine, Penn State College of Medicine, Hershey, PA; ⁶communication, texas a&m university, Collegfe Station, TX. (Control ID #3874737)

SETTING AND PARTICIPANTS: A 36-hour course in communications skills for second-year medical students in the latter half of their pre-clerkship education. Settings included large (140 students) and small (7-8 students plus a faculty facilitator) group sessions.

DESCRIPTION: Communication skills courses are commonplace in undergraduate medical curricula and tend to follow a strong set of common-sense ideas about what works best. When we were tasked to overhaul the longstanding Communications course at our medical school, we took the opportunity to step back and re- examine such common-sense notions. Our approach was grounded in the theoretical framework of deliberate practice, as articulated by Anders Ericsson and others. In the process, we confronted several sacred “truths” and made conscious, theoretically-driven design choices that diverged from typical practice in teaching communication. First, we designed course objectives NOT to increase skill (because 2^nd-year students do not have significant affordances to practice), but rather to develop sophisticated mental representations of patient- centered communication. Second, we focused course content on specific behaviors (e.g., following the narrative thread, increasing latency time) rather than scenarios (e.g., breaking bad news). Third, we developed communication simulations to reinforce individuals’ mental building blocks and improvisation thereon, rather than applying algorithms or mnemonics (e.g., BATHE, NURS, etc).

EVALUATION: Preliminary data from course facilitators, standardized patients, and students’ feedback and assessment suggests that the course has transformed students’ mental models of patient-centered communication. Course facilitators and standardized patients described extraordinary growth in students’ communication behaviors as a result of this transformation. We plan formal qualitative and quantitative data collection about the effects of this course upon its completion in January.

DISCUSSION / REFLECTION / LESSONS LEARNED: Ericsson and colleagues point out that expertise and mastery is only gained through deliberate practice, with a key differentiating factor between deliberate practice and rote repetition being the presence of a robust mental representation. We designed a course to focus squarely on mental representations of patient-centered communication, which, to date, appears to have achieved gains that none of us observed previously in our teaching careers. This experience has compelled us to examine and challenge our own mental representations of effective ways to approach communications skills training.

DEVELOPING A CLINIC TO PROVIDE ASYLUM EVALUATIONS AT AN ACADEMIC MEDICAL CENTER

Farah Shaheen¹; Sharad Jain¹; Maha Kazmi²; Soroush Ershadifar²; Ellen Shank³; Fransia S. De Leon⁴

¹Internal Medicine, University of California Davis Department of Internal Medicine, Sacramento, CA; ²School of Medicine, University of California Davis, Davis, CA; ³Emergency Medicine, University of California Davis Health System, Sacramento, CA; ⁴Medicine, University of California Davis, Davis, CA. (Control ID #3872502)

SETTING AND PARTICIPANTS: Asylum evaluations were completed by faculty and learners at an academic medical center in the California-Hawaii region.

DESCRIPTION: Faculty at an academic medical center identified a need to provide medical evaluations to clients seeking asylum. A local Human Rights Initiative (HRI) was started to provide forensic documentation of the physical and psychological manifestations of torture and ill-treatment experienced by individuals applying for asylum in the United States. Faculty mentors developed relationships with local immigration attorneys to identify appropriate clients, participated in asylum trainings, identified space for examinations, and started to complete evaluations to be included in the clients’ applications. Students and residents joined the team and now assist in all aspects of this process, thereby becoming integral to the clinic’s function. In addition, faculty and learners have started a discussion series to educate the broader medical school community about the unique health issues faced by immigrant communities, including legal partners to weave in legal context where appropriate.

EVALUATION: This project is still in its early stages, and quantitative and qualitative evaluation is ongoing to inform program improvement. We have established partnership relationships with lawyers in our community and continue to receive feedback from them on ways to improve our efforts. We also track the number and status of the clients with whom we have worked so we can better understand the impact of our work. Additionally, our assessment data from our lectures have been outstanding, with talks receiving very high evaluations from the student audience. Finally, we plan to pool data from our institution with others with similar initiatives to create scholarship opportunities in this important area.

DISCUSSION / REFLECTION / LESSONS LEARNED: There is a significant need for medical and mental health providers to assist with forensic asylum evaluations, as data shows that physician collaboration with immigration lawyers considerably increases the success of their clients receiving asylum. This initiative is an outstanding example of community partnership and service-learning activities for physicians and trainees that can have a significant positive impact on their community. There is considerable student interest in these efforts, and our work has inspired students and residents to learn more about the advocacy and care of asylees and to participate in client evaluations, as part of their commitment to making the world around them a better place. We hope to highlight opportunities and challenges so others can implement a similar model at their own institution.

ONLINE RESOURCE URL: None

DEVELOPING A STUDENT-DRIVEN GENDER AND SEXUAL HEALTH CLINICAL ELECTIVE

Jenna Moser¹; Richard E. Greene²; Rebecca Markson²

¹Office of Medical Education, New York University Grossman School of Medicine, New York, NY; ²Medicine, NYU Grossman School of Medicine, New York, NY. (Control ID #3865312)

SETTING AND PARTICIPANTS: This curriculum is designed for third and fourth year undergraduate medical students at an academic medical center in the Northeast.

DESCRIPTION: The purpose of this project is to develop a curriculum for a clinical student elective rotation focused on caring for patients with diverse gender identities and sexual orientations. By designing an elective curriculum focused on this patient population, the intent is to increase medical student familiarity, knowledge, comfort, and competence in delivering quality healthcare to LGBTQ+ patients. The curriculum will aim to achieve this by building on prior LGBTQ+ health curriculum, with a multi-disciplinary didactic and clinical experience for students designed to teach best practices and allow students to develop core competencies in LGBTQ+ healthcare.

EVALUATION: Evaluation methods include pre- and post- surveys of students assessing their level of comfort and perceived level of competence with various aspects of LGBTQ+ healthcare. Objective assessments include pre- and post- exams to assess medical knowledge and assessment of clinical skills via simulated patient encounters.

DISCUSSION / REFLECTION / LESSONS LEARNED: Among the first steps in designing the elective was to determine what knowledge and skills are necessary for medical students to learn in order to provide quality care to LGBTQ+ patients across clinical settings, and to identify where gaps exist in the current clinical curriculum. While there is still a need for continued research to determine how best to address the health care needs of this community, there are resources from reputable organizations such as the AAMC, WPATH, the Fenway Institute, etc. which outline competencies. Assessing the existing clinical curriculum was challenging, complicated by the need to evaluate many individual clerkship rotations, as well as the fact that students' exposure to LGBTQ+ patients is not standardized across rotations. Identifying sufficient expert faculty, and affirming clinical settings with a sufficient LGBTQ+ population, to accommodate students for the elective is also a challenge. In addition to meeting the needs of students, the curriculum must also prioritize patient comfort and safety; many LGBTQ+ patients seek out specific providers and clinics that they know to be affirming. It can be difficult to incorporate students, who may still be learning how to properly approach sensitive issues around LGBTQ+ health, into this interaction. Finally, by virtue of designing a curriculum that is "elective" rather than required, this project faces the likely problem of attracting largely students who already have an interest in LGBTQ+ health, and additionally may give the erroneous perception that caring for the health of LGBTQ+ people is supplemental or optional. However, despite these issues, this elective provides a foundation for developing curriculum, building capacity, and identifying faculty and clinical sites.

DON’T WAIT TO TALK ABOUT WEIGHT: A NOVEL WEIGHT MANAGEMENT COMMUNICATION SKILLS CURRICULUM FOR MEDICAL STUDENTS

Anita Ganti¹; Elizabeth Oczypok²; Amar Kohli³

¹Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ²Department of Medicine, VA Pittsburgh Healthcare System, Pittsburgh, PA; ³General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #3873675)

SETTING AND PARTICIPANTS: Two ambulatory faculty delivered this curriculum to 3^rd and 4^th year medical students at a large academic medical center during their required 4-week Adult Outpatient Medicine Rotation (AOMC) beginning in June 2022.

DESCRIPTION: Obesity is an important public health concern and its burden on the healthcare system is significant. Providers at all levels of training are not adequately prepared to discuss, let alone manage obesity. Studies show that medical students want more opportunities to practice these skills during their training. To fill this gap, we developed and implemented a curriculum focused on both knowledge and communication skills related to weight management. The interactive didactic focused on the multimodal approach to obesity including nutrition, physical activity, behavioral change, pharmacotherapy, and bariatric surgery, the elements of a complete weight history, and use of people first language when talking about weight. This was followed by a one-on-one standardized patient encounter designed to practice these skills in real time as they work through a weight management case scenario. Students received formative feedback directly after this encounter from the standardized patient. Students’ skills were then evaluated during a summative observed structured clinical examination (OSCE) with a weight management focused case and unique checklist developed by our team in collaboration with the Standardized Patient Program at our institution.

EVALUATION: Between March 2022 – May 2022, 24 students rotated through AOMC and participated in a weight management case during their summative OSCE. Between June 2022 – August 2022, 34 students received the weight management curriculum and completed the weight management case during their summative OSCE. Students who participated in the weight management curriculum were more likely to ask permission to discuss weight (P < 0.05) and to obtain a complete weight focused history (p < 0.05). They were also more likely to set a complete SMART goal with their patients during an encounter (p < 0.001).

DISCUSSION / REFLECTION / LESSONS LEARNED: This curriculum represents a successful interdisciplinary collaboration between educators of various backgrounds in developing and delivering a weight management curriculum for medical students that fills an important gap in training. To ensure we could evaluate the success of our curriculum, we first developed our evaluation tools, including our OSCE checklist and cases with our specific curricular aims in mind. These were developed with input from our standardized patient team with expertise in case development and portrayal. They also provided valuable insight on the complexities of portrayal of these cases given the sensitive topic, and how to account for it in both the case development and delivery. Further data on student perceptions of the curriculum and their comfort with these conversations will be collected and can be incorporated into future iterations of this curriculum.

EFFICACY OF A PRECLINICAL LEARNING SCIENCE TEST-TAKING SKILLS COURSE ON CURRICULAR AND NATIONAL EXAMINATION PERFORMANCE

James T. Boothe^1,2; Lynn Foster-Johnson³; Tiffany D'cruze⁴; William Eidtson³

¹Department of Medicine, Johns Hopkins Medicine, Baltimore, MD; ²Johns Hopkins University School of Medicine, Baltimore, MD; ³Department of Medical Education, Dartmouth College Geisel School of Medicine, Hanover, NH; ⁴Dartmouth College Geisel School of Medicine, Hanover, NH. (Control ID #3872392)

SETTING AND PARTICIPANTS: The intervention involved all students (n=84) at the conclusion of the second year in the curriculum at a medical school in New England.

DESCRIPTION: Medical school curricula focus on training students in the basic sciences, clinical skills, and professional competencies necessary to practice as a physician. Many studies demonstrate instructional approaches that effectively improve medical learners' acquisition of biomedical and clinical knowledge. It is notable that, despite the importance of successful performance on standardized medical examinations (such as the USMLE series) for medical learners, there is little work demonstrating the utility of formal instruction in test-taking skills.

We designed and implemented a mandatory 7-session course for a class of 84 medical students at the end of their second year in the curriculum. We provided formal instruction on general test preparation strategies, question archetypes, and methods for constructing and deconstructing board-style multiple-choice questions used in standardized medical examinations. Instructional approaches included lectures, large-group active discussion, and small-group exercises.

EVALUATION: A repeated measures-matched pairs design was used to evaluate the impact of the test- taking training on multiple-choice written assessments measuring students' biomedical and clinical knowledge and understanding of test-taking strategies. Pre- and post-analyses of the effectiveness of the test- taking skills instruction show a statistically significant increase in students' foundational and clinical sciences knowledge scores after taking the course (p < .001). Post-course increases in associated scores on questions directly assessing test-taking skills were also statistically significant (p < .01). However, aggregated analysis of subsequent national examination performances showed that although the median USMLE Step 1 scores of participants were higher than the median scores of a matched comparison group (who were not in the intervention), the differences did not reach statistical significance.

DISCUSSION / REFLECTION / LESSONS LEARNED: These results are from a single medical school, limiting the generalization of results to the broader medical school community. Additional test-taking instruction may be necessary to impact standardized exam performance. However, these results demonstrate that participation in formal instruction on exam preparation and test-taking skills was associated with improved performance on assessments of both medical knowledge and test-taking skills, holding promise for future development of this curriculum to ideally produce measurable improvement in performance on both medical school course assessments and national medical standardized board examinations. Currently, this annual mandatory course is being expanded with additional content focused on applications of metacognition and learning science for medical learners, and the course is being broadened into a longitudinal curriculum that spans the two preclinical years.

HEALTH SYSTEMS SCIENCES EDUCATION: A BIDIRECTIONALLY MEANINGFUL EDUCATIONAL EXPERIENCE FOR RESIDENTS AS TEACHERS AND MEDICAL STUDENTS Karthik Sreedhara¹; Ghazaleh Goldar¹; Andrew M. Ford¹; Ian Persits¹; Jacqueline Baikovitz¹; Nicole Farha¹; Amy Maneker⁴; Vicente J. Velez³; Cory Chevalier²

¹Internal Medicine, Cleveland Clinic, Cleveland, OH; ²Palliative Medicine & Internal Medicine, Cleveland Clinic, Cleveland, OH; ³Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH; ⁴Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH. (Control ID #3874894)

SETTING AND PARTICIPANTS: Senior internal medicine residents from the specialized Clinician Educator Track (CET) developed curriculum for and taught a longitudinal Health Systems Sciences (HSS) course with faculty experts for third-year medical students.

DESCRIPTION: The initiative aimed to provide residents with an opportunity to develop skills needed for success as clinician-educators. Over the course of one year, six PGY-2 and PGY-3 CET residents were responsible for development of five HSS workshops: 1) high value care and cost of diagnostic testing, 2) development of a quality improvement initiative, 3) transitions of care, 4) social determinants of health, and 5) climate change and health.

One CET resident per workshop served as co-leader with a designated faculty expert, responsible for creation of a case-based curriculum in one HSS domain over a 10-week planning period for each workshop. The resident leader met with the faculty expert to seek feedback on learning objectives, content, and structure. They wrote manuals to provide the remaining CET residents with guiding questions to facilitate small groups discussions.

For example, the workshop on high value care (see URL below) began with a didactic lecture and shifted to a case of first-time venous thromboembolism. Small groups discussed criteria to screen for inherited thrombophilia, merits of panel testing and strategies to reduce improper testing. The second case was of a patient presenting to a clinic with acute low back pain seeking imaging. The discussion focused on lab testing in preventative care, appropriateness of imaging for uncomplicated low back pain, resources for evidence- based testing and patient/physician/payer factors that promote unnecessary testing.

EVALUATION: Outcomes included the resident’s satisfaction with the program structure, curriculum planning process, and their interactions with the faculty expert, as well as medical student satisfaction with content and their facilitator. Data were collected via questionnaires distributed to workshop leaders and students after each session, answered on a Likert scale (see URL below). After each session, the workshop leaders and resident facilitators also participated in a focus group to reflect on the curriculum planning process and the session. The discussion was transcribed to develop actionable changes for later sessions.

DISCUSSION / REFLECTION / LESSONS LEARNED: Overall, students felt the course material was relevant to their education and appreciated that residents could share clinical insights appropriate to their level of training. They also provided specific feedback to their respective resident facilitator. Workshop leaders felt the program offered a meaningful opportunity to develop as educators as it allowed for independence and ownership of the curriculum. They also reflected on their first experience navigating curriculum development with multiple team members including faculty and the importance of relationship building with all key program stakeholders to achieve shared goals.

ONLINE RESOURCE URL: https://tinyurl.com/2p95ee4x

HUNGRY FOR NUTRITION: AN ELECTIVE FOR SENIOR MEDICAL STUDENTS

Kristen A. Ehrenberger³; Nora Porter¹; Mackenzie A. Stice²

¹Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO; ²University of Minnesota Health Sciences, Minneapolis, MN; ³Internal Medicine & Pediatrics, University of Pittsburgh, Pittsburgh, PA. (Control ID #3876968)

SETTING AND PARTICIPANTS: Third- and fourth-year medical students at medical schools in the United States (Mid-Atlantic, Mid-West, and Southern regions)

DESCRIPTION: This is an interdisciplinary, partially synchronous elective for advanced undergraduate medical students covering core topics in nutrition across the lifespan from both clinical and historical perspectives. The syllabus consists of 17 free-standing modules with pre-class preparation (articles, podcasts), lecture topics or discussion questions, and 3 student research projects. Having been piloted at one institution, the syllabus is being taught at other medical schools to determine the feasibility of implementation in diverse settings, from large academic centers to smaller regional campuses.

EVALUATION: The pilot course (Pitt IRB# STUDY22010051) was evaluated by a post-course survey of attitudes; students self-reported improved knowledge of both clinical skills (calculating total parenteral nutritrion [TPN], counseling about nutrition labels) and historical content (the racialized history of diabetes mellitus, the origins of fad diets). The current course (Pitt IRB# STUDY22100100) is being evaluated at all sites by pre- and post-course surveys of both subjective attitudes and objective knowledge, using questions adapted from the secondary literature. Preliminary data from both studies suggest that students desire more education on nutrition and that this curriculum improves both clinical skills and historical knowledge relating to high-yield topics such as obesity and hypertension.

DISCUSSION / REFLECTION / LESSONS LEARNED: Both patients and trainees are clamoring for more attention to nutrition. This curriculum seeks to answer that call. It is innovative not just in its content– which ranges from the history of infant formula to the latest refeeding guidelines in anorexia nervosa–but also in its method of delivery. Class can be partially or wholly online for students who may be at satellite campuses, traveling during a non-clinical block, or isolating for health reasons. Because the range of topics is so broad, the course directors have partnered with local experts such as registered dieticians and bariatric surgeons for guest lectures. Such interdisciplinary collaboration is just as important in medical education as in clinical practice and provides a humbling reminder of just how deep the field of dietetics is compared to what is typically offered in medical training.

IMPLEMENTING HEALTH SYSTEMS SCIENCE AS THE THIRD PILLAR OF MEDICAL EDUCATION

Kristin Furfari, Kayla Thomas, Rita Lee

University of Colorado Denver School of Medicine, Aurora, CO. (Control ID #3862665)

SETTING AND PARTICIPANTS: As part of curriculum reform, an academic medical center in the mountain west integrated a health systems science (HSS) pillar into the core curriculum. All medical students participate in this longitudinal curriculum.

DESCRIPTION: Recognition that medical education fails to prepare students for the practice of medicine has led many schools to integrate HSS – the competencies needed for physicians to deliver high quality, value-based health care – into core curriculum. Our HSS pillar leverages the Gonzalo, et al.¹ curricular framework and focuses on structural competency. It was developed in collaboration with experts within each core and cross-cutting HSS domain¹ who identified learning objectives spanning foundational to advanced content. The content was mapped longitudinally and integrated with medical and clinical sciences pillars. HSS content is taught primarily in small groups by a cohort of trained facilitators and includes a required service-learning curriculum.

EVALUATION: Both facilitators and students evaluated the content, design, and effectiveness of sessions.

Student data shows that overall, 63.6% (n=178) agree or strongly agree (6-point scale) that sessions were engaging and facilitated learning. Slightly over half (53.3%) rated the overall quality of sessions as very good or excellent (5-point scale). While many students acknowledge the importance of HSS content, their comments suggest the time allotted to HSS is too much and could be better used to study for exams. Others would like discussions to go deeper. Facilitator feedback suggests additional faculty development would be helpful, specifically on small group facilitation of difficult conversations, discussions about racism and discrimination in medicine, and evidence-based medicine.

DISCUSSION / REFLECTION / LESSONS LEARNED: Using a framework to teach HSS content is helpful to guide curriculum development and is critical to orient students to the broad nature of HSS. Students prefer content be presented with direct clinical application and deeper conversations on issues related to health equity. Intensive faculty development is critically important to the success of curriculum implementation. Our results are in alignment with previously published literature on the challenges of implementing HSS. Per feedback, sessions will be adjusted to improve the timing and depth of content with a focus on enhancing clinical application and increasing advocacy content. We will develop a robust faculty development series with the goal of increasing content expertise, facilitation skills, and comfort navigating discussions about structural racism and oppression and health equity.

1. Gonzalo, Jed D. MD, et al. Health Systems Science Curricula in Undergraduate Medical Education: Identifying and Defining a Potential Curricular Framework, Acad Med. 2017 Jan;92(1):123-131.

INNOVATION METHODOLOGY TO EXPLORE HEALTH DISPARITIES IN A HEALTH SYSTEMS SCIENCE PRE-CLINICAL CURRICULUM

Deepa R. Nandiwada¹; Erik X. Tan²; Sam Porter³; Austin S. Kilaru⁵; Nadia L. Bennett⁴

¹General Internal Medicine, University of Pennsylvania, Philadelphia, PA; ²Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; ³Medicine, University of Colorado, Denver, CO; ⁴Internal Medicine, University of Pennsylvania, Philadelphia, PA; ⁵Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #3876281)

SETTING AND PARTICIPANTS: This course occurs in fall of the second year of medical school at the University of Pennsylvania. There are 140 students in each medical school class and the curriculum has been implemented for the 2021 and 2022 academic years.

DESCRIPTION: Health systems science (HSS) has been advocated as the third pillar of healthcare training.

HSS is an umbrella category of topics including social determinants of health, advocacy, teamwork, policy, insurance, leadership, population health, information technology, quality improvement, leadership, and patient safety. We have created a brand new curriculum that uses principles of human centered design and innovation methodology to have pre-clinical students explore health disparities through the lens of HSS and systems thinking. In this course students choose a pre-determined health systems topic including surgical healthcare disparities, racial disparities in pregnancy, gaps in child abuse screening, access to medications for opioid disorder, or racial disparities in diabetes. Students had a foundational lectures that covered insurance, high value care, innovation methodology, patient safety, quality improvement, and advocacy. Within their small groups we invited stakeholders and content experts to come for the students to do empathy based interviews to take a deep dive into their topics. Over 5 sessions, each small group interviewed a patient representative, a clinician, and a member of the interdisciplinary team or leadership team. After each interview, students developed a deliverable based on the interview including a 5 whys diagram, a fishbone, a process-journey map, and an impact-feasibility graph for brainstorming solutions. Students presented their solutions to each other and to health system leadership for their final presentations.

EVALUATION: Students wrote two health systems action commitments that they would implement on their clerkship rotations and reflected on the role of health systems science as part of the role identity of a physician. We are doing a qualitative content analysis of these reflections coded by two independent reviewers to assess where in professional identity formation the students are regarding HSS including accepting, compromising, rejecting. The commitments were also assessed for themes including innovator, systems aware clinician, systems improver, systems leader, or equity focused clinician. 115 of 144 of the 2021 class has been reviewed to date. 80% was accepting of the role of HSS in the professional Identity of a clinician, 17% compromising, and 1 individual rejected it. Of the 230 commitments 26% fell under systems thinking, 16% under high value care, and 16% as advocacy.

DISCUSSION / REFLECTION / LESSONS LEARNED: HSS, pre-clinically, is challenging as students have limited exposure to clinical care. Our goal was to provide new perspectives and tools students could use to be more comprehensive with patients while on the wards.Students struggled with balancing the importance of these topics with more traditional organ based courses.

LEARNING IN CLERKSHIPS: PROMOTING SELF-DIRECTED LEARNING AND PROACTIVITY AMONG MEDICAL STUDENTS TRANSITIONING TO CLERKSHIPS

Robert Short, Aline Zorian, Stephanie Rennke

Medicine, University of California San Francisco, San Francisco, CA. (Control ID #3874143)

SETTING AND PARTICIPANTS: Pre-clerkship medical students at a large academic medical center participated in this required 2.5-hour workshop as part of their transition to clerkships course.

DESCRIPTION: Studies have identified that early clerkship students often struggle with understanding their new roles, shifting to self-regulated learning (SRL), and demonstrating clinical skills.[1] While various forms of transition-to-clerkship curricula exist across the country, innovations targeting self-regulated learning are scarce. Self-directed learning is also a core competency defined by the LCME.[2] We created a workshop for pre-clerkship students that addresses five pillars of self-directed learning with objectives including: 1) initiate discussions regarding expectation-setting with supervisors, 2) develop personal goals to guide knowledge and skill development during clerkships, 3) ask and answer clinical questions that arise during clerkships, 4) utilize clinical downtime during clinical rotations, and 5) solicit and interpret targeted feedback. This workshop took place in groups of 6 students, facilitated by their longitudinal faculty physician “coach.” We used a case-based approach to address the learning objectives. Each case included a brief scenario, discussion questions and an associated small group exercise. For example, after presenting a case of a student struggling to prepare for their upcoming surgery clerkship, we then asked students to explore the course objectives for their first clerkship and develop two SMART goals.

EVALUATION: A total of 172 students participated in the workshop in December 2022. Seventy-four students completed both pre- and post-surveys (43%). We measured students’ perceptions regarding their (1) ability to engage in self-directed learning and (2) preparedness for clerkships using Hendry’s and Ginns’ Self- Directed Learning Readiness Scale.[3] Each item used a 5-point Likert scale (strongly disagree to strongly agree).

Example item: “I feel prepared to start a conversation with my resident or attending about their expectations of me at the start of a rotation.”

After the session, the proportion of students who felt they knew how to direct their own learning on

clerkships increased from 45.5% to 86.5%. Comfort with starting a conversation about expectations increased from 15.8% to 46.0%. Understanding of how to utilize clinical downtime increased from 5.9% to 40.0%. Strong confidence in asking for targeted feedback increased from 7.9% to 42.0%.

DISCUSSION / REFLECTION / LESSONS LEARNED: When beginning clerkships, medical students transition from being at the center of the learning environment to becoming a member of the clinical team— with the patient and team now the focus. This creates a novel onus on students to guide their own learning and professional development. We aimed to create a workshop to improve student preparedness for self- regulated learning on clerkships.

ONLINE RESOURCE URL: http://bit.ly/3FNiXRF

MANDATORY MEDICAL SCHOOL SERVICE-LEARNING CURRICULUM: IMPLEMENTATION, LESSONS LEARNED, AND FUTURE DIRECTIONS

James E. Carter¹; Kristen Vossler²; Christy Angerhofer¹; Kristin Furfari³; Rita Lee⁴

¹Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; ²Internal Medicine, University of Colorado, Denver, CO; ³Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO; ⁴Medicine, University of Colorado, Aurora, CO. (Control ID #3877310)

SETTING AND PARTICIPANTS: Academic medical center in the Mountain West with 2 branch campuses and a rural track. 184 entering medical students participate in the service-learning curriculum.

DESCRIPTION: Health and Society was added as a third curricular pillar to develop community leaders, advocates, and contributors to health equity. Our new curriculum was implemented in 2021 with a service- learning requirement as a component of health systems science education.

The service-learning curriculum is comprised of core content and community engagement. Education framed within the context of the socioecological model provides students with foundational content prior to community service, including power, privilege and position, structural racism, implicit bias, intersectionality, conflict management, and collaborative leadership.

For community engagement, we outreached to local community-based organization(s) (CBO). In the mid- first year, 184 students were matched to 67 CBO who signed collaboration agreements. Students co-designed non-clinical bi-directional service for a minimum of 60 hours over 18 months. Students log their hours and participate in narrative self-reflection.

EVALUATION: Qualitative review of narrative reflection is ongoing, looking for impact on attitude, knowledge, and skills. 5 students were rematched due to scheduling conflicts. 1 CBO relationship dissolved due to student safety concerns.

CBO are surveyed every three months. Based on preliminary analysis, students generally demonstrate knowledge of the CBO mission and utilize effective communication skills. Impact of school schedules and service-learning on CBO is being reviewed.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our service-learning curriculum is unique. It is mandatory, longitudinal, non-clinical, and not project mandated.

However, there are challenges identified from multiple perspectives. Nurturing CBO relationships require investment of administrative time and effort. Student schedules may not align and some students struggle with time management. Students often prioritize biological and clinical sciences, due to perception of the impact of the traditional pillars on medical school transcripts and the need to focus on maximizing scores for residency program acceptance. CBO adjust to accommodate, utilize internal resources, and their workforce may unpredictably change.

To measure the impact of service-learning qualitative review of reflections can identify attitudes regarding service. Graduate medical education (GME) programs may benefit from identifying students who show aptitude as systems citizens.

In conclusion, mandatory service-learning is a valuable component of health systems science undergraduate medical education. Future modifications include sophisticated assessment, financial support for CBO, tools for GME evaluation, and alignment with GME health systems science education.

MEDICAL STUDENT NOTES: TRANSFORMING “NOT CONFIDENT” AND “INEFFICIENT” TO “CONFIDENT” AND “EFFICIENT”

Michael Houghan, Laura Zakowski, Jennifer Passini

Department of Medicine, University of Wisconsin- Madison, Madison, WI. (Control ID #3874776)

SETTING AND PARTICIPANTS: Third year medical students rotating on inpatient general medicine services at an academic hospital

DESCRIPTION: Note-writing for students is an important aspect of learning how internists practice and helps learners organize their thought process in patient care. Currently, third-year medical students on our inpatient general medicine service do not use a standard, customized note template, and students either copy a note template from a resident physician or start from scratch. Both options are not ideal, as they either provide too much or too little detail and do not teach the learner how to write a unique and efficient note.

We created standardized H&P and progress note templates with embedded help text to guide daily note- writing for students. This was generated within the EHR and automatically populated for students to use. The help text guides students in standard note-writing techniques and clinical decision-making. The goals of this note were to (1) increase confidence level in organizing an assessment/plan for presentations; (2) improve efficiency in writing notes; (3) reduce unnecessary information in notes; and (4) reduce reference to other notes when writing their own notes. We provided a guide to this note template and proper note-writing techniques during their orientation to the medicine rotation.

EVALUATION: We measured these goals with a pre-rotation and post-rotation survey sent to all medical students on inpatient general medicine services. We summarized all data as counts and frequencies. All pre- and post-comparisons were made using Fisher’s exact test. The level of organizing an assessment/plan endorsed as “confident” increased from 17% to 83% after the intervention. Additionally, students rating their ability to write admission and progress notes as “efficient or very efficient” increased from 24% to 58% and 67% to 92%, respectively. Lastly, the amount of unnecessary information endorsed as “<25%” changed from 26% to 67% of respondents. Each of these results was statistically significant with 95% confidence intervals.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our pre- and post-survey data showed a significant increase in student confidence level when organizing an assessment/plan for presentations, an increase in subjective efficiency in writing notes, and a reduction in subjective unnecessary information in notes. Implementing a standardized note template for medical students is an effective teaching tool for perceived proper note writing and enhanced confidence in note organization.

Our evaluation was based on self-reported survey data. To determine whether this intervention reduces note bloat and unnecessary information, we would need to closely examine length and content before and after the intervention.

MODULE-BASED CURRICULUM FOR IMPROVING MEDICAL STUDENTS’ ATTITUDES AND KNOWLEDGE OF PUBLIC HEALTH: A MULTI-YEAR STUDY

Spencer Dunleavy¹; Amir Hassan¹; Gabrielle Wimer¹; Cameron D. Clarke¹; Nathalie Moise^1,2

¹Medical School, Columbia University Vagelos College of Physicians and Surgeons, New York, NY; ²Department of Medicine , Columbia University Medical Center, New York, NY. (Control ID #3872449)

SETTING AND PARTICIPANTS: Public health is an essential component of modern medical education. While numerous studies demonstrate benefits of public health education during medical school among self- selected students, there are few examples of effective models for implementation, particularly across general medical student populations. This study examined the effect of a multi-year, case-based, longitudinal online public health curriculum required for all pre-clerkship medical students at an urban, research-focused medical school in the United States.

DESCRIPTION: In 2020, senior students and faculty cooperatively implemented case-based public health oriented educational modules to supplement an existing, year-long pathophysiology and pharmacology course for all pre-clerkship medical students. Students were required to complete eleven case-based public health-oriented educational modules, one for each of the organ systems taught. Topics included disease prevention, racial health disparities, policy interventions, nutrition, social determinants of health, health economics, biostatistics, and more.

EVALUATION: All first- and second-year medical students in 2020 and 2021 completed these modules and took part in repeated surveys throughout the year. Second-year medical students in 2019 were also surveyed to provide an end-of-course comparison group of students who were not required to complete the modules. In these surveys, before and after completion of each module, we assessed students’ attitudes toward public health (using Likert scales from 1 to 5) and knowledge of public health material related to each organ system.

Across the three cohorts of students from 2019-2021, 409 (97.8%) of students provided responses. In pre- post analyses, students reported greater importance of public health to nearly every medical specialty (p < .001) and increased knowledge of public health content (p < .001). Further, students reported improved attitudes toward public health across multiple domains (p < .001); findings were consistent when compared across cohorts and over time within cohorts.

DISCUSSION / REFLECTION / LESSONS LEARNED: This project highlights the success of integrating an interactive public health curriculum during the pre-clerkship education at a large, academic medical school in the United States across multiple cohorts of students. Our findings suggest that embedding public health content within the medical school curriculum in a manner that highlights this theme longitudinally can improve medical students’ knowledge of public health and positively affect students’ attitudes toward the field. With a collective shift in perspective that public health training is essential to medical training, we can begin to address the major problems facing our healthcare system today, including health inequity, access to care, and the burden of chronic disease.

ONLINE RESOURCE URL: https://www.publichealthcommute.com/available-topics

NATIONAL VALIDATION STUDY OF A TRAUMA-INFORMED CARE COMPETENCY SET FOR UNDERGRADUATE MEDICAL EDUCATION

Megan R. Gerber¹; Martina Jelley²; Jennifer Potter³; Amy Weil⁴

¹Medicine, Albany Medical College, Albany, NY; ²Internal Medicine, The University of Oklahoma - Tulsa, Tulsa, OK; ³Medicine, Harvard Medical School, Boston, MA; ⁴Medicine, University of North Carolina System, Chapel Hill, NC. (Control ID #3877129)

SETTING AND PARTICIPANTS: Multi-center study;clinician educators, medical students, and behavioral and social scientists, community members with lived experience of trauma.

DESCRIPTION: The adoption of trauma-informed care (TIC) into undergraduate medical education (UME) may increase competency for providing care to trauma-exposed patients, while also recognizing and addressing the impact of trauma on students. TIC is recognized as a key tool for clinicians, yet standardized curricula are lacking. The Trauma-Informed Health Care Education and Research (TIHCER) national collaborative formed a working group of 13 to develop draft UME TIC competencies based on the Physician Competency Reference Set (PCRS).

EVALUATION: Draft competencies were validated using a modified Delphi approach. Validators were medical educators, TIC experts, medical students, and community members who had lived experience with trauma. These educators, experts, and students were recruited via email from medical schools in 4 regions: Northeast, South, Midwest, and West. Community members were recruited from an online community, Positive and Adverse Childhood Experiences Connection (PACES). Participants received surveys containing the competencies and rated each via 5-point Likert scale (1=very inappropriate, 5=very appropriate) in four minimum standards: 1) testable, 2) attainable for UME learners, 3) related to TIC, and 4) unique or not redundant. Scores of 4 or 5 met the minimum standard. Quantitative consensus was achieved if greater than or equal to 70% of participants felt the competency met each standard. Participants had the option to provide qualitative feedback. Competencies not reaching quantitative consensus and those with qualitative feedback were either edited or discarded. All edited competencies were resurveyed until consensus occurred for all competencies or until three rounds had been completed. If, after the third round, a competency still had not reached consensus in all four minimum standards, the competency was eliminated.

A total of 81 participants were recruited (24 educators, 23 experts, 24 students, and 10 community members). The first-round survey received 53 complete and 9 partial responses, a 65% response rate. Eight competencies did not meet quantitative consensus and were edited and included in the second-round survey, where response rate was 57%. After the second-round survey, 4 competencies had not reached the consensus threshold. An additional 3 competencies were revised based on qualitative feedback. The final set contains 43 competencies.

DISCUSSION / REFLECTION / LESSONS LEARNED: The competencies represent the first validated, UME-level TIC competencies developed to date. The set provides a framework to assist medical educators and institutions in developing TIC curricular content and learner assessments to ensure that medical students attain developmentally appropriate competency in TIC. Future work includes application of the competencies to Internal Medicine teaching settings.

ONLINE RESOURCE URL: https://tihcer.weebly.com/tic-competencies.html

PATIENT PERCEPTIONS OF STUDENT EMPATHY: A VALUABLE FEEDBACK TOOL FOR MEDICAL EDUCATION

Carly E. Sokach¹; Reed Van Deusen^3,2

¹Internal Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA; ²University of Pittsburgh School of Medicine, Pittsburgh, PA; ³UPMC, Pittsburgh, PA. (Control ID #3875410)

SETTING AND PARTICIPANTS: Setting: Internal Medicine inpatient wards

Participants: 3rd & 4th year medical students completing inpatient Internal Medicine rotations.

DESCRIPTION: Empathy is key to the formation of positive physician-patient relationships. It improves patient satisfaction and results in better clinical outcomes. Empathy is, however, nebulous and difficult to teach. On clinical rotations medical students are not typically provided feedback from the patients they care for. Direct feedback from patients on empathy, bedside manner, and communication can be a valuable educational tool. The CARE Measure is a validated scale that measures patients’ perceptions of provider empathy. This project sought to develop an innovative educational intervention to provide medical students with feedback on empathy, communication skills, and bedside manner. The CARE Measure was administered to patients who were followed by 3rd and 4th year medical students on their Internal Medicine rotations. Compiled results of the CARE Measure were shared with students as feedback at the mid-point and end of their rotations.

EVALUATION: After receiving mid- and end-rotation formative feedback, the students were surveyed on this educational intervention. The primary aim of this study is to assess student perspectives on receiving feedback on empathy from the patients they are caring for on their Internal Medicine clerkship. DISCUSSION / REFLECTION / LESSONS LEARNED: Data collected from April 2021-April 2022 included 153 participating medical students. 107 students received feedback at the end of rotation. 41 students responded to the follow-up survey for a 38% response rate. 100% of respondents stated that they would find further real patient feedback beneficial in their medical education. 66% of students agreed or strongly agreed that this real patient feedback was helpful. 56% of students agreed or strongly agreed that this educational intervention led them to focus more on communication skills in patient interactions. 58% of students felt that this feedback would directly change future patient interactions. Student comments were overall very positive, noting that this was one of the only times they have received direct feedback from patients. Students stated that this intervention would be more helpful with a greater number of patient evaluations per student and the incorporation of narrative feedback.

188 unique patient surveys were received for 107 students. All responses were distributed on a five point Likert Scale with 1 being poor and 5 being excellent. The medical students were overall rated very positively by their patients, scoring an average above 4.4 on each of the questions.

Medical student education would benefit from further real patient feedback. A majority of respondents found patient feedback on empathy, communication skills, and bedside manner beneficial and directly impactful on future patient interactions. Patient feedback to students is a valuable medical education tool for the development of empathy, bedside manner, and communication skills.

PILOT: COMMUNICATIONS CURRICULUM IN THE INTERNAL MEDICINE SUB- INTERNSHIP

Nabeel Akhtar, Nicholas Duca, Jennifer Cooper, Rachel S. Casas

Division of General Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA. (Control ID #3856597)

SETTING AND PARTICIPANTS: The communications curriculum was piloted in the Internal Medicine (IM) sub-internship (sub-I) rotation at an academic tertiary hospital associated with a medical school. This was open to all rotators enrolled from June-September 2022; 9 IM sub-interns participated. DESCRIPTION: In 2018, the Alliance of Academic Internal Medicine (AAIM) released the Internal Medicine Subinternship Curriculum Guide 2.0 to facilitate the development of competency-based curricula for IM sub-interns, which the organization recommended back in 2012. However, the IM sub-I has historically been a clinical exposure, and the AAIM guide has not been widely adopted amongst medical schools. Therefore, we decided to implement skills sessions based off the recommendations of the AAIM guide.

A local needs assessment with rotating IM sub-interns, medical educators, and the IM sub-I leadership team identified communication skills as a focus for targeted education. To address these local needs and AAIM recommendations, we subsequently piloted a communications curriculum in the IM sub-I to improve rotators’ communications skills for patient care.

We selected communication-based entrustable professional activities (EPAs) 5, 8, & 9 and their corresponding skills from the AAIM guide which included: To call a consult, write a cross-cover note and discharge summary, sign out to a provider, work on an interdisciplinary team with a care coordinator and social worker, and respond to a nurse’s page. Five hour-long workshops were given in the first week of the four-week long rotation. Workshops included discussion and practice of the corresponding skills. Participants voluntarily provided feedback following each session via SurveyMonkey. The survey asked four questions: two free responses pertaining to strengths and areas of improvement and two close-ended questions about the usefulness of the workshop and if it should be recommended to another IM sub-intern.

EVALUATION: Preliminary data showed that all participants found the workshops to be useful and would recommend them to other IM sub-interns. A central theme was that the focused communication skills were pertinent to their responsibilities on the rotation.

DISCUSSION / REFLECTION / LESSONS LEARNED: We piloted an innovative, EPA-based communications curriculum in the IM sub-I. Participants were receptive to the curriculum despite it expanding upon the traditional clinical exposure, possibly because it focused on skills needed for clinical duties. Based on the responses, the curriculum will be offered year-round to anyone enrolled in the rotation. We will expand our evaluation by issuing pre- and post-session surveys to measure participants’ attitudes regarding the communication skills taught in the workshops.

PRESERVING EMPATHY IN THE THIRD YEAR OF MEDICAL SCHOOL: A PILOT INTERVENTION

Marita Meyer^1,2; Alana Iglewicz⁵; Meghan Sebasky⁴; Simerjot K. Jassal²; Abbey Ervin³

¹Internal Medicine, University of Colorado, Denver, CO; ²Medicine, University of California San Diego Health Sciences, La Jolla, CA; ³School of Medicine, University of California San Diego, La Jolla, CA; ⁴Medicine, University of California San Diego, La Jolla, CA; ⁵University of California San Diego, La Jolla, CA. (Control ID #3868115)

SETTING AND PARTICIPANTS: Twenty-five third-year medical students rotating through the core internal medicine clerkship at an academic medical center.

DESCRIPTION: Given that medicine at its core is a humanistic profession, empathy is of the utmost importance in strengthening the physician-patient relationship. Furthermore, research has demonstrated that higher levels of physician empathy are associated with improved patient outcomes. Several studies have shown that empathy declines significantly during medical education, particularly during the third year. Burnout, another phenomenon highly prevalent among physicians, is inversely associated with empathy. Literature suggests that mindfulness, stress management, and small group discussions may be promising strategies for preventing physician burnout. Our team created, piloted, and evaluated the utility of a randomized-controlled intervention, virtual process groups, as a method for preserving empathy and mitigating against burnout in medical students. The groups were structured with the goal of creating a safe and supportive environment for students to discuss shared experiences encountered during clerkships. Third- year medical students rotating through the core medicine clerkship were invited to participate in the study. Twenty-five students consented to participate and were randomized to either the control or intervention group.

EVALUATION: Students in both the intervention and control groups completed two validated surveys, the Toronto Empathy Questionnaire (TEQ) and the Oldenburg Burnout Inventory (OLBI), to measure baseline levels of empathy and burnout. Subsequently, students in the intervention group met monthly for three sessions in facilitator-led virtual process groups. Upon completion of the sessions, students in both groups once again filled out the TEQ and OLBI. Students in the intervention group also completed a brief satisfaction survey to provide feedback on their experience. There were no differences in TEQ scores pre- and post-intervention between the control and intervention groups. However, the OLBI scores post- intervention were found to be significantly increased compared to pre-intervention in the control group (p=0.03*), but not the intervention group, suggesting higher levels of burnout in the control group. The intervention was highly reviewed by students based off satisfaction survey results. Almost all participants reported that the process groups would be helpful if offered during other clerkships and that other students would benefit from similar sessions.

DISCUSSION / REFLECTION / LESSONS LEARNED: The results from the study suggest that process groups may mitigate against burnout by fostering a strong sense of social connection and peer support amongst students. While further research is needed to determine whether the groups have a meaningful impact on empathy, it is that evident that students found value in the intervention and that such groups have the potential to alleviate burnout, strengthen community, and promote wellbeing.

PROFESSIONAL IDENTITY FORMATION WITHIN A COMMUNITY OF PRACTICE: BUILDING MENTORED LONGITUDINAL RELATIONSHIPS BETWEEN MEDICAL STUDENTS AND PATIENTS LIVING WITH CHRONIC ILLNESSES

Lydia Busey¹; Elizabeth Bradley²; Natalie May¹; Kara Harrison¹; Margo Tanner¹; Rachel H. Kon^1,2

¹Internal Medicine, UVA Health, Charlottesville, VA; ²University of Virginia School of Medicine, Charlottesville, VA. (Control ID #3852214)

SETTING AND PARTICIPANTS: Data were collected at academic medical center in the Southern region.

DESCRIPTION: Our institution recognized a need to provide context for medical students’ professional identity formation through mentored experiences building clinical and interpersonal skills. In order to address this need, a novel program was started partnering each matriculating first-year medical student with a patient suffering from chronic illnesses. The patients selected to participate in the program ranged from pediatric to geriatric patients and represented a wide economic, political, religious, and social spectrum. Every medical student participated in a home visit, multiple clinic visits, conducted narrative and medical interviews, performed medication reconciliation, and learned to navigate and communicate via the electronic medical record. Over the course of their four years of medical education, medical students progressively gained experience with chronic disease management in interprofessional spaces, and discussed their personal development with one assigned clinical mentor and small group of peers regularly between the White Coat ceremony and graduation.

EVALUATION: This innovation is rooted in three core conceptual frameworks: medical student professional identity formation, experiential learning, and communities of practice. Using thematic and directed content analysis and cross-sectional frequencies, we discuss qualitative and quantitative survey responses collected between 2018-2022 for the first class completing the four year curriculum. The investigators received IRB approval for exemption from further review.

DISCUSSION / REFLECTION / LESSONS LEARNED: Preliminary assessment of qualitative data demonstrates that many students gained practical knowledge about the trajectory of chronic disease and the intricacies of patient-clinician trust through communicating directly with patients, family members, and clinicians. In the words of one fourth-year medical student, “Through our relationship, in which I was initially just an observer but grew to be a support and a foundation of my patient’s experience with the healthcare system, I bore witness to the realities of our field”. Depending on the course of the patient’s illness and their specific circumstance, smaller subsets of medical students navigated patient deaths, served as advocates, and learned to navigate complex ethical and social circumstances. Challenges of the program included communication limitations, variability in compatibility between medical students and patients, varying degrees of medical student interest and engagement, patient deaths, and the COVID-19 pandemic. Ultimately, this longitudinal patient relationship represents an innovative approach for medical students to partner with a patient over the course of four years of undergraduate medical education.

RADIOLOGY TEACHING ROUNDS IN INTERNAL MEDICINE CLERKSHIP-TAKING STUDENTS TO THE READING ROOM.

Barath Rangaswamy¹; Srikanth Mukkera²; Stephanie Stroever³; Rahul Atodaria⁴

¹Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; ²Rheumatology, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; ³Division of Biostatistics, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; ⁴Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX. (Control ID #3876897)

SETTING AND PARTICIPANTS: A Cross sectional study of Third (MS3) and fourth year (MS4) medical students at School of Medicine, Texas Tech University Health Sciences Center, Permian Basin.

DESCRIPTION: There is evidence that medical students are not receiving adequate education in radiology. Radiology education requirements in U.S. medical schools are variable with only a minority requiring a clerkship in radiology. In the absence of separate radiology elective, we explored preferences for radiology education in the internal medicine (IM) clerkship. Students completed a survey about their perceptions and preferences in radiology education in the IM clerkship. We used a Likert-type scale for questions and calculated descriptive statistics to summarize results. We used Fisher’s exact to compare responses across years and set α = 0.05 a priori for hypothesis testing.

EVALUATION: The response rate was 66.6% (n = 30) with 15 from each cohort. Eighty percent of respondents agreed that radiology education is very/critically important to their future practices. The majority believe current radiology education is inadequate (60.0%) or very inadequate (23.3%), though only half thought it likely they would do a radiology elective during school. When asked about their confidence to interpret basic x-rays, 23.3% were not at all confident, 46.7% were slightly confident, and 20.0% were somewhat confident. Only 3 students were very confident (10.0%). Seventy-six percent of students ranked a radiologist as their top preference for teaching fundamentals of radiograph interpretation. Internal medicine and emergency medicine faculty were ranked first by 16.7% and 3.0% of students, respectively. Ninety percent of students either agreed or strongly agreed that including brief reading room visits into the IM curriculum could be a valuable alternative when a separate rotation is not feasible. Forty percent of students preferred weekly visits, whereas 30.0% preferred biweekly, and 23.3% preferred monthly. When asked how confident they would be to take an exam at the end of the clerkship following education in the reading room, the majority were somewhat to completely confident. Thirty percent were either not at all or slightly confident. Lastly, 53.3% of students prefer additional education in radiology to be didactic and 36.7% prefer group learning. Ten percent prefer online learning modules. Interestingly, there were no significant differences in perceptions across cohorts. Many questions had almost identical endorsements across categories including confidence to interpret x-rays (p = 0.91), the value of reading room visits (p = 1.00), and frequency of these visits (p = 1.00).

DISCUSSION / REFLECTION / LESSONS LEARNED: Radiology education of medical students is increasingly important and when a separate radiology elective is not feasible, arranging reading room visits for increased teaching and student engagement with radiologists is a welcome option during the IM clerkship.

RENAL MED-LIBS: CLINICAL REASONING SEMINAR FOR MEDICAL STUDENTS WITH A FOCUS ON GLOMERULAR DISEASE

David Kudlowitz¹; Kelly Crotty²; Magdalena Robak³; Norkila Sherpa⁵; Summar Al-Najjar⁵; Madelyn J. Noyes⁵; Verity Schaye⁴

¹Internal Medicine, NYU Langone Health, New York, NY; ²Medicine, NYU Langone Health, New York, NY; ³Emergency Medicine, NYU Langone Health, New York, NY; ⁴Division of General Internal Medicine, NYU School of Medicine, New York, NY; ⁵NYU Langone Health, New York, NY. (Control ID #3875502)

SETTING AND PARTICIPANTS: This innovation took place at NYU Grossman School of Medicine with 1st year medical students.

DESCRIPTION: Medical school pre-clinical curriculum can focus on medical knowledge and not the clinical reasoning (CR) process to apply that knowledge to patient care. Additionally, gamification is a teaching strategy that can foster clinical problem-solving skills that is not often utilized. NYU Grossman School of Medicine has successfully integrated CR into most pre-clerkship organ modules, however, our renal module lacked an organized CR educational activity. To remedy this, we created a renal CR seminar using gamification techniques to foster application of this medical knowledge content domain.

The seminar is 2 hours divided into two parts. First year medical students in 3 groups of 4 students spend the first half of the seminar creating an illness script chart of assigned paired diseases—focusing on epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment. Given the importance of comparing and contrasting in the formation of illness scripts, we paired diseases that share key similarities focusing on glomerular diseases. Disease pairs included Post-streptococcal Glomerulonephritis and IgA nephropathy, Granulomatosis with Polyangiitis and anti-GBM disease, and Minimal Change Disease and Class V Lupus nephritis. Then each small group share their charts, focusing on a discussion that compares and contrasts the individual components of the illness scripts.

For the second half, students fill out a mad-libs paragraph scenario for each assigned pair of diseases, highlighting key differences. As an example, for IgA nephropathy and Post-streptococcal glomerulonephritis: “A 28-year-old female who works as a(n) (insert type of job) developed (name a color) urine (at the same time as/1 week after contracting) an upper respiratory infection.” Each group of students then presents their completed “mad-libs”to the other small groups who determine which disease is being described.

Outcomes

EVALUATION: Thus far we have collected data at the reaction level of the Kirkpatrick model of program evaluation. Seventy-five perecent of students (N=6) strongly agreed that the seminar aligned well with the renal module curriculum and that the seminar helped consolidate material. A representative comment: “I loved how this session was […] geared to what we have been learning about, with some interesting clinical pearls and really relevant ways of thinking about these diseases and their differences and similarities.”.

DISCUSSION / REFLECTION / LESSONS LEARNED: Reviewing glomerular disease through an innovative, gamified, method of comparing and contrasting illness scripts is an engaging method to teach pre-clinical learners. Next steps are to gather further data on program evaluation to help inform changes in other organ system modules.

RETHINKING MEDICAL SCHOOL ORIENTATION WITH AN EMPATHY BOOTCAMP DESIGNED TO NAME AND TEACH PERSPECTIVE BELIEVING AND EMPATHY AS FUNDAMENTAL COMPETENCIES

Jennifer Adams²; Colleen Gillespie¹; Maura Minsky³; Cristina Gonzalez⁴; Jonathan La Pook³

¹PrMEIR/IIME, NYU Grossman School of Medicine, New York, NY; ²Internal Medicine, NYU Langone Health, New York, NY; ³The Empathy Project, NYU Langone Health, New York, NY; ⁴Institute for Excellence in Health Equity, NYU Langone Health, New York, NY. (Control ID #3877230)

SETTING AND PARTICIPANTS: During NYU Grossman School of Medicine's orientation all incoming medical students (n=106) participated in a 3-hour immersive experience at the MET.

DESCRIPTION: To name the critical importance of and develop students' core skills in empathy, we partnered with the Metropolitan Museum of Art (the MET) - renowned for the breadth and diversity of its collections - to deliver an innovative curriculum to medical students during orientation. Goals were for students to embrace the complexity of observation and the intellectual flexibility it requires; value engaged curiosity; and recognize that diverse viewpoints and interpretations lead to deeper understanding. The experience started with a group introduction to the concepts of empathy and perspective believing and then students individually spent one hour with a pre-selected piece of art, thinking about what they saw and reflecting on their emotional responses. Next, students worked together in small groups to interpret the art, practicing listening to, learning from, and building onto their peers’ ideas. The groups then shared and discussed interpretations. After each group presented, the art historians provided historical context as well as curatorial and their own interpretations.

EVALUATION: 59/106 students completed a brief, anonymous survey about the experience (56% response). The vast majority reported that the experience was engaging (98%), stimulated their curiosity (95%), was valuable (95%) and that they would want to participate in more sessions like this (93%). Most agreed (somewhat or strongly) that the session had an immediate impact by challenging them to be more intellectually flexible (98%), improving their ability to recognize patterns (97%) and their observation skills (98%), and providing practice in shifting perspectives (96%). Looking to the future, 95% felt it would make them better able to understand patients' perspectives. When asked to provide takeaways, students' responses confirmed achievement of objectives (e.g, "Different perspectives are extremely valuable, and each person’s innate viewpoint is necessary. Keeping an open mind enables us to ask deeper more meaningful questions. Medicine takes time, especially to understand people and their history."). Students also cited the following as likely to improve their future practice: appreciation for collaboration, recognition of empathy as a core skill, cultivation of a curious mindset and attention to detail, and the ability to believe perspectives (e.g., “I think this session will be extremely useful to me as a physician. We discussed the relationship of empathy and perspective-taking in gathering detailed histories, the foundation upon which accurate diagnosis and appropriate treatment rest").

DISCUSSION / REFLECTION / LESSONS LEARNED: This innovation, delivered by a team of medical school faculty and art historians, appears to be an effective way to promote empathy and perspective believing as essential core competencies and to give students opportunities to develop these foundational skills.

SAY WHAT YOU'LL WRITE, WRITE WHAT YOU SAY: A PATIENT-CENTERED DOCUMENTATION SKILLS CURRICULUM IN THE ERA OF PATIENT-ACCESSIBLE NOTES Kathleen Eng¹; Katherine Johnston²; Anita Vanka³

¹Medicine, Harvard Medical School, Boston, MA; ²Medicine, Massachusetts General Hospital, Boston, MA; ³Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #3869482)

SETTING AND PARTICIPANTS: All first-year medical students at an academic medical center in the New England region during the foundational clinical skill course in the 2022-2023 academic year.

DESCRIPTION: Since the 21^st Century Cures Act in April 2021, new federal rules mandate all patients (with several permitted exceptions) are offered rapid, online access to their clinical records and notes (‘open notes’). We developed this curriculum within the foundational first-year clinical skills course to teach medical students patient-centered documentation skills that will rise to the ethical and practical standards that an open notes era demands.

Participants completed an online module introducing open notes prior to an in-person workshop. The workshop began with a general overview of the purpose and anatomy of written notes, followed by a student- driven discussion of the impact of open notes from both patient and provider perspectives. Students then worked in smaller groups to apply these concepts hands-on, dissecting a prepared note and determining elements which did not meet a patient-centered focus and why. Using a predesigned checklist and rubric as a guide, students then rewrote this note with a focus on inclusive, nondiscriminatory, and non-judgmental language.

Students will continue to encounter this theme throughout the year, writing 15 clinical notes with our newly developed checklist and rubric as the cornerstone of their evaluation.

EVALUATION: 172 of 173 first-year medical students completed a pre-workshop survey. While all students agreed that writing a patient-centered note was somewhat important or very important for effective patient care (100%), the majority felt somewhat unprepared or not prepared at all to write a clinical note (63%), write a patient-centered note (68%), or talk to patients and families about their note (58%). We plan to compare these attitudes to mid- and end-of-year evaluations. Additionally, knowledge will be assessed within three written exams and skills will be assessed by preceptor evaluation of 15 notes via standardized rubric.

DISCUSSION / REFLECTION / LESSONS LEARNED: The recent decision to make medical notes accessible to patients has created significant opportunities to strengthen patient-clinician teamwork and better engage patients with their healthcare. However, from our pre-session evaluation, we identified a notable gap in the preparedness and comfort that new medical students feel with writing a note, especially in a patient- centered manner. We created this curriculum to prepare the next generation of learners to utilize notes as a tool to communicate mindfully with patients and providers, as well as understand key ethical considerations. Our approach begins with first-year students, laying foundational principles from the start of their training. We have also developed similar sessions to educate the key teachers of our students; future plans include expanding this curriculum to reach all levels of learners, including resident and faculty teachers, and better address the hidden curriculum.

STUDENT PERCEPTIONS OF ABILITY TO BE VULNERABLE WITHIN A COACHING PROGRAM FOCUSED ON CLINICAL SKILL DEVELOPMENT AND PROFESSIONAL IDENTITY FORMATION

Michael R. Kaufman¹; Andrew Parsons²; Elizabeth Bradley³; James Martindale³; Rachel H. Kon²

¹Internal Medicine, UVA Health, Charlottesville, VA; ²Medicine, University of Virginia, Charlottesville, VA; ³Medical Education, University of Virginia, Charlottesville, VA. (Control ID #3849173)

SETTING AND PARTICIPANTS: Based on Goffman’s theory of impression management, learners often behave differently when on the “front stage” of clinical performance including when actively being evaluated. In contrast, vulnerability in regards to sharing clinical performance deficits may often be reserved for the “back stage.” Coaching relies on vulnerability as student’s sharing and self-reflection on performance deficits are necessary to augment growth. The University of Virginia (UVA) School of Medicine attempts to overcome this conflict between coaching and assessment through the formation of longitudinal relationships between coaches and students built on trust within a coaching program. Students and coaches reflect on performance strengths and weaknesses, and co-create learning goals as a means of formative feedback, avoiding direct summative assessments. To our knowledge, no study has assessed student perceptions of vulnerability with respect to their clinical performance deficits as part of a longitudinal coaching relationship.

DESCRIPTION: A 10 item survey composed of eight Likert questions and two open ended questions regarding sharing performance deficits with faculty involved in evaluating students such as attendings on rounds vs clinical skills coaches was emailed to all 183 rising UVA rising 4^th year medical students. The survey was administered anonymously over 5 weeks during the summer of 2022. There were no exclusion criteria. Likert questions were analyzed via Related Samples Wilcoxon Signed rank tests using a Bonferroni correction for multiple testing. Open ended questions were analyzed via conventional content analysis. This project was approved by the UVA IRB-SBS, #5104.

EVALUATION: 38 total responses were received (38/183, 20.8% response). When interacting with their coaches compared to other formative assessors, students were more comfortable asking questions (p<0.001), more able to communicate freely about struggles in clinical performance (p=0.001), felt they could be more honest about clinical skill gaps (p=0.001), and were less likely to conceal gaps in knowledge or clinical skills (p<0.001). Qualitative analysis led to the formation of 35 codes and four code clusters for factors that influence student vulnerability: characteristics of faculty, characteristics of the relationship between student and faculty, characteristics of the environment, and personal characteristics of the student.

DISCUSSION / REFLECTION / LESSONS LEARNED: Medical students perceive that they can be more vulnerable with their coach compared to other formative assessors in regards to their clinical performance deficits. Qualitative analysis further supports Goffman’s theory as applicable to the medical education environment, which allows for optimization of factors to promote student vulnerability. These findings suggest that a longitudinal coaching program for clinical skill development and professional identity formation may allow more student vulnerability and may serve as a model for programs at other medical education institutions.

TEACHING HEALTH EQUITY: REDESIGNING THE CURRICULUM TO TEACH HEALTH EQUITY TOPICS IN THE INTERNAL MEDICINE CLERKSHIP.

Karen C. de la Garza¹; Sherine Salib^2,3; Beth Nelson³

¹Internal Medicine, Dell Seton Medical Center at The University of Texas, Austin, TX; ²Internal Medicine , Dell Medical School, Austin, TX; ³Medical Education, Dell Medical School at UT Austin, Austin, TX. (Control ID #3872203)

SETTING AND PARTICIPANTS: Medical schools widely recognize the role of health equity on patients and the community, and yet most trainees receive little training in this subject. Dell Medical School recognized the importance of teaching health equity early on and added it as a core competency required for graduation. This addition created a unique opportunity for the Internal Medicine (IM) Clerkship to redesign its curriculum to incorporate health equity topics with the goal of empowering students with knowledge and mental frameworks to address inequities faced in the clinical setting. The students participating are second year medical students completing their IM Clerkship. The students rotate at Dell Seton Medical Center, the county hospital in Austin, Texas.

DESCRIPTION: The IM Clerkship sought to develop a more intentional health equity curriculum during the rotation using some of the existing assignments without significantly increasing the workload. Firstly, a written reflection assignment on health equity was added with a grading rubric that faculty members review with the students. This encourages the students to reflect on a specific patient case where inequities affected their care. Secondly, an existing check-in was redesigned into a facilitated health equity debrief that provides a safe space for students to share their health equity reflections. Thirdly, students identify 3 patient encounters in the case log where health equity issues were explored. Lastly, we assessed current health equity topics being discussed during didactic lectures.

EVALUATION: Our interventions will be evaluated formally and informally. We obtain feedback informally after the debriefing sessions and formally using the end of clerkship survey. During the debrief, we will record common topics shared by learners. Currently, there is one relevant question on the end of clerkship survey: “this clerkship meaningfully addressed education on health equity competencies” with initial data reflecting high scores on this question (4.8/5.0). We will compile the data at the end of the year to further assess our efforts.

DISCUSSION / REFLECTION / LESSONS LEARNED: Using some of the existing assignments in the clerkship curriculum, we redesigned our curriculum to incorporate more health equity topics without significantly increasing the workload on the students and faculty. Initial debriefing sessions with students have allowed the group to identify inequities and potential interventions like diversifying the workforce, providing language concordant care, and supporting transitions of care efforts. Furthermore, investigating current practices during lectures has provided informal feedback to faculty, creating opportunities to incorporate health equity topics. By redesigning reflection exercises and adding clinical examples in our lectures, our students are being challenged to think beyond the disease, to train well-rounded physicians that will make an impact in their community.

ONLINE RESOURCE URL: https://drive.google.com/drive/folders/1E0pUlymN35AJeXjDKdwu3_ucxP5tS3ab?usp=share_link

TEACHING HOLISTIC LGBTQ+ HEALTH: MOVING BEYOND PATHOLOGICAL FRAMING

GIFTYMARIA J. NTIM, Allison Clement, Maliha Khan, Emery H. Chang

Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #3876133)

SETTING AND PARTICIPANTS: UCLA David Geffen School of Medicine (DGSOM) medical students.

DESCRIPTION: Traditionally, medical school curriculum tends to provide a cursory overview of LGBTQ+ care to students, if an overview is provided at all. Lack of knowledge on the part of budding health care providers worsens the disparities and health outcomes that LGBTQ+ populations experience. The curriculum redesign at UCLA DGSOM, presented an opportunity to teach LGBTQ+ content in a meaningful way to medical students using LGBTQ+ champion providers in the UCLA Health System. The vision of the LGBTQ+ programming at DGSOM is to provide students with the skills to address LGBTQ+ health from a holistic and wellness viewpoint. Through a lens focusing on cultural humility, a LGBTQ+ course for 31 first year medical students was developed in 2020. Experiences included participating in gender health intakes and eight half-day workshops on LGBTQ+ fundamentals. These interactive sessions focused on empathy, resilience and diversity of LGBTQ+ populations, and featured stories in curated films, small group projects, and discussions. Particular attention was given to intersectionality including age, race, religion, cognitive and physical disabilities, socio-economic factors, and geography. In subsequent years, the pilot has expanded to all medical students. First years now get foundational workshops; second years get more clinical integration and application; third years are able to participate in gender health research projects; fourth years can do an optional LGBTQ+ clinical rotation.

EVALUATION: Baseline and endpoint data were collected from students at the beginning and end of each academic year of implementation. Quantitative and qualitative feedback suggest students felt material was critical to their medical education and they felt better equipped to meet the needs of LGBTQ+ patients. DISCUSSION / REFLECTION / LESSONS LEARNED: The LGBTQ+ curriculum at DGSOM touches on the following AAMC core entrustable professional activities:

Taking a comprehensive sexual history on patients

Performing trauma informed physical exam

Inclusivity in EMR documentation

Shared decision making through LGBTQ+ lens

Intersectionality and health

The team took an interactive approach to curriculum development and integrated feedback, allowing for fine tuning of educational offerings while staying true to the goal of providing whole-person, non-siloed, culturally humble care to LGBTQ+ people. Integration of LGBTQ+ health topics in medical school curriculum can improve quality of interactions and clinical care between healthcare providers and members of the LGBTQ+ community. Improving instruction on these topics is crucial to combat inequitable health outcomes. The curriculum at DGSOM provides a framework for other medical schools to move beyond pathological framing when teaching about care of LGBTQ+ patients.

TRANSITION-TO-RESIDENCY COURSE SUCCESSFULLY UTILIZES LESS TIME AND FACULTY RESOURCES BY EMPLOYING HYBRID SYNCHRONOUS AND ASYNCHRONOUS LEARNING MODALITIES

Erin Murphy¹; Julianna Brown²

¹Medicine, University of Louisville School of Medicine, Louisville, KY; ²Department of Medicine , University of Louisville, Louisville, KY. (Control ID #3877291)

SETTING AND PARTICIPANTS: Medical University Teaching center

17 M4 students bound for internal medicine internships

DESCRIPTION: Many schools are challenged by the delivery of Transition-to-Residency courses being very labor-intensive. Due to covid-related changes to our course content, we now utilize multiple teaching modalities with a combined synchronous and asynchronous learning approach in our 2-week elective TTR course.

The course took place in spring 2022. Students met in-person on a daily basis while following a structured independent learning plan utilizing free and open access medicine and conducting team-based learning (TBL) pre-session group work.

Part 1- Faculty-led teaching

- TBL cases- evaluation & management of common hospital issues

- Jeopardy competition- hospital management skills

- Opiate prescribing in the hospital

- Intern 101 Professionalism- Cross Cover, Pre-rounding, Task Management

Part 2- Skills practice

Simulations (Sim) and Standardized Patients (SPs): Longitudinal patient case following multiple events in a patient’s hospitalization:

- Code status discussion

- Delivering informed consent

- Central venous line training

- Decompensating/ Coding patient

- Mock Cross Cover Paging

EVALUATION: Pre- and post- course student surveys assessed global readiness for internship, confidence about evaluation and management of case topics and clinical skills delivered throughout course. Responses utilized a 5-point likert scale ranging from “strongly disagree” to “strongly agree”.

Students reported improvement on every item surveyed. Overall ratings showed significant improvement from 2.8->3.8 (p <0.001). Placing central venous line and treating the decompensating patient were skills delivered via simulations. Students showed the highest rate of improvement in these skills (average 1.5->3.4, p <0.001)

Sessions most highly rated by students were Simulations, TBL cases, and Jeopardy. The course was taught 2 weeks before graduation; this timing improved many students' readiness to receive the material. Course instructors noted high levels of engagement.

Total student hours spent= 25.

Total faculty teaching and administrator person-hours spent= 65

DISCUSSION / REFLECTION / LESSONS LEARNED: This multi-modal teaching utilizing both in- person and asynchronous learning was very successful at leading students to engage with a large breadth of material, make progress in learning, while efficiently utlilizing the time of students and faculty. We divided teaching and administrative duties between 2 course co-directors and 6 guest instructors (faculty/fellows/residents). Once course materials were prepared, hours spent on administration and teaching are highly manageable and can be easily shared between instructors at various levels of training.

While our course focused on topics and skills for the Internal Medicine intern, we find our materials are translatable to multiple specialties, as they focus on managing common and critical situations for any hospitalized adult patient.

ONLINE RESOURCE URL: Teams invitation available upon request

TRAUMA INFORMED MEDICAL EDUCATION: PILOT STUDY OF A LONGITUDINAL FOUNDATIONAL MEDICAL SCHOOL COURSE

Megan R. Gerber¹; Katherine Wagner²

¹Medicine, Albany Medical College, Albany, NY; ²Family Medicine, Albany Medical College, Albany, NY. (Control ID #3877060)

SETTING AND PARTICIPANTS: An academic medical center in the Northeast, 1^st year medical school class (n=145)

DESCRIPTION: More than 89% of US adults experience a traumatic event. Trauma can be associated with adverse health consequences and negatively affects learning and professional development. Trauma-informed care (TIC) offers a framework to address and mitigate these consequences and promote safety and health. TIC is an important foundation providing fundamental skills to engage in patient-centered, healing-focused care. Currently, TIC is not routinely taught in undergraduate medical education (UME).

In the context of curricular change for years 1 and 2, we developed TIC training beginning in the 1^st week of school during a week-long, novel “Intro to Medicine” course. Using recently developed UME competencies, we designed a series of case-based learning sessions that continue across years 1 and 2 during mandatory quarterly intersessions. The sessions include interactive, didactic content (using Poll Everywhere) and small case-based discussions (12 students per group) led by interdisciplinary faculty (nursing, physical therapy, psychology, general medicine/geriatrics/cardiology). The curricula address trauma epidemiology, physiology, and effects; trauma-informed clinical skills including sensitive communication and physical exam techniques. One session trains students to recognize and respond to toxic stress by addressing identity-based microaggressions and moral distress, fostering trauma-informed self-care.

EVALUATION: Students completed a post survey after the Introduction to Medicine session; 123 students responded (84% response rate). Most students (99%) agreed either “strongly” or “somewhat” that the workshop increased their understanding of how adverse childhood experiences (ACEs) affect health outcomes and that the workshop increased their understanding of trauma-informed care. We asked the question, “what surprised you the most about what you learned today?” and analyzed the responses for themes. Three dominant themes emerged, students were surprised by: 1) the degree to which ACEs/ trauma impact health, 2) the potential impact of TIC, 3) the experiences and insights of fellow students. When asked about improving the sessions, students asked for smaller discussion groups, more cases/more time for case discussions. Evaluation data from the 2^nd session is pending; by May 2023 we will have data for 4 total sessions.

DISCUSSION / REFLECTION / LESSONS LEARNED: The prevalence of trauma and its profound health impact creates an imperative for UME to include this foundational training early in students’ education. Our newly matriculated medical students found the topic important and meaningful, yet it is uncommon for medical schools to include this critical content in the first week of school. Challenges include creating smaller discussion groups due to space and faculty availability. We will continue to study and improve the sessions which will continue through years 1 and 2 and include students in the development of future content.

VIRTUAL CASE BASED CARDIOLOGY CURRICULUM FOR THIRD YEAR MEDICAL STUDENTS

Phillip S. Hamilton¹; Michael Dunleavy³; Kerry J. Rubadue⁵; William Marshall⁴; Jeff Barbee⁵; Daniel McFarlane²

¹Hospital Medicine, The Ohio State University, Columbus, OH; ²Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; ³Rush University Medical Center, Chicago, IL; ⁴Cardiology, The Ohio State University Wexner Medical Center, Columbus, OH; ⁵Office of Curriculum and Scholarship, The Ohio State University College of Medicine, Columbus, OH. (Control ID #3868875)

SETTING AND PARTICIPANTS: Third-year medical students at a Midwestern medical school were offered an online asynchronous cardiology curriculum during internal medicine clerkships.

DESCRIPTION: Seven asynchronous case-based modules were developed that allow students to proceed through diagnosis and management of atrial fibrillation, congestive heart failure (CHF), and myocardial infarction (NSTEMI) in a “choose-your-own-adventure format”. Students learn introductory clinical reasoning skills by practicing patient management and receiving immediate feedback on their medical decision making in a simulated environment.

EVALUATION: To measure impact on medical knowledge and learner confidence, pre and post module assessments were developed. The assessments included multiple choice medical knowledge questions derived from module specific learning objectives. These instruments also included items that measured the quality of the modules and learner confidence in developing a disease specific work-up.

DISCUSSION / REFLECTION / LESSONS LEARNED: Cardiology is an important subject within internal medicine and the largest subject on the board exam. The time dedicated to teaching on rounds has decreased over time. Giving medical students case-based interactive modules that simulate real time clinical decision making in a safe environment should improve baseline medical knowledge, learner confidence on rounds and improve clinical performance, as well as easing the transition from pre-clinical to clinical learning.

Over one year of data shows a positive impact of the modules on medical knowledge, learner confidence, and disease specific work up and management. For the atrial fibrillation module, which was released first, 62% of students rated the atrial fibrillation module as excellent with the remaining 35% rating as good (N=37) and the average pre- and post-survey medical knowledge scores improved from 35% to 84% (p <.001).

One limitation of this project is that it was implemented as an optional supplemental curriculum. The modules were offered to third-year medical students who have many competing interests for their time and may opt not to participate in this curriculum. Those who do choose to participate may be a result of selection bias.

Given the initial data showing a positive impact on medical knowledge and learner attitudes, potential future directions include expanding to a mandatory curriculum, creating modules for other clinical clerkship rotations, or adapting in-person simulation sessions with high fidelity mannequins.

Innovation in Medical Education (IME) - DEI, Health Equity, and Social Determinants of Health

A BRIEF CURRICULUM INTERVENTION TO REDUCE WEIGHT BIAS AMONG INTERNAL MEDICINE RESIDENTS

Molly B. Leavitt¹; Madeline Konsor²; Jen Rusiecki³; Neda Laiteerapong⁴

¹Internal Medicine/Graduate Medical Education, University of Chicago Pritzker School of Medicine, Chicago, IL; ²Pyschiatry and Behavioral Services, Rush University Medical Center, Chicago, IL; ³Internal Medicine , University of Chicago, Chicago, IL; ⁴Medicine, University of Chicago, Chicago, IL. (Control ID #3877056)

SETTING AND PARTICIPANTS: A one-hour presentation about weight bias was introduced to a residency lecture series at a Midwest academic medical center. Fifty internal medicine residents received the lecture; 46 residents completed both pre- and post-lecture surveys.

DESCRIPTION: Bias against patients with a higher body mass index (BMI), known as weight bias, has been demonstrated across many medical specialties. Weight bias has been shown to contribute to worse patient care and health outcomes. Residency training programs spend minimal time discussing weight bias and there are limited data on interventions to reduce weight bias in resident physicians. The project’s objective was to develop a brief intervention for internal medicine residents to recognize and reduce their weight bias to improve clinical care of patients with higher BMIs. An interdisciplinary team developed a one- hour interactive presentation that provided education on non-modifiable contributors to weight, the role of genetics, physiologic reasons weight loss attempts fail, impact of medical weight bias, and strategies to

reduce bias and improve clinical interactions.

EVALUATION: To evaluate the presentation’s impact, a pre-post survey was administered to participants. This included a weight bias questionnaire developed by Kushner et al. with 16-Likert questions (1=strongly disagree to 5 = strongly agree) across three domains: negative obesity stereotypes, empathy for obese patients, and confidence in clinical interaction with obese patients. Paired t tests were used to assess pre-post changes in each domain. Of the 46 residents who completed the pre-post surveys, improvements occurred in each domain. The largest gain was in confidence in clinical interaction with obese patients (mean 3.39 (SD 0.72) to 3.79 (0.49), p=0.002). Empathy for obese patients was high at baseline at 4.14 (0.64) and increased to 4.29 (0.52) (p=0.002) Negative obese stereotypes was low at baseline (1.88 (0.58)) and decreased further (1.71 (0.65)) (p=0.001). Post-intervention, the majority reported increased understanding of their own biases against patients who have higher weights (80.4% agree or strongly agree) and of the health impact of weight bias (84.7%). Most also endorsed motivation to further assess their own biases (87.0%) and to improve patient interactions with patients who are higher weights (95.7%).

DISCUSSION / REFLECTION / LESSONS LEARNED: Our interactive presentation was effective in improving resident confidence managing people with higher BMI, increasing empathy, and decreasing negative obese stereotypes. Given the widespread and detrimental effects of weight bias on patients, residency programs should consider including similar lectures in their didactic curriculums.

ONLINE RESOURCE URL: 1drv.ms/u/s!AgRPA-35sqZ_gnrbV2uKotTEPGCv?e=dSQzVv

ACKNOWLEDGING & ADDRESSING MICROAGGRESSIONS: A SIMULATION-BASED FACULTY DEVELOPMENT CURRICULUM

Sneha S. Daya¹; Jenna Essakow²; April Edwell²; Elisabeth Smith³

¹Internal Medicine, MedStar Georgetown University Hospital, Washington, DC; ²Pediatrics, University of California San Francisco, San Francisco, CA; ³University of California San Francisco, San Francisco, CA. (Control ID #3877188)

SETTING AND PARTICIPANTS: The ACGME and other accreditation organizations are increasingly emphasizing the importance of clinical learning environments (CLEs) that value diversity, equity, and inclusion (DEI). Although many programs teach educators to recognize bias and microaggressions, very few teach behavioral skills to address these issues. These behavioral skills are critical for faculty to practice, as they are primarily responsible for the cultivation of inclusive CLEs. We created a virtual simulation curriculum for faculty leaders and educators to practice behavioral skills surrounding microaggressions in the learning environment.

DESCRIPTION: Using Kern’s six-step approach to curriculum development, we designed a curriculum including four different workshops, offering each twice throughout the academic year for CME/MOC credits. Each workshop utilized approaches such as role play, practiced rehearsal, and case-based simulation for skills development. Sessions were intended for small groups of 5-15 participants each, and structured to prioritize trust and community building first, followed by didactic teaching, dedicated time for skills practice via simulation, and group debriefing with facilitator feedback. This curriculum used iterative skill-building surrounding the following topics: 1) recognizing, labeling, and naming microaggressions, 2) apologizing when learners are harmed, 3) setting expectations surrounding microaggressions, and 4) debriefing microaggressions. Attendance was voluntary, allowing participants to join workshops based on their own self-assessment of knowledge and growth interests.

EVALUATION: Thirty-six faculty members from 13 programs participated in this curriculum. Pre and post- session surveys analyzing participants’ self-assessments of confidence and comfort in applying skills were conducted. We calculated averages and standard deviations for each value set and utilized paired participant t-tests to determine statistical significance. Notably, immediately after these sessions, participants were more confident in openly naming bias (P<0.05), discussing stereotypes (P<0.01), delivering expectations surrounding microaggressions (P<0.0001) and identifying context (P<0.05) and power dynamics (P<0.05) when debriefing microaggressions with learners. Participants reported greater comfort in apologizing to learners when harm has occurred in public (P<0.001), in person (P<0.05), and electronically (P<0.001). We collected qualitative commentary to determine skills acquired during this curriculum as well.

DISCUSSION / REFLECTION / LESSONS LEARNED: In order to create an inclusive learning environment, faculty require comfort and confidence with addressing bias and microaggressions. Our curriculum demonstrates that experiential learning can be a tool for transformational change in increasing confidence and comfort with skills to promote DEI. Future work will assess if faculty are actually applying these skills in the learning environment and the impact it has on learners.

ADVANCING HEALTH EQUITY EDUCATION: TEACHING INTERNAL MEDICINE RESIDENTS THE INTERPLAY BETWEEN SOCIAL SERVICES SYSTEMS AND TRAUMA

Mahala Schlagman¹; Andrea Garroway²

¹Internal Medicine, University of Rochester Medical Center, Rochester, NY; ²Psychiatry and Medicine, University of Rochester Medical Center, Rochester, NY. (Control ID #3877228)

SETTING AND PARTICIPANTS: This lecture was part of a didactic curriculum on health equity that included 6 required lectures which took place over the 2021-2022 academic year as part of our outpatient curriculum for Internal Medicine (IM) residents at an academic medical center. Our center hosts the largest IM residency program in the city and our major outpatient primary care resident practice serves high number of patients with social need (73% Medicare, Medicaid, or dual eligible).

DESCRIPTION: In our initial curriculum we focused on social determinants of health, impact on health outcomes, and advocacy skills. Some residents disclosed increased hopelessness surrounding the care of marginalized patients in feedback on this curriculum. Previous literature describes the bueracratic oppression of individuals through social services systems and the obligation of clinicians to pathologize social problems in order to assist their patients in obtaining benefits that allow for their survival (Lipsky, 1980, Hansen et al., 2014). In order to attempt to tackle some of the experience of hopelessness in this setting, we set out to create a lecture that addressed the traumatic experience implicated in navigating the bueracracy of poverty for both patients and clinicians. We hypothesized that giving residents the practical tools to address patient needs efficiently and the language to address suffering in this setting would allow them to feel more comfortable serving patients with high social need.

EVALUATION: A physician and clinical psychologist partnered to enhance the health equity curriculum by integrating trauma informated care content. We measured efforts in a mid-year lecture most strongly reflective of our efforts titled: “Social suffering through ‘street level bureaucracy’ and resilience”. We collected data pre- and post-lecture from residents (n = 59) regarding their knowledge about our local governmental social services, disability paperwork, and understanding of impact of trauma on healthcare engagement using a 1-10 Likert scale. Two-tailed t-test results showed statistically significant improvements in resident self-reported knowledge regarding social services (p < .001), increased comfort completing paperwork for the social services agency (p < .001), and increased understanding of impact of trauma on patient healthcare engagement (p < .01) (pre-lecture response rate = 95%; post-lecture response rate = 98%). We received multiple detailed comments (n=7), all of which used the thematic term "helpful."

DISCUSSION / REFLECTION / LESSONS LEARNED: At times social barriers may be a higher priority for our patients than medication management. We identified that it was possible to integrate trauma informed care into discussion surrounding social suffering and that residents found this practical information on language to use and forms to complete "helpful" for the very real patients they would face. Next steps include considering mechanisms to test not just self-reported knowledge but also resident skills and abilities on this topic.

AN INNOVATIVE MODEL FOR FORGING BIDIRECTIONAL, LONGITUDINAL COMMUNITY PARTNERSHIPS IN A MULTICULTURAL URBAN MIDWESTERN CITY

Trishya L. Srinivasan¹; Abhijay Kumar²; Allison Surma¹; Margaret S. Bove³; Iyanna Peppers¹; Rafael Ramos¹; Emily Fisher¹; Zoha Qureshi¹; Nimra Hassan⁴; Sara I. Koussa¹; Diane L. Levine⁵

¹School of Medicine, Wayne State University, Detroit, MI; ²Medicine, Wayne State University School of Medicine, Detroit, MI; ³School of Medicine, Wayne State University School of Medicine, Detroit, MI; ⁴Medical Education, Wayne State University School of Medicine, Detroit, MI; ⁵Internal Medicine, Wayne State University, Detroit, MI. (Control ID #3876688)

SETTING AND PARTICIPANTS: The Honors Society (HS) at a Medical School in the Midwest region is a service organization that consists of 65 MD and MD/PhD students, dedicated to advocating for social justice in a diverse urban community. Every year, we select a Community Partner of the Year (CPOTY) based on alignment with mission, material and financial need, and opportunity for student involvement. During this partnership, student members volunteer, fundraise, and meet community needs while enhancing their professional development.

DESCRIPTION: We selected the 2021-2022 CPOTY based on their commitment to ameliorating literacy skills among school-aged Black and Latine youth, and expanding access to health literacy resources for the families they serve. As student doctors who recognize that literacy and racism are social determinants of health, we developed health literacy materials with the community, for the community. We utilized a community-based participatory framework in which residents are trained to conduct systematic research to improve social and health outcomes in their community. We implemented this by eliciting the organization’s expertise on their community’s infrastructural and literacy needs and developed action projects in response. Our main intervention was to create culturally responsive health education workshops for children and their caregivers. With the goal of strengthening community relations, we fostered community-centered improvements and value-driven education.

EVALUATION: HS fundraised $12,000 and volunteered 650 hours towards our collaborative projects. We beautified three community spaces intended for gardening, outdoor dance-fitness courses, and after-school education. HS members tutored CPOTY students (ages 5-15 years old) in reading comprehension and math. We facilitated family-centered health education sessions on topics ranging from vascular diseases to anxiety and depression with a focus on providing resources to enhance health literacy and self-efficacy. We initially delivered four live Zoom sessions in English and, based on enthusiastic community feedback, translated the presentations in Spanish for community use. HS members improved communication skills and learned how to incorporate “play” and visual aids as health literacy teaching tools.

DISCUSSION / REFLECTION / LESSONS LEARNED: We collaborated with the CPOTY to develop health education materials that reflect community values and address disenfranchising structural factors. This highlights the need for a bidirectional relationship between a medical institution and its surrounding community. A responsible, bidirectional partnership enables medical students to leverage the knowledge and expertise of community members, promote health literacy, and nurture trust between the community and medical professionals. To better understand the impact of this collaboration in 2023, we plan to work with Latine community organizers in the same Urban Midwestern region to study the outcomes of this community-based participatory research framework.

AN INNOVATIVE SOCIAL JUSTICE CURRICULUM: BUILDING LASTING COMMUNITY PARTNERSHIPS, PROMOTING HEALTH EQUITY, AND FOSTERING COMPASSION IN MEDICINE

Megha Shankar¹; Megan King³; J.W. Wiebe-Anderson²; Crystal Tsui⁴; Nissma Bencheikh³; Ana Skomal³; Colin King³; Jin Su³; Stacy T. Charat^1,5

¹Medicine, University of California San Diego, La Jolla, CA; ²Public Health, University of California San Diego, La Jolla, CA; ³School of Medicine, University of California San Diego, La Jolla, CA; ⁴Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Pomona, CA; ⁵Medicine, VA San Diego Healthcare System, San Diego, CA. (Control ID #3872718)

SETTING AND PARTICIPANTS: A social justice curriculum is being implemented within an internal medicine residency primary care pathway with N = 9 resident physicians through six community site visits paired with academic didactics.

DESCRIPTION: The social justice curriculum didactics were developed through narrative literature review co-created by medical student research assistants. The curriculum is being implemented through half-day sessions with community site visits on the following topics: refugee health, family violence, senior care, carceral medicine, environmental justice, and homeless healthcare. Respective community partners include: Asylum Shelters Clinic (Jewish Family Services/Catholic Charities), Your Safe Place, Serving Seniors, Donovan Correctional Facility, Environmental Health Coalition, and Father’s Joes Villages. The didactic workshops have been administrated through facilitated discussion during the site visit.

EVALUATION: Baseline surveys were administered to internal medicine residents using the Social Justice Scale and Santa Clara Brief Compassion Scale, with a plan to repeat these at the end of the academic year. For each session, a pre/post survey on knowledge of the social justice topic is being administered. Each survey has a qualitative component for open-ended feedback on the curriculum. We have completed two sessions thus far.

DISCUSSION / REFLECTION / LESSONS LEARNED: The co-creation of curriculum with medical students, community partners, and faculty allowed for rich discussions and diverse perspectives. There has been positive feedback on the curriculum from internal medicine residents, who have enjoyed the community-based experiences to learn more about their diverse patient populations and have experiences outside of the clinical environment. Baseline social justice attitudes, perceived behavioral control, subjective norms, and behavioral intentions were rated at an average of 6.02 on a scale of 1 (strongly disagree) to 7 (strongly agree). Baseline compassion was rated at an average of 5.52 on a scale of 1 (not at all true of me) to 7 (very true of me). In the completed sessions on refugee health and family violence, residents had an increase in social justice topic-specific knowledge. Expanded research needs to be done to evaluate if training in social justice leads to improved social justice behavioral intentions and decreased burnout.

AN INTERDEPARTMENTAL SURVEY ON POSTGRADUATE TRAINEES’ EXPERIENCES OF RACE AND ETHNICITY

JENNY WEN^2,1; Todd Liou^3,1

¹Harvard Medical School, Boston, MA; ²Cambridge Health Alliance, Cambridge, MA; ³Cambridge Health Alliance Department of Psychiatry, Cambridge, MA. (Control ID #3875639)

SETTING AND PARTICIPANTS: Participants are post-graduate trainees across departments at our academic community-based training sites (including Internal Medicine, Psychiatry, Family Medicine, social work and psychology, among others).

DESCRIPTION: Our goals were to

1. Better understand trainee experiences of race and ethnicity and the perceived climate at our institution’s training programs

2. Identify priority areas for improvement in our institution’s Diversity, Equity, and Inclusion Efforts on race and ethnicity

EVALUATION: We conducted a brief, confidential, 10-minute online survey of post-graduate trainees to assess their perceptions of treatment based on race/ethnicity, preparedness of faculty and supervisors to address issues of race/ethnicity, understand incidents of experienced or witness microagression and their priorities for DEI initiatives. The 22 questions included quantitative and qualitative short answers. We also compared the responses of minority and non-minority identifying trainees. 37 out of 168 eligible trainees responded (22%). Around half identified as minorities (n=19, 51%) with the majority Asian American (n=16). Most trainees were satisfied with overall training (87%) and rated our institution as better than peer institutions in the DEI environment (81%). However, only 65% rated curricula as adequately preparing trainees to care for patients of color, and 43% felt faculty were unequipped to respond to incidents of racism. Minority trainees were twice as likely to feel they are treated differently by patients and staff (22% vs 11%) and less likely to rate faculty as preparedness to address incidents of racism (50% vs 63%). Other items such as overall satisfaction were similar. In free-response items, respondents shared many examples of differential treatment, examples of positive and negative responses to incidents, and their recommendations for DEI priorities and activities.

DISCUSSION / REFLECTION / LESSONS LEARNED:

1. Brief, anonymous surveys can be a simple and powerful tool to capture voices of trainees who may otherwise not have a space to express their experiences of race and ethnicity, particularly for minority- identifying trainees.

2. Learning and working environments are institution-wide and not limited to single departments, so efforts to understand and address DEI should also occur at the institutional level

3. Similar surveys should be conducted with institutional support periodically, and can alternate amongst various experiences of diversity to better capture intersectionality (eg gender and sexual identity, SES, etc)

A NOVEL STREET MEDICINE EDUCATION MODEL: LEVERAGING NARRATIVE- CENTERED CURRICULUM AND STUDENT-RUN CONSULTATIONS IN A BLACK-MAJORITY CITY

Nicole Hao¹; Abhijay Kumar²; Roxanne Ilagan¹; Nedda Elewa¹; Megan Seyerle¹; Richard Bryce¹; Seema Joshi¹

¹Medicine, Wayne State University School of Medicine, Detroit, MI; ²Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #3875097)

SETTING AND PARTICIPANTS: The street medicine organization (SMO) is run by 50 medical students at academic medical center in the Midwest region. Operating in a Black-majority city with 7,000+ persons experiencing houselessness (PEH), the goal of SMO is to advocate and deliver equitable access to primary and preventative care. To advance socially just relationships with this historically disenfranchised community, SMO is committed to reimagining a public health infrastructure that prioritizes PEH through equitable inpatient care delivery and formalized narrative-centered curriculum.

DESCRIPTION: Houselessness discriminates. Although black families constituted 79% of those experiencing poverty in our city in 2020, they represented a sobering 97% of PEH. In addition, compared to matched low-income controls, PEH suffered from a quadrupled rate of hospital readmission. This disparity is perpetuated by barriers, like lack of transportation, reliable phone or email, and stable housing, which all complicate follow-up. To effectively address structural racial inequities in health, standard intake must include housing status in the discharge plan.

To promote continuity of care in a chronically overlooked population, SMO clinical students lead, to our knowledge, the only student-run inpatient consultation service for PEH in the US, which coordinates follow- up via our street outreach team. To account for blind spots in primary care, our students leverage consult time to provide preventative health recommendations, including routine vaccines and screenings.

To lead the consult service, SMO preclinical students engage in narrative-centered curriculum informed by guest speakers who not only experienced houselessness but now work as housing navigators. The goal is to prepare students to strengthen our patients’ trust in healthcare by challenging ignorance and recognizing our patients’ unique social determinants of health.

EVALUATION: In a year, our team reaches approximately 500 PEH by meeting patients where they are, both physically and emotionally, in the city’s streets and shelters. In November 2022, 5 of 12 consult patients received vaccinations, and 50% of patients indicated for follow-up were successfully seen on our street runs. Furthermore, our training has been shown to teach students how to cultivate strong relationships with PEH through our street runs. When surveyed on their post-training knowledge, students rated themselves an average score of 4.5/5 and reported that the testimonials critically influenced their perspective in equitably caring for PEH.

DISCUSSION / REFLECTION / LESSONS LEARNED: To further build an innovative, anti-racist infrastructure that justly centers PEH, SMO aims to (1) standardize the incorporation of housing status in discharge protocol and (2) expand curriculum by broadcasting diverse narratives on an international street medicine podcast. We hope our model may be replicated at other medical education institutions to responsibly address housing, racial, and health inequities.

ANTI-RACIST STRUCTURAL INTERVENTION AT THE INSTITUTIONAL REVIEW BOARD LEVEL

Francois G. Rollin⁴; Vanessa Van Doren²; Jessica Alvarez¹; Rebecca Rouselle³; Jada Bussey-Jones⁴

¹Endocrinology, Metabolism and Lipids, Emory University, Atlanta, GA; ²Medicine, Emory University, Atlanta, GA; ³Human Research Protection Program, Emory University, Atlanta, GA; ⁴Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #3851495)

SETTING AND PARTICIPANTS: BACKGROUND: Scholars across disciplines agree that racial categories are social constructs, not inherent biologic or genetic classifications. Race and ethnicity have large impacts on health outcomes through lived experience, structural racism, provider bias, and environmental racism. Racial inequities in health outcomes persist; therefore finding, explaining, and rectifying these racial health inequities is important and therfore, racial categories must be used appropriately when describing inequities and examining the effects of racism on biology and health. However, biomedical research continues to produce knowledge about racial differences that misattributes the cause of health inequities to genetic and inherent biological differences rather than racism.

DESCRIPTION: METHODS: In early 2021, members of the Department of Medicine (DOM) Diversity, Equity, and Inclusion (DEI) council and some Internal Medicine residents engaged in multiple meetings over several months with diverse research stakeholders at the University level. We outlined a possible structural intervention to ensure the appropriate use of race and ethnicity in biomedical research.

EVALUATION: RESULTS: We proposed a change to the IRB biomedical submissions that asked researchers to: “(1) Describe the definition you are using for “Race” and/or “Ethnicity” in this study (examples here). (2) State whether you are using racial and ethnic classification of subjects for descriptive statistics or within an explanatory model (as a covariate). (3) If you are using race and/or ethnicity as a variable to explain differences between patients (as a covariate), please describe the proposed mechanism of action (what is race being used as a proxy for?).” After careful review, the University-wide IRB adopted this change starting in January 2022.

DISCUSSION / REFLECTION / LESSONS LEARNED: CONCLUSIONS: Improving scientific research practices around race and ethnicity will require ongoing education as well as multi-level structural changes. Medical journals have published updated guidelines on the appropriate use of race in studies asking for careful definitions and explicit rationale for inclusion of racial and ethnic categories. Research institutions and IRBs should also encourage appropriate use of racial and ethnic categories to ensure scientific validity of the conclusions and to avoid unscientific reification of race as an inherent biological concept. This anti-racist intervention at the IRB will require further refinement over time, evaluation of impact with IRB and researchers. We believe that also with ongoing education of researchers this intervention will help to illuminate the role of racism in creating and maintaining racial and ethnic health inequities so that it can be addressed.

A WIN FOR ALL: ACCOMPLISHMENTS AND EXPERIENCES OF THE LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES DIGITAL EQUITY STUDENT WORKGROUP Kenneth M. Um^1,2; Meera Bhagat^3,2; Anshu Abhat^5,6; Alejandra Casillas⁴

¹University of Pennsylvania, Philadelphia, PA; ²Los Angeles County Department of Health Services, Los Angeles, CA; ³University of California Los Angeles, Los Angeles, CA; ⁴Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; ⁵The Lundquist Institute, Torrance, CA; ⁶University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #3867335)

SETTING AND PARTICIPANTS: The Coronavirus-19 disease (COVID-19) pandemic abruptly integrated telemedicine as a needed health care tool, but also raised concerns about equitable access for safety-net settings. Safety-net health systems disproportionately care for racial/ethnic minorities, low-income, Limited English Proficient (LEP), and other vulnerable groups facing a multilevel digital divide. A student-led workgroup formed in January 2021 to help develop telemedicine patient-engagement in the Los Angeles safety net. We summarize pilot projects and students’ educational experiences over 19 months within the Los Angeles County Department of Health Services (LAC DHS) - the second-largest safety-net in the US. DESCRIPTION: The workgroup was developed by the LAC DHS Office of Patient Access, utilizing the expertise of tech-savvy young persons who were seeking clinical experiences, given the paucity of volunteer activities for medical learners during the pandemic. We describe two student projects that focused on increasing patient portal registration and use. Our results also include students' reflections regarding this work and its impact on their education.

EVALUATION: Three undergraduates and two medical students met over Zoom weekly from January 2021- November 2022 with a physician, health educator, and health services researcher. In one project, students wrote and filmed 20 patient tutorial videos (3-5 minutes each) in Spanish and English on various aspects of the patient portal (portal enrollment, provider messaging, medication refill; to be posted to the LAC DHS website). In the second project, three students delivered in-person education to patients re: portal enrollment: using iPads and Workstation on Wheels in the waiting rooms of a primary care clinic. This nearly doubled portal enrollments from baseline (n=105) over the two-month study period (n=168). This project also served as a prototype for a health technology navigator program, that now consists of 15 navigators across all LAC DHS sites.

Student experiences included the following responses: this was an invaluable experience for students interested in pursuing healthcare careers; it allowed for increased exposure to the health care system and access to one-on-one mentorship with physicians, researchers, and staff; this work and collaboration increased engagement and understanding of care of safety-net populations during the COVID-19 pandemic.

DISCUSSION / REFLECTION / LESSONS LEARNED: This digital equity student workgroup represented a “win-win” for student learning, staff (who have limited resources to work on patient engagement), and patients at LAC DHS. It also offers a potential strategy for other systems to integrate motivated volunteers into future digital equity work, with some work that lends itself to be conducted remotely. This model may particularly be of value to education-research initiatives that seek to create volunteer opportunities for medical learners coming from underserved, urban, and/or remote communities.

BEYOND THE BASICS - A CURRICULUM IN HISTORY, STRUCTURAL HUMILITY, AND LGBTQ+ HEALTH

Benjamin L. Jones¹; Megha Garg^2,1; Archna Eniasivam¹

¹University of California San Francisco School of Medicine, San Francisco, CA; ²San Francisco VA Health Care System, San Francisco, CA. (Control ID #3861119)

SETTING AND PARTICIPANTS: We developed a new small group curriculum for medical students on LGBTQ+ health. It was integrated into an existing pre-clinical course on social determinants of health and followed an introductory lecture on LGBTQ+ definitions, healthcare, and health inequities. This required session was facilitated by volunteer faculty instructors and was delivered to 158 first-year medical students in 2020.

DESCRIPTION: The health of LGBTQ+ communities is shaped by structural forces like policy, economics, and social discrimination. To explore how these forces affect communities and individual patients, it is helpful to understand their origins in LGBTQ+ history. Our curriculum employed a “structural humility” framework, which uses diverse sources of knowledge from disciplines outside of medicine to understand how structural forces impact the health of marginalized patients.

Students completed a pre-reading on strategies to improve LGBTQ+ healthcare and prepared group presentations for peer teaching on topics from LGBTQ+ history. Topics included LGBTQ+ liberation movements, the HIV/AIDS crisis, and global transgender health activism. We provided curated resources spanning news articles, documentaries, artworks, and excerpts from LGBTQ+ activists. Student presentations during the small group session explored how these historical events relate to current day LGBTQ+ health. Students then read a case of a transgender man with a pelvic mass. They used their pre-reading and learnings from presentations to imagine clinical, health systems, and socioeconomic interventions to improve his care. EVALUATION: Forty students completed a post-session survey (response rate 25%), of whom 97.5% agreed the session was valuable to their medical education. Thirty (19%) completed paired pre- and post- session surveys. They reported an increase in knowledge of LGBTQ+ history and its impact on current healthcare issues, from a mean of 3.5 to 4.5 on a 5-point Likert scale (p<0.001, Wilcoxon signed rank test). Mean self-rated ability to design interventions to improve LGBTQ+ health increased from 3.0 to 3.9 (p<0.001). One student wrote that the session helped them “understand nuances about LGBTQ+ health that I would not otherwise have been exposed to.”

DISCUSSION / REFLECTION / LESSONS LEARNED: We sought to move students toward a richer understanding of LGBTQ+ health using resources from LGBTQ+ history. Addressing these complex structural issues requires investments in curricular time and faculty development. This 2-hour small group was in addition to a foundational lecture. Student feedback recommended still more time for the small group activities and an additional, dedicated session on transgender health. It was also challenging to identify facilitators comfortable with LGBTQ+ health topics. As we expand LGBTQ+ health education, we must also prepare faculty to teach these new curricula.

Health inequities persist even as LGBTQ+ social acceptance improves, making innovation and reimagination integral to the future of LGBTQ+ health in medical education.

BIAS, MICROAGGRESSIONS, AND BURNOUT AMONG ACADEMIC HOSPITALISTS

Jessica Berwick, Gabrielle K. Bromberg, Sherri-Ann M. Burnett-Bowie

Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #3867949)

SETTING AND PARTICIPANTS: We surveyed hospitalists at a large, urban, academic medical center. All hospitalists (MD/DOs and advanced practice providers [APPs]) were eligible; participation was voluntary.

DESCRIPTION: We used a 30-item instrument, including questions from the Maslach Burnout Inventory - Human Services Survey and tools developed by the authors. Participants rated their agreement with statements such as “My experiences of bias at work contribute to my imposter syndrome,” “My experiences of bias at work make me enjoy my work less” and “My experiences of bias at work make me feel more burned out at work.” The survey was administered using RedCap and was accessible from 2/1/2022 to 3/21/2022. Participants received a $5.00 gift card. The study was deemed exempt by the Mass General Brigham IRB.

EVALUATION: Of 145 eligible hospitalists, 103 (71%) completed the survey. Respondents were cisgender female (67%), cisgender male (29%), and “other” or “prefer not to say” (4%); and Asian (22.3%), Black (4%), Latinx (5%), White (62%), and “prefer not to say” (9%). Most participants (62%) had completed training in the prior five years. Both APPs (30%) and physicians (70%) participated.

Respondents endorsed experiencing bias frequently, reporting gender bias (62%), racial bias (30%), and other forms of bias, including bias “based on gender identity or expression, perceived sexual orientation, body habitus, age, accent, country of origin, socioeconomic status” (50%). Few participants reported consistently addressing bias with the source (11%).

Over half of respondents reported observing bias directed towards others. Only 36% of respondents “often” or “always or almost always” debriefed with targeted colleagues after observing expressions of bias. While patients and visitors were the most common source of bias/microaggressions, non-hospitalist co-workers, consultants, and hospitalist colleagues were also sources of bias.

Hospitalists connected their experiences of bias at work with burnout. Specifically, 46% of respondents endorsed that bias experienced at work contributed to imposter syndrome. Sixty three percent reported it led to enjoying work less, 61% linked it to burnout, 41% said bias negatively impacted their self confidence, and 36% reported it driving callousness towards patients.

DISCUSSION / REFLECTION / LESSONS LEARNED: In this study, we identified high rates of bias experienced and observed by physician and APP hospitalists at a large academic institution. Respondents identified experiences of bias as contributors to burnout. These results align with our prior work on trainees’ experiences of bias.

Our findings underscore the critical need to address the impact of bias in hospital medicine, and the importance of providing both individual and system-level interventions. Further study is needed to understand how to manage these encounters in a multidisciplinary setting, and to assess the longer-term impact on hospitalists.

CURRICULUM TO IMPROVE PATIENT ACCESS TO RESOURCES IN A RESIDENT CLINIC

Dedeepya Konuthula¹; Margaret Shang²; Vivek Ashok²; Anna Maria Coronata²; Allie Dakroub²; Anna- Binney McCague²

¹Internal Medicine-Pediatrics, University of Chicago Division of the Biological Sciences, Chicago, IL; ²Internal Medicine-Pediatrics, UPMC, Pittsburgh, PA. (Control ID #3858835)

SETTING AND PARTICIPANTS: Without social work support at our Internal Medicine-Pediatrics (MP) clinic, we often fail to connect patients with community organizations which can improve patient health by helping to overcome barriers related to social determinants of health (SDOH). Many of our patients have low socioeconomic status and are affected by systemic racism (>75% primary Medicaid, >60% Black). Our staff includes 5 MP attendings, 16 MP and 9 pediatric residents, and 2 physician extenders. There are many competing learning objectives for residents in clinic, and becoming familiar with local resources is often not a priority. The purpose of this quality improvement project is to increase patient access to appropriate community-based referrals.

DESCRIPTION: From June to December 2020, we conducted a needs assessment asking patients and providers what types of resources would be helpful. Using this data, we created a resident curriculum addressing 9 common needs: behavioral health, bereavement, childcare, employment, finances, food insecurity, housing, transportation, and utilities.

Educational sessions in the spring of 2021 highlighted multiple local and national organizations for each need. We surveyed residents regarding their familiarity and comfort discussing resources with patients before and after the series using a 5-point Likert scale (5=most familiar/comfortable). To minimize reliance on memory, we created two mechanisms for referral which became available in December 2021: dotphrases (shortcuts in the electronic health record to insert resources easily) and a website that patients could access directly via a QR code posted in the clinic.

EVALUATION: Based on survey responses, resident familiarity with resources improved immediately after sessions but subsided after one month.

From January to June 2022, dotphrases were used 278 times, comprising 10.1% of completed office visits (13% of resident visits). 29 of 32 providers used any dotphrase. The most frequently used dotphrase was behavioral health (used 133 times), followed by transportation, food insecurity, and financial support. Monthly use stayed steady. Over this period, the website had 128 site visits and 86 unique visitors.

DISCUSSION / REFLECTION / LESSONS LEARNED: To reduce provider burden and barriers to patient access, dotphrases simplify the distribution of resources, and the website is directly accessible to patients so that they do not have to disclose needs to providers. Dotphrase usage was consistent and sustained over time in a way knowledge of local resources was not. New residents are now introduced to these tools annually during orientation. Because residents benefit from understanding the critical influence of SDOH on patient health behaviors and outcomes, the objectives of our curriculum have evolved and now focus on cultivating resident commitment to addressing these factors. This dedication can be brought with them to their future practice in a way local knowledge cannot, further increasing the impact of our curriculum.

ONLINE RESOURCE URL: tchelp.wixsite.com/site/video

DIVERSITY, EQUITY, INCLUSION IS MORE THAN CHECKING THE BOX: HOW TO CREATE A DEI AND ANTIRACISM CURRICULUM

Tracey Henry^7,2; Ore Olakunle⁷; Amy Miller⁴; Jason S. Schneider³; Luwi Shamambo⁷; Karen A. Clarke⁵; Marshall Fleurant^2,1; Christopher Hillhouse⁵; Sheryl Heron⁶; Olivia Veira⁷; Francois G. Rollin²

¹Medicine, Emory, Powder Spgs, GA; ²General Internal Medicine, Emory University School of Medicine, Atlanta, GA; ³Division of General Medicine & Geriatrics, Emory University School of Medicine, Atlanta, GA; ⁴Medicine, Emory University, Atlanta , GA; ⁵Medicine, Emory University, Atlanta, GA; ⁶Emergency Medicine, Emory University School of Medicine, Atlanta, GA; ⁷Emory University School of Medicine, Atlanta, GA. (Control ID #3874243)

SETTING AND PARTICIPANTS: The setting is undergraduate medical education (UME) institutions and the participamts are UME learners, faculty, deans and staff.

DESCRIPTION: DEI and anti-racism are key parts of patient care and medical education as they empower health professionals to be advocates for their patients both within the clinical space and beyond leading to better healthcare outcomes and more culturally and socially sensitive healthcare professionals. Despite this reckoning in medicine along with LCME’s standards to include structural competency and other equity principles in the medical curriculum, medical schools are still struggling on how to specifically do so. This innovation serves as a blue print to prepare medical faculty, staff and learners of how to either begin de novo or scale their current DEI and antiracist curricular efforts effectively, and thus meeting the promise of tomorrow of a more structually aware physician workforce.

EVALUATION: Highlighted Summary

-Development of evaluative framework for DEI Antiracism Curriculum, surveys, course/clerkship evals, focus groups and results.

-Results of Curriculum Inventory/Mapping, DEI Antiracism Curriculum Review for bias, Composition of a

Best Practice Check List for Course/Clerkships

-Appointment of DEI Antiracism Leads (Champion) for each DEI Antiracism subcategory of bias

-Tracking DEI Antiracism Student Concerns-types, frequency, mode of delivery of curriculum e.g. lecture, workshop, small groups, bedside reaching

-Patient Panel Recommendations

-Reviewed over 800 lectures, 23 Courses,10 Clerkships, 1 Thread, 10 course exams

-Summary Letters of the DEI Antiracism Curriculum review on ways to mitigate bias in their respective curriculum for each course/clerkship director with varying responses and levels of implementation and enegagement

-8 Course/Clerkship directors, faculty lectures, Research Discovery- requested to meet for feedback on their curriculum content

(mostly IM and IM subspecialties)

Mapped SOM Learning Objectives from core curricula to AAMC TAACT

--6/28 SOM Core Curricula Courses had at least 1 Learning Objective that mapped to AAMC TACCT

--2/22 SOM Clerkships had at least 1 Learning Objective that mapped to AAMC TACCT

-DEI Antiracism Curriculum additions

DISCUSSION / REFLECTION / LESSONS LEARNED: The framework for DEI and anti-racism approach to mitigating bias, microagressions and racism in UME, can also be utilized in GME.

Simply having DEI and antiracist curriculum in and of itself does not necessarily equal change or meaningful impact in medicine. Successful DEI and antiracist curriculum efforts will require ongoing research to assess attitudinal and behavioral changes of our learners that lead to practice change and eventually better health outcomes for historically marginalized communities. A concerted faculty development is required to educate and empower faculty to update their courses/clerkships/residency didactics, specifically to thread in DEI and antiracism with their current curriculum and their bedside teaching.

EARLY LESSONS IN SUPPORTING UNDERREPRESENTED PRE-COLLEGE AND COLLEGE STUDENTS ON A PATH TO MEDICINE THROUGH SHADOWING

J A. Albright⁴; Luckson Omoaregba³; Jennifer M. Oswald²; Kyla Dewar^1,2

¹Internal Medicine, Brown University Warren Alpert Medical School, Providence, RI; ²Brown Medicine, Brown Physicians Inc, Providence, RI; ³Office of Diversity and Multicultural Affairs , Brown University Division of Biology and Medicine, Providence, RI; ⁴Brown University Warren Alpert Medical School, Providence, RI. (Control ID #3876262)

SETTING AND PARTICIPANTS: High school and college underrepresented in medicine students (UiMs) participating in a northeast academic institution’s pathways Initiative programs.

DESCRIPTION: Shadowing is integral for improving pre-medical students’ confidence, self-efficacy, motivation, and understanding of the culture of medicine. We believe this experience, may in turn increase UiMs’ likelihood of pursuing a career in medicine. UiMs face particular barriers to shadowing, as most learners arrange shadowing experiences through personal connections. We created formal shadowing opportunities as part of two existing programs. One program, Pathways to Medicine (PM), focuses on UiM high school students interested in healthcare careers. PM combines a variety of information and skills sessions and one-on-one mentorship; our initiative added the opportunity to shadow in medical offices. The second, Month of Medicine (MOM), provides local UiM college students a chance to participate in Year 1 medical school didactics and to receive mentorship from current medical students, residents, and physicians.

Our initiative added the opportunity to be paired with faculty mentors for monthly shadowing sessions for the remainder of the year.

EVALUATION: We created an IRB-approved set of pre- and post-session surveys administered through REDCap. We used Social Cognitive Career Theory to develop questions to elucidate if the shadowing components of PM and MOM improved students' understanding of healthcare careers, impacted their current and potential abilities within medical careers, and increased outcome expectations and self efficacy in their desire to pursue a career in healthcare and medicine. We performed a focus group at the last PM session. The focus group was recorded, transcribed, then analyzed for themes and subthemes. 24 out of 52 PM students completed the initial survey, with the final survey pending at time of submission; 15 PM students participated in the focus group. All 6 MOM students completed the initial survey with final survey and exit interviews pending. We plan to continue the surveys, focus groups, and exit interviews with each iteration of the program.

DISCUSSION / REFLECTION / LESSONS LEARNED: Preliminary qualitative analysis from our first PM focus group suggested that even with structured shadowing opportunities, students still faced barriers. Recurring subthemes point to logistical difficulties and conflicts with academic responsibilities. Suggestions for improvement included providing more options for settings/specialties and providing clearer information ahead of the shadowing opportunities. For those able to shadow, experiences were positive. Most said it allowed them to picture a career as a physician and solidified their interest in pursuing a career in medicine. Exit interviews are still pending, but MOM students informally reported that shadowing has given them insight into the relationship between medical students, residents, and attendings, and has deepened their motivation to continue pursuing their goals of medical school.

EVALUATING THE IMPACT OF A NOVEL FIRST-YEAR MEDICAL STUDENT HEALTH EQUITY CURRICULUM ON MEDICAL STUDENT PROFESSIONAL IDENTITY AND BEHAVIOR

Marcus Hines¹; Katherine O. Chebly¹; Tiffany E. Cook²; Richard E. Greene¹

¹Medicine, NYU Grossman School of Medicine, New York, NY; ²Diversity and Inclusion, University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #3876695)

SETTING AND PARTICIPANTS: Health equity content is an essential component of undergraduate medical education (UME), but it is rarely prioritized and, when present, is not granted the same level of attention as the basic sciences. Further, the impact of health equity curricula on learners’ outcomes is not commonly studied in a longitudinal way.

In this innovation, we longitudinally evaluate the impact of a novel first-year health equity curriculum at an urban, northeast, academic medical center. Participants include 104 students who participated in an inaugural health equity course (2020). During a first phase of evaluation in 2020, over 90% of learners felt the course completely met the objectives of “understanding the relative influence of SDOH on overall health” and “understanding race as a social construct”, but fewer felt it completely met the objectives of “formulating strategies for anti-racism in healthcare practice” (59%) and “identifying strategies clinicians can use to address SDOH” (52%).

Now that the study participants are MS3s and have completed clinical clerkships, a next, current round of evaluation–via a survey and focus groups–will investigate if the curriculum has met its more action-oriented objectives after students obtain clinical experience.

DESCRIPTION: We designed a survey instrument to collect participants’ self-perceptions about competencies in health equity principles, based on recently disseminated AAMC Diversity, Equity, and Inclusion Competencies. A control group of students from a class who did not participate in the health equity curriculum are also being surveyed, to compare self-perceptions. Surveys aim to reach at least 50 students in each cohort. Semi-structured focus groups are also being conducted to gain a deeper understanding of the curriculum’s impact on individual behaviors, and qualitative data will be coded for themes using a grounded theory approach.

EVALUATION: Initial data collection and analysis, presented in a previous conference, suggested that the health equity course had a significant impact on students’ knowledge base, core competencies, and professional identity development. In this next stage of data collection–which will be available and analyzed by the time of the conference–we will evaluate if and how the course impacted clinical behaviors during the clerkship year.

DISCUSSION / REFLECTION / LESSONS LEARNED: Although Phase II data is not yet available for analysis, this innovation represents a novel approach to health equity curriculum evaluation, namely pursuing a longitudinal approach by comparing student perspectives from their first year and third year, after having experienced clerkships and had opportunities to put their knowledge into action. To truly ascertain the impact of the curriculum on patient care, additional testing modalities would need to be deployed such as direct observation or simulation.

EVIDENCE-BASED ANTIRACISM: IMPLEMENTATION OF A HEALTH EQUITY JOURNAL CLUB

Andrew J. Klein¹; Tanya Nikiforova²; Amar Kohli³; Thuy Bui⁴

¹Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²Internal Medicine, University Of Pittsburgh Medical Center, Pittsburgh, PA; ³General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ⁴Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #3876138)

SETTING AND PARTICIPANTS: The literature exposing structural inequities and racism in health care and dismantling race-based medicine is expanding at an exponential rate and educational initiatives to this end are imperative. We sought to evaluate trainee perspectives and the feasibility of implementing a health equity journal club. Residents and pharmacy students within the global health and generalist track of the internal medicine and medicine-pediatrics residency program at a large, academic medical center were invited to participate during the 2021-2022 academic year.

DESCRIPTION: We piloted a monthly, trainee-led health equity journal club noon conference over a virtual platform. Participants were asked to complete a survey both prior to and after 10 sessions. A resident or student leader chose an article related to health equity, summarized the findings, and led the discussion for each session, mentored by faculty. At the end of each session, participants were asked to identify one change they could make to their future practice to increase equity and combat structural racism.

EVALUATION: A total of 27 of 65 (42%) of participants responded to the pre-survey, including 9 pharmacy students (33%), 8 first- (30%), 6 second- (22%), and 4 third- or fourth-year residents (15%). Twenty-six of 27 survey participants (96%) agreed or strongly agreed with the statements that “systemic racism is pervasive in healthcare”, “it is important for me to critically assess the role of race in studies”, and “it is important for me, as a health care provider, to continually learn about disparities within healthcare”. Only 4 participants (15%) on the pre-survey identified self-directed learning from primary literature while the rest overwhelmingly identified secondary sources, such as podcasts, news articles, med twitter, and books, as the way they currently learn about race and racism in medicine. Only 5 of 65 participants (8%) responded to the post- survey, including 1 pharmacy student (20%), 3 first- (60%), and 1 second-year resident (20%). All 5 agreed or strongly agreed with the statements that health equity journal club has “helped me learn about important health disparities that may affect my patients”, “helped empower me to address social determinants of health with my patients”, and “helped me to provide better care for my patients”. A major limitation throughout was low and inconsistent session attendance and survey participation.

DISCUSSION / REFLECTION / LESSONS LEARNED: Residents and students recognize the critical need for further training combatting racism in medicine. A health equity journal club may offer a readily implementable way to augment antiracism training or curricula and foster meaningful discussions around inequities and racism in medicine. Thoughtful approaches to encouraging strong participation are needed to maximize success.

FRAMEWORK FOR IMPLEMENTING A LONGITUDINAL RESIDENT-LED STRUCTURALLY COMPETENT CASE CONFERENCE SERIES

Zainab Mabizari, Iman Hassan, Shwetha Iyer

Internal Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #3876522)

SETTING AND PARTICIPANTS: A resident physician led case-based structural competency conference delivered to 170 Internal Medicine residents during noon conference at a large urban academic center DESCRIPTION: Structural competency is an educational framework that explicitly prompts clinicians to consider structures that impact clinical care and imagine solutions. By training residents physicians to consider structural barriers they develop the tools to promote health equity in patient care.

We used these principles to create a facilitation guide for noon conference that incorporates structural and social determinants of health into clinical reasoning. The guide aids residents in crafting case presentations that teach social, economic, and political factors along with institutional barriers that serve as root causes for clinical health outcomes. Using a root cause analysis worksheet, residents build a problem representation and differential diagnosis that (1) recognize structural factors impacting health and result in health inequities, and (2) approach structural inequities as addressable and intervenable problems within patient care. By using this framework, we hypothesize that medical residents can cultivate a critical and socially conscious way of approaching patient care that promotes equity and social justice in healthcare settings. Case conferences were developed and piloted and will continue to be implemented at least monthly during conferences attended by 30 internal medicine residents each.

EVALUATION: A pre and post-survey developed in collaboration with educators with structural competency expertise will assess knowledge and attitudes regarding structural competency among residents attending the conference. We will collect residents’ completed structural root cause analysis worksheets before and after case conferences and assess them for changes in ability to identify core social and structural factors pertinent to patient care in the presented case. A survey for residents leading case presentations will provide feedback on use of the facilitation guide and training materials developed for implementation. Participant root cause analysis worksheets from our pilot show limited resident ability to identify comprehensive social and structural factors.

DISCUSSION / REFLECTION / LESSONS LEARNED: Resident-led case presentations have potential to result in understanding of social and structural barriers to health. Implementation during noon conference allows for longitudinal resident training. Our facilitation guide derives features from traditional case presentations and novel social-justice informed methods to teach health equity in clinical settings. The autonomy granted to resident physicians to craft these presentations and teach them to their peers likely enables deeper exploration and learning on the part of resident teachers. Future evaluation will assess whether resident clinical documentation of structural and social barriers in the electronic health record increases after participation in structurally competent case conferences.

HEALTH E-CHATS: DEVELOPING A COMMUNITY HEALTH EDUCATION PROGRAM TO EMPOWER UNDERSERVED COMMUNITIES

Daniel Liauw¹; Luisa P. Acosta¹; Mandy Bass²; Jackie Wiley²; Paul Ridker¹

¹Internal Medicine, Brigham and Women's Hospital, Boston, MA; ²Center for Community Wellness at Sportsmen's Tennis Enrichment Center, Brigham and Women's Hospital, Boston, MA. (Control ID #3877085)

SETTING AND PARTICIPANTS: Sportsmen’s Tennis & Enrichment Center (STEC) is the nation’s first tennis club built by and for the African-American community in 1961, guided by a vision that tennis can promote opportunities for Boston’s youth and their communities. STEC’s Center for Community Wellness offers extensive community-centered programming beyond tennis, such as COVID vaccines/testing, healthy cooking workshops, fitness classes, and health chats. Participants of Health E-Chats are primarily African American community members from underserved neighborhoods in the Boston area.

DESCRIPTION: STEC’s Center for Community Wellness aims to promote health in three of Boston’s poorest communities: Dorchester, Mattapan, and Roxbury. Since 2017, internal medicine residents have created curricula of hour-long, health education workshops designed to discuss social determinants of health, health disparities, and community resources. During the COVID pandemic, the initiative evolved into Health E-Chats under the direction of medicine residents, a community engagement coordinator, and a nurse director. The Health E-chats program offers twice monthly, dinner-time forums led by medical residents and community health leaders. Community members participate via online video chats and on-site attendance at the tennis club. Topics have included Skin and Hair Care for People of Color, Heart Health 101, CPR Training, COVID Recovery, and Cancer Screening. Speakers are guided on tools to effectively engage community members. Topics are determined by community participants via surveys.

EVALUATION: We assessed participants’ interests and engagement with the curriculum. In Spring 2022, each workshop included 10 to 120 participants. During one of these workshops, 28 Health E-chats participants completed an online survey. Most participants identified as Black or African-American (78%) and as women (82%). Respondents spanned ages 18 to 75 years or older, with the most common age demographic (46% of respondents) being 55 to 64 years old. Number of health chats previously attended spanned from 0 (43% of respondents) to greater than 10 (7% of respondents). 100% of participants said they feel seen, and 93% of participants said the health chats have benefited them in one or more ways. While there was high interest in a large number of topics, participants were especially interested in learning about heart health (61%) and mental health (50%).

DISCUSSION / REFLECTION / LESSONS LEARNED: Health E-chats have effectively engaged a diverse audience of community members. Participants select topics that feel particularly relevant to themselves and their families, aligned with issues that disproportionately affect underserved populations. Survey data shows that participants enjoy the E-Chats, feel seen, and benefit personally from the information shared. We hope to improve this curricula by expanding on topics of community interest, developing a resident-community member co-facilitation model, and establishing a Health E-Chat referral process from resident primary care clinics.

IDENTIFYING AND ADDRESSING SOCIAL DETERMINANTS OF HEALTH DURING THE CLINICAL ENCOUNTER: A STANDARDIZED PATIENT SESSION FOR RESIDENTS

Tamara Goldberg²; Raul Chibas Sandoval¹

¹Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; ²Internal Medicine, Mount Sinai St. Lukes West, New York, NY. (Control ID #3847740)

SETTING AND PARTICIPANTS: Although principles of social determinants of health (SDH) have increasingly been introduced into internal medicine (IM) residency curricula, evaluating a resident’s ability to identify barriers to care in practice has not been well studied. To ensure competency in SDH identification and mitigation during the clinical encounter, we designed a faculty-observed, standardized patient session as part of a two-week health equity curriculum for PGY1 residents in an academic Primary Care Track program between September 2019 and September 2022. DESCRIPTION: To prepare residents to turn SDH concepts into practice, we developed two standardized outpatient case scenarios, each focused on a separate barrier to care commonly faced in their outpatient practice. During the standardized patient session, residents are expected to identify a barrier contributing to poor disease control, document appropriately, and address the barrier with the patient. Prior to the session, residents engaged in a two-week block focused on local health disparities, SDH screening and documentation, cost-effective prescribing, community-based resource utilization, and principles of cultural humility. Each standardized session consists of a 30 minute faculty review of concepts, a 20 minute observed patient encounter, and a 20 minute post-encounter feedback/ reflection session. Participants are observed and evaluated by faculty and or a senior resident facilitator via a one way mirror utilizing a case-specific checklist. To assess the impact of our educational intervention, residents were surveyed pre and post encounter regarding a variety of affective domains.

EVALUATION: To date, 9 residents have engaged in the simulated case exercise. At baseline, 33.3% (n=3) reported previous experience in screening and addressing SDH in the clinical encounter and 44.4% (n=4) felt comfortable initiating a conversation about social barriers to care for their patients.

Our post-session survey showed that 100% of participants (n= 9) reported greater confidence in taking a history of social barriers to care, 100% felt more confident about how to use available resources to address social barriers, 100% reported a greater likelihood of identifying and addressing a social barrier to care in future encounters, and 100% reported they were more likely to start a conversation about social barriers to care.

DISCUSSION / REFLECTION / LESSONS LEARNED: Results to date suggest that incorporating standardized patient cases on SDH during the clinical encounter serve as a useful way to increase confidence in applying principles of SDH to clinical practice for primary care trainees. Since self- reported surveys do not necessarily reflect real-world change in behavior, next steps will be to assess documentation and resource utilization by residents in their clinical practice.

IMPLEMENTING A HEALTH, EQUITY, AND JUSTICE CURRICULUM INTO AN INTERNAL MEDICINE RESIDENCY

Kelly McDermott¹; Rachel Cohen²; Joshua Mendoza¹; Christopher Prater¹

¹Internal Medicine, Washington University in St Louis, St Louis, MO; ²Internal Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL. (Control ID #3854956)

SETTING AND PARTICIPANTS: A Health, Equity, and Justice curriculum was created and implemented into the ambulatory didactics of a Midwest Internal Medicine residency.

DESCRIPTION: This curriculum included threads in structural and social determinants of health (SSDOH), systemic and structural racism, implicit bias, and racism in medicine. Curricular objectives emphasized understanding and defining structural and social determinants of health, developing solutions to patients’ barriers to health on an individual and population level, recognizing and combating implicit bias, and developing strategies to foster anti-racism at all levels of the medical system.

EVALUATION: This curriculum had a multi-faceted evaluation system, including a pre-design needs assessment, standard qualitative topic evaluations, informal interviews, and a quantitative pre-post evaluation. The pre-post quantitative evaluation consisted of 7 Likert-scale questions focused on application of course content and included the following questions: understanding principles of SSDOH, comfort asking patients about SSDOH, implementation of SSDOH in patient care, understanding of anti-racist principles, witnessing anti-racism, and actively being anti-racist. This was designed as a prospective observational cohort study. Although all seven measured variables improved after 1 year of curricular implementation, only one approached statistical significance. Residents were significantly more likely to actively engage in anti- racism in the post-curricular survey (p = 0.045).

DISCUSSION / REFLECTION / LESSONS LEARNED: While undergraduate medical education recognized the need and has largely integrated diversity, equity, and inclusion into the curriculum of medical students, the graduate medical education has space to improve and broaden the education and perspective of residents in this area. Creating and implementing a thread of health, equity, and justice into an internal medicine residency created a safe space for open dialogue and information related to racism in medicine, medical mistrust, and implicit bias in healthcare. Residents were significantly more likely to engage in anti- racism behavior after one year of the new curriculum. There might be additional behavior changes after residents have received all three years of the curriculum.

IMPLEMENTING A HEALTH EQUITY, ADVOCACY, AND ANTI-RACISM (HEAAR) CURRICULUM FOR INTERNAL MEDICINE RESIDENTS

Anna M. Morenz¹; Ryan Abe²; Hasib Yousufzai³; Lynsey Bernfeld¹; Helen E. Jack⁴; Angeilea Yancey- Watson⁵; Anne L. Cravero⁶; Anders Chen⁷

¹Department of Medicine, University of Washington, Seattle, WA; ²Department of Medicine, University of Washington Department of Medicine, Seattle, WA; ³Internal Medicine, University of Washington Department of Medicine, Seattle, WA; ⁴Medicine, University of Washington, Seattle, WA; ⁵African Americans Reach and Teach Health, Seattle, WA; ⁶Department of Medicine, University of Washington, Seattle, WA; ⁷Internal Medicine, University of Washington, Seattle, WA. (Control ID #3874929)

SETTING AND PARTICIPANTS: Society and health care continue to perpetuate racism and health inequities. We created a comprehensive health equity, advocacy, and anti-racism (HEAAR) curriculumnto provide future physicians with the understanding and skills to contribute to dismantling harmful structures and policies. HEAAR is a longitudinal, three-year curriculum developed for a large internal medicine residency program. The first portion launched in summer 2022, reaching 54 PGY-1 residents during their first ambulatory block of residency.

DESCRIPTION: The intern curriculum began with foundational didactics on the history of racism in medicine and race-based trauma taught by a representative from a non-profit organization embedded in the local Black community. This was followed by an interactive session on the history of racist policies in our city and a walking tour led by community members through a neighborhood near our county hospital that has been impacted by redlining and gentrification. A subsequent physician advocacy session introduced different ways physicians can be involved in advocacy and emphasized a culture of physicians seeing themselves as change agents for more equitable policies and systems. Lastly, the interns participated in a case discussion analyzing social determinants of health and potential solutions at multiple levels.

EVALUATION: Interns were anonymously surveyed before (93% completion, n = 50) and after (52% completion, n = 28) the curriculum using 5-point Likert-style and open-ended questions. 56% (n = 28) reported feeling comfortable or very comfortable recognizing systems of oppression in the pre-survey compared to 100% (n = 28) in the post-survey. After the session, 89% of residents (n = 25) were able to recognize wealth stripping, or policies that deprive assets from low-income and particularly Black individuals and communities, compared to 16% (n = 8) before. 96% believed the curriculum increased their

understanding of oppression facing the Black community, and 93% agreed that residents should be trained in community-based advocacy. Unprompted, 75% requested more sessions, highlighting the need to expand training on these topics.

DISCUSSION / REFLECTION / LESSONS LEARNED: Internal medicine trainees responded positively to a community-grounded, collaborative curriculum on health equity, advocacy, and anti-racism. After the curriculum, they had greater understanding of how societal policies shaped by oppression mediate patients’ social and medical realities. Community-based organizations and members of affected communities are often experts in this realm and should be included and compensated for educating our future internists. Residents should be empowered and trained to advocate within their communities, institutions, and multiple levels of government for policies that mitigate social and structural determinants of health. Subsequent PGY 2-3 training will focus on advocacy skills and opportunities for clinic-based organizing experience.

IMPROVING TRAINEE UTILIZATION OF INTERPRETER SERVICES FOR PATIENTS WITH LIMITED ENGLISH PROFICIENCY

Delia Shen¹; Christine Wang¹; Daniel Liauw¹; Esteban Gershanik²

¹Internal Medicine, Brigham and Women's Hospital, Boston, MA; ²Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #3874269)

SETTING AND PARTICIPANTS: Patients with limited English proficiency (LEP) represent one in twelve patients at this academic medical center, mainly on trainee medical services. Patients with LEP experience inequity in quality and patient safety. Interpreter use is inconsistent despite availability of multiple interpreter modalities (in-person, tablet device, and phone). Pre-intervention data showed that patients who required interpretation services received less than 1 interpretation per bed day (0.96 interpretations). Our project aims to identify and address medicine trainee barriers to using interpreter services.

DESCRIPTION: The internal medicine residency was surveyed. The most common barriers to interpreter use were time to get an interpreter, difficulty finding an interpreting device, and difficulty using an interpreter. Based on trainee feedback, we advocated for increased access to interpreter services and developed interpreter use training.

We advocated for more interpreter access within the departments of medicine and interpreter services, leading to an increased number of tablet devices per unit. A training presentation was created with input from the interpreter services department and a literature review to guide how to use interpreters and when to preferentially use in-person versus virtual interpreters. This presentation, with hospital specific interpreter service options and best practices, was presented to internal medicine interns at orientation and residency- wide meetings. To streamline time to reach interpreters, a badge was created to be placed behind ID cards, including pagers, phone numbers, and tablet device location. Patient preferred language signs were placed in patients’ rooms. Training also included electronic medical record templates for proper interpreter use documentation, complying with Joint Commission Hospital Standards.

EVALUATION: Primary outcome will be utilization of interpreter services via phone, tablet and in-person interpreter use on medicine trainee services. Outcomes will include 1) number of times of interpreter use per patient per bed day and 2) frequency of documented EMR interpreter encounters pre and post intervention. Trainee impact will also be assessed by qualitative surveys.

DISCUSSION / REFLECTION / LESSONS LEARNED: In academic medical centers where numerous LEP patients are cared for, it is imperative for medical trainees to provide comparable quality of care through interpreters. Pre-intervention patient analysis and survey results suggest that trainees were not appropriately utilizing interpreter resources and believed there were numerous barriers to correct usage. This multi-pronged approach was used to improve quality of interpreter utilization and bolster trainee relationships with interpreter services department and patients. The next phase of this intervention will incorporate trainee feedback to improve training curricula and additional interventions to engage trainees.

ONLINE RESOURCE URL: https://docs.google.com/presentation/d/1v5ygfIHyxdfg7-3hMtqX8KsYS6FXyUrLGfIEtXjA0cE/edit#slide=id.p

INTEGRATING NON-TRADITIONAL TOPICS INTO MEDICAL SCHOOL CURRICULA

James K. Sullivan¹; Brady Greene¹; Katherine E. Lowe¹; Will Patterson²; Colleen Colbert³; Robert Dean¹; Ilyssa O. Gordon¹; Maeve Hopkins¹; Henry Ng¹; Jason Lambrese¹; Bud Isaacson⁴; Neil Mehta¹

¹Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; ²Education Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; ³Education Institute, Cleveland Clinic, Cleveland, OH; ⁴Internal Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #3874963)

SETTING AND PARTICIPANTS: Pre-clerkship and clerkship medical students at a Mid-West United States medical school.

DESCRIPTION: Medical students need education in social, economic, and environmental determinants of health, in addition to traditional biomedical curriculum related to human physiology and disease. Adding these non-traditional topics can be difficult because of limited time in medical school courses. At our medical school, we incrementally incorporated concepts and learning activities related to the effects of climate change on health as well as lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual/aromantic /agender (LGBTQIA+) health into existing curricula during the pre-clerkship and clerkship years. Working groups consisting of collaborations between faculty, interested students, and medical school administration identified and proposed learning objectives and associated content materials for integration into specific pre- existing curricular activities. Content was successfully integrated into pre-clerkship small group case-based discussions (problem-based learning), interactive seminars, journal club, doctoring courses (including medical humanities, clinical skills, and physical diagnosis), and clerkship-based didactic sessions. Examples of integration included 1-2 discussion points in problem-based learning sessions or 1-2 additional slides in a seminar presentation.

EVALUATION: Learner assessment included multiple choice questions and narrative peer-to-peer and faculty formative feedback after small group discussions, as well as annual IRB-approved student surveys. Students also used formative feedback to reflect on their performance and progress within semi-annual reflective portfolios which call for self-assessment related to nine different competencies with multiple milestones.

DISCUSSION / REFLECTION / LESSONS LEARNED: After 1 year of integration work, approximately half of learning objectives identified ahead of time were implemented into pre-existing curricular activities.

The majority of remaining learning objectives were in progress at the time of writing this abstract. Previously reported barriers to integrating additional content into curricula include lack of time and faculty buy-in. Our integrative model addressed those barriers through 1) dedicated committees to communicate and educate existing faculty and 2) integrating content into existing curricular activities rather than developing entirely new seminars or cases. Challenges included finding time to teach basic introductions to these topics and meeting faculty needs and interests while still delivering a comprehensive curriculum for these non- traditional topics. In total, our method represents a way to rapidly and comprehensively integrate non- traditional topics that medical students need to develop an understanding of in order to apply new knowledge and skills in clinical practice.

INTEGRATING POINT-OF-CARE SCREENING FOR SOCIAL DETERMINANTS OF HEALTH WITH SPACED LEARNING IN A LARGE INTERNAL MEDICINE RESIDENCY CONTINUITY CLINIC

Zachary Boggs¹; Rachel H. Kon²

¹Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA; ²Medicine, University of Virginia School of Medicine, Charlottesville, VA. (Control ID #3847447)

SETTING AND PARTICIPANTS: Academic Resident Clinic, Internal Medicine Residents DESCRIPTION: Screening for and addressing social determinants of health (SDOH) in the outpatient setting via experiential learning is a potential method for teaching residents how to manage health care disparities, now an ACGME competency. Spaced learning, particularly module-based e-learning, has been shown to be effective in improving knowledge among medical residents. Our SDOH screening rates by internal medicine residents in their continuity clinic were low at baseline, and many residents did not know how to access resources to assist with social needs. This study assessed attitude and knowledge attainment and retention on addressing SDOH in the outpatient primary care setting. All internal medicine residents at our institution participated in a lecture on screening for and addressing SDOH, with an emphasis on the risk of contextual errors. Note templates were adapted to auto-populate answers to screening questions using the SDOH screening tool. Residents were provided with an easily accessible document to offer resources to their patients. To improve knowledge, residents were e-mailed every month with 3 to 4 “Fast Facts” clinical vignette questions during their clinic weeks for 6 months, which were developed at the University of Pittsburgh.

EVALUATION: 100 residents were invited to participate in a knowledge, attitude, and practice survey before the lecture series, immediately after the lecture and after 6 months. 46 residents completed the pre- survey, 36 residents completed the immediate post-survey and 14 completed the post-intervention survey. At baseline, 95% of residents felt that it was a part of their job to screen for SDOH. Residents found the lecture on “Contextual Errors in SDOH” to be at least moderately useful, 40% found it to be extremely useful. 53% of residents reported to have used the resource document. Nearly half of residents reviewed the “Fast Facts” questions at least a moderate amount of the time. After 6 months, residents felt more prepared to address their patients’ social needs (χ2=11.63, p=0.009). Residents perceived that their screening rate, documentation and comfort level would improve immediately after lecture, however this improvement was not significantly sustained at 6 months. Knowledge did not significantly improve post-intervention.

DISCUSSION / REFLECTION / LESSONS LEARNED: The multimodal SDOH curriculum helped residents feel more prepared to address social needs. Despite their baseline beliefs, the lecture and note template changes, residents did not perceive that they were screening or documenting more after 6 months. The clinical vignette questions were well-received but the study was under-powered to determine differences in knowledge retention. A major limitation was post-survey participation. In the future, we will assess the effect on documentation and utilization of the SDOH screening tool in our EHR.

IT TAKES A VILLAGE: INITIATING AN INTERPROFESSIONAL EDUCATION (IPE) LEARNING EXPERIENCE IN AN ACADEMIC HEALTH CENTER

Lauren Meade, katie costa, Jennifer Glisson, Reva Kleppel, Paul A. Pirraglia

Medicine, Baystate Health, Springfield, MA. (Control ID #3875933)

SETTING AND PARTICIPANTS: Information is scarce for Interprofessional Education (IPE) in the clinical years compared to classroom or simulation. We initiated an IPE, social justice focused, inter- institutional curriculum embedded into a primary care rotation at an academic health center. Learners from medicine, nursing and pharmacy are integrated into a Medicaid Accountable Care Organization (M-ACO) team consisting of community health workers (CHW), nurses and pharmacists. The M-ACO team works collaboratively to improve chronic disease management by addressing barriers of social determinants of health (SDOH).

DESCRIPTION: The curriculum consists of an orientation, a clinical immersion, a case conference, and structured reflection. At orientation learners introduce themselves to enhance familiarity of each profession, discuss a landmark anti-racism article (Jones, 2000) and meet the M-ACO team. Learners and the M-ACO team are then immersed in patient care. From this, learners choose a case to present with the M-ACO team. The curriculum concludes with a structured reflective group session. The curriculum occurs virtually or in person as per pandemic guidelines. The reflective session is used as a data source for discovery of themes related to professional identity and teamwork. We obtained IRB approval.

EVALUATION: Ten groups of IP learners, ranging from 1 – 5 learners, have rotated through this curriculum; total learners/34; physician assistant students/6, medical students/10, pharmacy students/7, nurse practitioner residents/2, medical residents/5, and other learners/4. We use two question cues for reflection: 1. How do you see the roles, responsibilities and scope of your practice and the practice of other team members? and 2. What impact did working on this healthcare team have on person centered care? We recorded and transcribed the reflective session which range in length from 28–40 minutes. The authors, from unique health professions, independently review the transcripts, compare and consolidate codes, recode, and reconcile differences (Dedoose software). The five themes that emerge are: 1. It takes a village; professionals from different disciplines bring multiple perspectives to deliver highly coordinated, individualized care. 2. Patients are invested in their care when they feel heard and receive advocacy. 3. CHWs, a new role to many, have lived experience which is key to building trusting relationships. 4. Learners gained a new appreciation for the impact of SDOH on barriers to care and 5. Understanding other roles on the team clarifies the learner’s own role and leads to reflection on future career path.

DISCUSSION / REFLECTION / LESSONS LEARNED: This study reveals IP learners gain new discernment for scope and roles of professionals, especially the CHW, a new role to many. They recognized new value and a potential career path in the collaborative team approach in a primary care setting with a myriad of SDOH. A relatively simple intervention has promise for developing professional identity and teamwork competence.

MICROLESSONS FOR MICROAGGRESSIONS

Theresa H. Liao^1,2; Ramya Prasad^1,2; Talia Kahn^1,2

¹Portland VA Medical Center, Portland, OR; ²Oregon Health & Science University, Portland, OR. (Control ID #3874088)

SETTING AND PARTICIPANTS: Portland VA

Oregon Health & Science University Hospitalist and Outpatient Medicine Faculty

DESCRIPTION: Although faculty wish to support residents experiencing microaggressions, residents indicate support is inadequate and inconsistent. No faculty-focused training currently exists at our institution, and trainings must be sought out, may be time-intensive, and are typically “one-and-done”. Using Kern’s approach, we developed “Microlessons for Microaggressions”, a curriculum that incorporates 10-minute sessions into established faculty meetings. To date, three sessions have been delivered during both monthly hospitalist and generalist section meetings. Sessions covered were: (1) microaggressions- impact and recognition; (2) when to respond; and (3) how to respond.

EVALUATION: We received a waiver from our institutional IRB. Two sets of anonymized surveys were developed: (1) linked pre- and post-surveys for the entire mini-curriculum and (2) post-session surveys for each microlesson. Pre-curriculum survey data included faculty demographics, attitudes, and behaviors around microaggressions and Diversity, Equity and Inclusion (DEI) topics. Combined post-microlesson survey data for sessions 1-3 indicated faculty found session format effective (31/32) and content helpful (30/32). A majority indicated they would do something different after individual sessions (24/32). Survey data for sessions 2 and 3 showed that 6/15 respondents indicated they had changed behavior and 5/15 respondents had reviewed DEI resources since the prior session. Some who changed behavior had not reviewed additional DEI resources. Narrative comments noted brief format, case examples and specific language were most helpful. Post-curriculum survey data has not yet been fully collected.

DISCUSSION / REFLECTION / LESSONS LEARNED: A mini-curriculum of brief, recurring didactic sessions delivered longitudinally during preexisting faculty meeting time is feasible and may be helpful in changing faculty knowledge, confidence and behaviors around addressing microaggressions experienced by trainees. Limitations to our work include small sample size, low survey response rates, and implementation at only a single site. Respondents to surveys may at baseline feel this topic is important and be more apt to find these sessions useful and change behavior. We developed a year-long curriculum, but this may not be feasible in many groups; generalist leadership was ultimately only able to provide time during three meetings. Session format necessitates and demonstrates leadership support of DEI principles, which may also impact faculty attitudes and behaviors. Next steps include spread to other divisions within our institution, engaging

additional faculty to lead sessions, and exploring the benefit of separate, supplemental skill-building sessions.

PATHWAYS TO MEDICINE: AN EARLY LOOK AT THE SUCCESSFUL COMPONENTS OF A PRE-COLLEGE PATHWAYS PROGRAM SUPPORTING UNDERREPRESENTED STUDENTS.

Ana V. Guimaraes⁴; Alexander Homer³; Luckson Omoaregba²; Kyla Dewar^1,5. ¹Internal Medicine, Brown University Warren Alpert Medical School, Providence, RI; ²Office of Diversity and Multicultural Affairs , Brown University Division of Biology and Medicine, Providence, RI; ³Warren Alpert Medical School, Brown University Warren Alpert Medical School, Providence, RI; ⁴Primary Care and Population Medicine Program, Brown University Warren Alpert Medical School, Providence, RI; ⁵Brown Medicine, Brown Physicians Inc, Providence, RI. (Control ID #3874540)

SETTING AND PARTICIPANTS: High school underrepresented in medicine students (UiMs) participating in a northeast academic institution’s Pathways to Medicine Program (PM)

DESCRIPTION: Black, Hispanic, and Native American people remain underrepresented in the healthcare workforce. To address these disparities, the PM created a rating system based on well-studied cumulative disadvantage factors to score and select students. Our program's main objective was to work collaboratively with other professional schools to host a cross-disciplinary program that increased participants’ sense of self- efficacy and desire to pursue a career in healthcare. Over 7 sessions, students heard from panelists, practiced history taking via case studies, learned basic life support skills and vital signs, toured an anatomy lab, improved their interview and resume-writing skills, and gave a conference-style presentation. Two other unique features included 1:1 mentorship with a health professional student and a clinical shadowing program.

EVALUATION: An IRB approved set of pre- and post-program surveys were administered through REDCap. Questions derived from Social Cognitive Career Theory (SCCT) were used to elucidate if the PM program improved students' understanding of health care careers and increased their confidence, self efficacy, and desire to pursue a career in health care. We performed a focus group at the last session with open ended questions focusing on this and feedback for improvement. This was recorded, transcribed, then qualitatively analyzed for themes and subthemes. Informal feedback after each session was also solicited. We plan to continue the surveys and focus groups with each iteration of the program.

DISCUSSION / REFLECTION / LESSONS LEARNED: This program consisted of 52 high school students, grades 10-12. Of these, 33 identified as first-generation, 24 as Black, 22 as low income, 19 as Hispanic, 8 as LGBTQ+, 4 as undocumented, and 3 as having a disability. 46% of students completed the pre survey with the final survey pending. 15 students participated in the focus group. Session feedback was positive, with students wishing for more hands-on activities. In the focus group, questions regarding mentorship and understanding of the medical field elicited the most responses and indicated benefits to self- efficacy. Mentorship increased confidence in recovery from failure and networking skills. Mentorship and the career panel clarified paths to medicine and corrected assumptions that academic perfection is required for a medical career. The anatomy lab proved divisive, with some mentees indicating the experience affirmed their interest, and others saying that aversion to the activity caused them to question it. Overall, preliminary findings indicated that PM increased mentee confidence, self efficacy, and desire to pursue a career in health care. Ultimately, high-school students self-reported benefits from the PM program according to SCCT, though additional followup will be required to determine if these effects lead to improved long-term outcomes.

REDUCING HEALTH INEQUITIES FOR CRIMINALIZED INDIVIDUALS AND COMMUNITIES: AN ABOLITIONIST CURRICULUM FOR MEDICAL STUDENTS AND RESIDENTS

Mary Thomas²; Mackenzie Mitchell³; Clare Idehen³; Joseph Truglio¹

¹Internal Medicine, Pediatrics and Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY; ²University of Minnesota Twin Cities, Minneapolis, MN; ³Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #3875520)

SETTING AND PARTICIPANTS: Over the past three years we delivered progressive iterations of this session in small-groups (20 participants) and large-groups (140 participants) to a total of 300 participants.

Learners ranged from first year medical students to senior residents.

DESCRIPTION: Mass incarceration and the criminalization of racialized communities are major drivers of health inequities in the United States. Criminalized individuals have increased risk of physical and mental health conditions and marked increased risk of death. Such inequities fall sharply along racial lines, with one in three Black men compared with one in seventeen white men being incarcerated in their lifetime, and over 10% of Black children having at least one parent incarcerated. Health systems and individual clinicians contribute to these outcomes through numerous policies and practices, including introducing police into racialized communities, inequitable use of urine drug testing and exclusion of formerly incarcerated individuals from hiring practices. Clinicians have a unique opportunity to reduce these inequities via individual clinical practice and dismantling unjust policies. However, published curricula focus exclusively on individual medical care for current and recently incarcerated individuals. Further, none include individuals with lived experience of incarceration.

Grounded in anti-racist pedagogy we engaged with our local community and individuals with a history of incarceration to design and deliver a workshop within an abolitionist framework. Facilitators included faculty with experience caring for patients with a history of incarceration, senior medical students and individuals with lived experience of incarceration. Through interactive discussions, think-pair-share exercises and break- out groups participants identified current policies and practices within healthcare that contribute to criminalization, and opportunities for change within their spheres of influence. Participants developed individualized abolitionist toolkits, organizing their skills within interpersonal, community, research and policy/advocacy domains.

EVALUATION: We used live interactive poll data and post-session surveys for session improvements. Future evaluation methods will include survey-based assessments of knowledge and follow-up surveys to assess behavioral change in the clinical environment.

DISCUSSION / REFLECTION / LESSONS LEARNED: We developed an innovative session medical students and residents identify the role of healthcare in perpetuating criminalization and develop abolitionist skills within their individual spheres of influence. Lessons learned included the positive impact of partnering with individuals with a history of incarceration, and the practical benefit of participants developing individualized toolkits to increase the generalizability of the session to different levels of learners. Next steps include formal evaluation and dissemination to additional institutions.

SAY WHAT?! IMPLEMENTING A MULTIDISCIPLINARY INTERVENTION TO REDUCE STIGMATIZING LANGUAGE IN THE MEDICAL RECORD

David S. Edelman¹; Ashley A. Duhon²; Sara Isani²; Zoon Naqvi³; Tiffany Lu¹; Patricia Driscoll¹; Shwetha Iyer¹

¹Internal Medicine, Montefiore Medical Center, Bronx, NY; ²Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Bronx, NY; ³Family and Social Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #3871785)

SETTING AND PARTICIPANTS: 79 residents, faculty and staff of 4 residency programs at an academic medical center in the Northeast.

DESCRIPTION: Stigmatizing language disproportionately affects marginalized populations, occurring more often in records of patients who are Black, Hispanic, female and use substances. These written choices, often unintentional and unconscious, impact clinical decision-making.

Few curricula teach how note-writing can produce stigmatizing language. At our institution, some residents complete a 2-week experiential elective in Addiction Medicine where they are exposed to topics of substance use, bias, stigma, person-first language and health impacts of systematic stigmatization. They also learn non- stigmatizing alternatives through curricula and observed behavior of Addiction Medicine faculty.

To fill the gap beyond this elective, a multidisciplinary group of residents and faculty innovated a 90-minute, peer-led, interactive anti-bias workshop consisting of role-playing, didactics, group work, small and large group discussion, and a resource toolkit. It was delivered 4 times (2 in-person, 2 virtual) to mixed groups of residents, faculty and staff in Family Medicine, Internal Medicine, OB/GYN and Pediatrics. Novel components include virtual delivery; discussion on the interaction of bias, stigma, and power; education on linguistic mechanisms that produce stigmatizing language; and inclusion of patient perspectives about shared clinical notes.

EVALUATION: We developed a pre-session survey with guidance from experts in medical education to evaluate baseline recognition of stigmatizing language. We plan for post-session evaluation of the workshop’s impact on knowledge and behavior.

Of 79 workshop attendees (63 residents, 16 faculty/staff), 56 completed the survey. Participants correctly identified 10.9/15 statements containing stigmatizing language (range 4-15, IQR 9.5-12). Recognition varied by topic; for example, 89% of stigmatizing language related to substance use was identified, compared to only 33% of statements that casted doubt on patient descriptions.

Participants who completed an Addiction Medicine elective identified 1.9 (95% CI 0.0-3.7) more stigmatizing statements compared to all other participants, controlling for demographics and potential confounders such as program and resident/faculty status.

DISCUSSION / REFLECTION / LESSONS LEARNED: We found baseline recognition of stigmatizing language varied by topic and that participation in an Addiction Medicine elective was significantly associated with identification of stigma. As most participants identified stigmatizing language in substance use, this finding highlights the potential of experiential learning and role-modeling for teaching non-stigmatizing language alternatives.

We also successfully implemented a multidisciplinary anti-bias workshop in the curricula of 4 resident training programs. Further evaluation will assess how this intervention impacts knowledge and behavior, an important step to reducing disparity introduced through stigmatizing language.

SOCIAL DETERMINANTS OF HEALTH, NAVIGATING THE HEALTHCARE SYSTEM

Linda Lemaster, James O'Neal. Medical Education, OhioHealth, Columbus, OH. (Control ID #3853523)

SETTING AND PARTICIPANTS: A Midwestern Outpatient Internal Medicine resident clinic, which provides primary care to a high-risk population of uninsured and underinsured patients with limited resources.

Participants/learners consisted of 56 preliminary and categorical Internal Medicine residents and 12 transitional medicine residents.

DESCRIPTION: Problem identified:

Deficiencies in the residents’ knowledge of healthcare system navigation were identified during ambulatory conferences and at the end of patient office encounters. This resulted in the development of an interactive social determinants of health curriculum.

Description of the Innovation:

The Social Determinants of Health (SDOH) curriculum consisted of four, in-person sessions, to improve the knowledge of available resources. Modules were developed for the following topics:

1. Appropriate staffing referrals

2. Health Care Disparities

3. Income Eligibility

4. Small Group - Flipping the Classroom regarding cost of coverage

EVALUATION: A pre- and post-test were developed to assess effectiveness and retention

DISCUSSION / REFLECTION / LESSONS LEARNED: Optimal training in SDOH requires more than “on the fly” instruction since the components are not intuitive to the learner. The curriculum provided a reference base for the learner to expand.

Lessons learned include:

1. Cost itemization required by the Health Care Price Transparency Act needs to be improved for patients under the Hospital Care Assurance Program (HCAP)

2. Although the Medicaid population had fewer out of pocket costs, the availability of specialty care is limited.

3. When feasible, direct patient admission to the hospital, avoids the high emergency room deductible.

4. Review of healthcare.gov insurance plan, costs vs coverage was surprising.

5. Consider utilizing non-facility fee imaging centers for patients with high annual deductibles.

6. Pharmaceutical assistance programs are available for the uninured for higher tier medication. However, patients with insurance coverage had longer prior authorization processes and higher out of pocket cost.

ONLINE RESOURCE URL: http://www.healthcare.gov

SOCIAL ISOLATION AS A DETERMINANT OF HEALTH: DEVELOPING CURRICULA TO IMPROVE RESIDENT SOCIAL HISTORY-TAKING

Michael Shen²; Katherine O. Chebly¹; Kathryn Havranek¹

¹Medicine, NYU Langone Health, New York, NY; ²Medicine, New York City Health and Hospitals Corporation, New York, NY. (Control ID #3849780)

SETTING AND PARTICIPANTS: Social isolation is an established risk factor for all-cause mortality. The Institute of Medicine recommends social isolation screening as part of routine social histories and the National Academy of Sciences recommends medical education programs include training related to social isolation. However, physicians generally do not inquire about a patient’s social networks and routine social histories rarely mention social support.

In this needs assessment of 84 resident physicians in an urban, academic medical center’s internal medicine residency program, we measure current knowledge, skills, and perspectives about screening for and documenting social isolation as part of a complete social history. Results will be used to improve existing curricula on social history-taking and social determinants of health (SDOH) and create clinical resources for residents to strengthen screening and documentation practices.

DESCRIPTION: This innovation aims to: (1) Survey residents for perspectives about social isolation as a SDOH; (2) Evaluate if and how residents document social isolation through an electronic medical record chart review. Descriptive statistics will be used to summarize quantitative data including Likert-scaled survey questions. Grounded theory will be used to identify common themes in qualitative responses.

EVALUATION: Preliminary data includes partial survey completion (n=48 residents). 52% of residents report receiving formal education in medical school about social isolation. Fewer report formal education so far in residency (26% PGY1s; 41% PGY2s; 42% PGY3s). Few residents are familiar with social isolation screening tools (13%) or the Z-code method of SDOH documentation (13%). Residents self-report screening for social isolation more often in inpatient settings vs. outpatient (73% vs. 65% ‘often/always’ asking), but document it more often in outpatient vs. inpatient care (56% vs. 50% ‘often/always’ documenting). Self- reported social isolation screening and documentation peaked among PGY2s and decreased among PGY3s. Residents report no central EMR location to document social isolation and most (92%) report including it as free text in a note. Residents generally agree that it is an internist’s job to screen for and document social isolation, though many cite “time constraints” and “feeling awkward” as primary obstacles to including isolation in a social history. Most residents express they lack resources to help isolated patients.

DISCUSSION / REFLECTION / LESSONS LEARNED: Resident physicians in this sample consider social isolation an important SDOH to screen for and document, but lack sufficient formal instruction to do so. More explicit education on the topic should include specific screening tools and standardized instruction about SDOH documentation including social isolation. Revised curricula will also include clinic-specific resources for severely isolated patients so that residents feel empowered to support isolated patients, and be responsive to resident concerns about timing and language.

STEPPING OUTSIDE THE CLINICAL WALLS: RESIDENT-LED NEIGHBORHOOD WALKING TOURS AS A PART OF A MULTIMODAL SOCIAL MEDICINE CURRICULUM FOR INTERNAL MEDICINE RESIDENTS

Ran Xu¹; Griffin Plattner²; Jessica Zeidman³; Rashmi Jasrasaria⁴

¹Internal Medicine, Massachusetts General Hospital, Boston, MA; ²Internal Medicine, Massachusetts General Hospital, Boston, MA; ³Department of Medicine, The Massachusetts General Hospital, Chelsea, MA; ⁴Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #3876607)

SETTING AND PARTICIPANTS: The walking tours were offered to Internal Medicine (IM) residents and took place in New England communities.

DESCRIPTION: The objective of the neighborhood walking tours was to go beyond the walls of the clinic and the traditional role of a physician trainee to experience the neighborhoods where our patients live and work, recognize the barriers to healthcare, highlight the community resources available and how to access them.

We designed walking tours that took place in two communities with community health centers (CHCs) affiliated with the academic medical center where IM residents had continuity panels. We interviewed longtime residents of the communities, community members affiliated with the CHCs, as well as leaders of community coalitions to gather valuable historical perspective, community experience, and resources from community organizations. Each tour concluded at a local restaurant with a debrief session. We piloted the tours with a group of interns in Spring 2022, then incorporated them in early ambulatory experiences for interns of the 2022-2023 class. We trained additional residents to help lead the tours.

EVALUATION: Quantitative and qualitative evaluations were assessed via surveys. Fifty-seven residents (49 interns), four medical students, and three administrators took one or both walking tours. Forty-four participants completed the survey. Over 93% of participants thought their tour contributed to their understanding of the community and nearly 98% found the experience enjoyable.

The qualitative feedback included recommendations to create resources lists addressing social determinants of health (SDH) such as food insecurity, to incorporate indigenous history, and to consider having a community member lead the tour with compensation. Participants cited feeling more invested in the community and appreciated being able to contribute to local small businesses.

DISCUSSION / REFLECTION / LESSONS LEARNED: This project was part of a larger effort to expand the Social Medicine Curriculum in our residency training, which includes an intern orientation session, updated ambulatory didactic sessions, and residency-wide conferences featuring healthcare innovations that address SDH. We targeted the intern class to introduce local communities, emphasize the importance of community engagement, and foster interest in disparities work. We received constructive feedback which we actively incorporated. The walking tours are an effective and engaging way to highlight the history, health disparities, and resources unique to each community as they are designed and led by near peers, which offered a welcoming layer of informal mentorship.

Future work will focus on designing additional tours in other communities. We are currently working with CHCs to expand the tours to other staff members. The ultimate goal is to develop a self-guided edition of each tour, with pre-recorded interview segments highlighting voices of local community members, which will allow us to deliver this important content to a wider audience.

TEACHING ANTI-RACISM IN MEDICINE: AN EVALUATION OF A NOVEL AND LONGITUDINAL CURRICULUM FOR RESIDENT PHYSICIANS

Elaine De Leon²; Katherine O. Chebly²; Blen Girmay¹; Lisa Altshuler²; Richard E. Greene³

¹Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD; ²Medicine, NYU Langone Health, New York, NY; ³Medicine, NYU Grossman School of Medicine, New York, NY. (Control ID #3873842)

SETTING AND PARTICIPANTS: Structural racism and the impact of race on health are infrequently taught explicitly in graduate medical education. In programmatic feedback, primary care resident physicians in an urban internal medicine program advocated for additional instruction on anti-racism. Following a careful literature review including published curricula and relevant texts, we developed and delivered a two- year anti-racism conference series (ARC) to enhance resident physicians’ abilities to better meet the needs of racially minoritized patients. A total of 40 resident physicians participated in the initial program.

DESCRIPTION: The ARC was implemented through 16 60-minute longitudinal conferences conducted between August 2020 and June 2022. Sample discussion topics included racial identity, racism as a social determinant of health, race in the medical literature, racism and reproductive justice, and intersectionality.

EVALUATION: Using optional surveys with items consisting of four-point Likert scales and open-ended questions, participants rated if sessions met stated learning objectives (LOs). Following the first year, to obtain in-depth feedback, we additionally conducted seven focus groups with a total of 19 participants which informed the second year of conference topics and delivery. Focus groups were recorded, transcribed and analyzed via grounded theory.

DISCUSSION / REFLECTION / LESSONS LEARNED: Over two years, 163 survey responses were collected. The vast majority of participants rated “Agree” or “Strongly Agree” when asked whether sessions met stated LOs. Exceptions included five individuals who expressed concerns about faculty participation in small groups after the Introduction session, and two individuals who expressed concerns in the second session (Racial Identity) about the centering of White identities. Notably, survey responses dwindled as the curriculum progressed, with 28 responses out of 30 session attendees initially to an average of 10 per session thereafter.

Themes identified through analysis of focus groups included opportunities for impact of the ARC at the intrapersonal, interpersonal and institutional levels. Participants reported that the curriculum helped them develop greater awareness of racism in healthcare and increased confidence discussing related topics. They valued multi-media pre-readings for level-setting and resident-led discussion which engendered trust. For guest facilitators, some learners wanted explicit content delivery, still others the sharing of anecdotal experiences. There was also a tension through surveys and focus groups reflecting the challenge of balancing necessary development of awareness, praxis, and internal progress on anti-racist practice with a desire for action-oriented content. Next steps include evaluating the impact of the curriculum on behaviors through simulation or direct observation.

TEACHING THE INTERPLAY BETWEEN EMPATHY AND IMPLICIT BIAS RECOGNITION AND MANAGEMENT FOR INCOMING FIRST-YEAR MEDICAL STUDENTS

Jessica Dennehy⁵; Jennifer Adams¹; Maura Minsky³; Renee Williams⁵; Colleen Gillespie²; Jon Lapook⁴; Cristina M. Gonzalez⁵

¹Internal Medicine, NYU Langone Health, New York, NY; ²PrMEIR/IIME, NYU Grossman School of Medicine, New York, NY; ³The Empathy Project, NYU Grossman School of Medicine, New York, NY; ⁴The Empathy Project, NYU Grossman School of Medicine, New York, NY; ⁵Institute for Excellence in Health Equity, NYU Grossman School of Medicine, New York, NY. (Control ID #3876143)

SETTING AND PARTICIPANTS: First-year medical students (N=183) at an urban medical school in Mid- Atlantic Region.

DESCRIPTION: An interactive 1-hour didactic introduced students to the impact of implicit bias on health disparities ending with a professionally produced short film, “The Elephant in the Waiting Room.” In it, a Black female patient’s and a White male physician’s lived experiences and good intentions collide during their encounter. An Empathy Elephant intervenes to coach the physician in implicit bias recognition and management, allowing for the demonstration of empathy, restoration of rapport, and appropriate diagnosis and treatment. Afterward, students submitted a reflection and transitioned to small groups. Trained faculty and senior student facilitators guided students through the movie, stopping three times for critical reflection and guided discussion. Students submitted the final reflection. Analysis of anonymously submitted reflections was deemed exempt by the IRB.

EVALUATION: We investigated the impact of this compulsory educational activity. Two investigators analyzed (N=324) responses using thematic analysis. For Prompt 1,“Choose one character in the film who is different from you and imagine how their lived experience might affect the doctor/patient interaction,” themes were: 1) Downstream Effects of Lived Experience “They have this preconception of how they will be treated which then causes mistrust in the medical system, avoidance, and greater health inequities;” and 2) Impact of Bias in Healthcare “The patient’s mother was not seen as an individual and not completely listened to.” Themes for Prompt 2 “Develop a strategy to empathize with another person’s perspective,” were: 1) Honest Inquiry, “Learning how to fully listen to them, while understanding you will never fully understand all the experiences that have brought them to the encounter”; 2) Partnering, “I may ask them what I could do to best meet their needs and then go from there in trying to get them the right care”; and 3) Centering Self “My strategy is to put myself in the other person’s shoes and take the perspective of the other person.”

DISCUSSION / REFLECTION / LESSONS LEARNED: Our educational activity met the intended learning objectives. Students were able to: 1) Recognize lived experience as a key influence on patient- physician interactions that can lead to actual and perceived bias; 2) Write about perspective-taking; and 3) Develop strategies grounded in empathy to connect with another who may be very different from them. Our data analysis also uncovered some student responses that should be addressed in future iterations. Some students placed the onus on the patient in the initial reflection for things such as mistrust and receiving suboptimal care. Others couldn’t relate to mistrusting physicians, coming from medical families themselves. Finally, some students struggled to ascribe bias to the physician in the film, a character with whom they share their emerging professional identity.

ONLINE RESOURCE URL: https://www.empathyproject.com/

THE HUMAN DIMENSION VOICES PROGRAM: TEACHING SOCIAL DETERMINANTS OF HEALTH VIA AN INNOVATIVE COMMUNITY ENGAGED CURRICULUM

Carmela Rocchetti, Jennifer Knight, Lawerence Rosen, Miriam Hoffman

School of Medicine, Hackensack Meridian School of Medicine, Nutley, NJ. (Control ID #3869972)

SETTING AND PARTICIPANTS:

Undergraduate Medical Education in the Mid-Atlantic Region.

DESCRIPTION: In 2020, the Society for General Internal Medicine issued a new call for action to address social determinants of health (SDOH), asking educators to “ensure social and relational competency for future physicians by developing curricula with SDOH at every stage of education and evaluation.” Those charged with teaching SDOH to future physicians, however, face a paucity of curricular guidance. Very few medical schools provide robust community-engaged medical curricula to train students formally how to address social determinants of health in clinical practice. Our academic institution developed the Voices Program, a required longitudinal undergraduate medical education program embedded within the innovative Human Dimension course. A key component of the curriculum matches student dyads with individuals (Voices Participants or VPs) from historically marginalized and under-invested communities to develop a longitudinal relationship over a series of home visits during the 3 year curriculum. This relationship helps students understand the main drivers of health outcomes by bringing the SDOH to life, while providing health coaching support to the family. Students are prepared for these community experiences through a variety of educational sessions including large group learning sessions, facilitated small group discussions, reflection activities, and community-based assignments. The students are provided knowledge and skills for cultural humility, health equity and health coaching, then apply these concepts as they work to help their VPs. Small group reflection and mentorship activities led by faculty are used to debrief these community experiences and prompt students to think critically about how to address SDOH and become change agents through advocacy.

EVALUATION: The majority of students surveyed reported that the Voices Program was the most valuable part of their community engaged curriculum experience. Students reported growth in their understanding of determinants of health, their ability to collaborate their own humanism, cultural humility and skills necessary to promote equity .

DISCUSSION / REFLECTION / LESSONS LEARNED: A distinguishing feature of the Human Dimension Voices Program is the longitudinal integration across the entire curricula, from basic science integration to the integration into the clinical setting via clerkship curricula. Students note that the program is an extremely valuable component of their medical education. They report growth in understanding determinants of health, cultural humility, humanism, and equity- promoting skills while providing meaningful service to the community. Faculty-led small group sessions focused on the reflection and processing of community experiences was universally cited by students as a key part of their learning experience.This program is an effective way for students to learn health system science while developing a professional identity rooted in humanism and resilience.

THE RESIDENT DIVERSITY, EQUITY, AND INCLUSION AMBASSADOR PROGRAM

Nicole Van Groningen, Mark Noah

Medicine, Cedars-Sinai Medical Center, Los Angeles, CA. (Control ID #3876815)

SETTING AND PARTICIPANTS: Our large, academic health system in Los Angeles serves a diverse population of patients, but our physician workforce does not mirror that of the community we serve. Recognizing this, the office of Graduate Medical Education (GME) has made recruiting residents from diverse and underrepresented backgrounds, and promoting an environment of inclusivity, a top prioritiy. Our health system does have a robust Office of Diversity and Inclusion (ODI) that coordinates education, events, mentorship, and other resources for all employees. However, although many of our resident physicians are interested in initiating or contributing to projects that promote diversity and inclusion, they historically have not been involved in or even aware of ODI offerings. To bridge this gap, the GME and ODI launched the Resident Diversity, Equity, and Inclusion (DEI) Ambassador Program to engage residents from various specialties in the ODI's efforts, and to support them in launching their own initiatives.

DESCRIPTION: Program directors from each residency program were asked to nominate 1 to 3 residents (depending on the size of the program) to serve as Resident DEI Ambassadors. A total of 17 Ambassadors were nominated and agreed to participate in the program, which began in June 2022. Ambassadors were tasked with initiating a project to promote DEI within their programs. They were also expected to attend bi- monthly meetings, during which they provided project updates and learned about news and updates from the ODI. Ambassadors received a $1,000 stipend for their involvment, which was dispersed quarterly and contingent on continued particiption in the program.

EVALUATION: The program has had excellent participation, with only one resident who was ultimately unable to participate in any capacity. Of the remaining 16 residents, all actively participated in projects within their residency programs. Projects included the creation of special recruitment events for residency applicants from underrepresented backgrounds, a DEI book club, a social media campaign to better highlight the diversity of the residency program to future applicants, and speciality-specific mentorship programs.

DISCUSSION / REFLECTION / LESSONS LEARNED: The Resident DEI Ambassador Program has become a successful method for engaging residents in DEI initiatives both at a small, local scale as well as at the health system level. Many members of the current generation of trainees are passionate about contributing to diversity and inclusion efforts, and offering them a clear route to participate - with appropriate compensation for their time - promotes professional satisfaction while also contributing to meaningful cultural change in the institution. Future directions will be to evaluate whether the program has had an impact on our ability to recruit more residents from underrepresented backgrounds, as well as to measure residents' perceptions of inclusivity within their programs both before and after the launch of the program.

UPSTANDER TO BYSTANDER TRAINING

Carlie Stein¹; Dan Wells²

¹Medicine, UAB, BIrmingham, AL; ²UT Memphis, Memphis, TN. (Control ID #3868950)

SETTING AND PARTICIPANTS: This one hour conference occurred virtually on zoom with two southern Med-Peds residency programs. We had 34 trainees and 12 faculty from both institutions present for the conference. The session was led by two residency program directors with faculty moderators in the breakout sessions.

DESCRIPTION: During the one-hour virtual conference, we started with introductions and ground rules to create safe space for active dialogue. We defined the bystander effect and “the 5 D” framework (Direct- Distract-Delegate- Delay-Display Discomfort) for responding to microaggressions. We then presented a case that was anonymously shared by residents in the programs. Next, we divided into six small groups- each with two faculty moderators along with 5-6 residents of similar PGY levels across both programs. Each group participated in a 15 minute “think-pair-share” exercise sharing thoughts about the case, focusing on one of the D’s and how they would react to this case. We then had a 10-minute report back with each group sharing reflections. We concluded by reviewing the “OW*TFD” framework and some of the ethical/legal considerations of how to confront micro and macroaggressions by patients.

EVALUATION: We sent an initial survey to both programs residents (n=66 total, n= 39 respondents) asking for PGY level, comfort level in responding to micro/macroaggressions, encounters residents have witnessed that they would be willing to share, and future interest in joining an inter-residency group that meets to discuss topics related to diversity equity, and inclusion. 74% responded with interest in joining an inter- residency group and 51% reported witnessing micro/macroagressions in their daily work in the past year.

We conducted a post lecture survey with overwhelmingly positive results. 12/12 respondents reported “the training created a safe environment for discussion”. 12/12 answered yes to “UAB-UTHSC Upstander Training was helpful in learning techniques that can be applied in situations where micro- and/or macro- aggressions are witnessed”. 11/12 reported they were “somewhat comfortable” when asked “how comfortable are you responding if you witness a micro or macro aggression? “

DISCUSSION / REFLECTION / LESSONS LEARNED: In conclusion, this innovative combined educational conference fostered active dialogue amongst trainees and faculty at two different institutions resulting in increased comfort level in acting as an upstander for colleagues and patients. We look forward to planning part two of conference in the spring prior to the national SGIM meeting. Part two will focus on further development of skills in responding to micro macroaggressions through deliberate practice with peers.

USING AN ANIMATED FILM TO FOSTER UNDERSTANDING OF AND ENGAGEMENT IN ADDRESSING IMPLICIT BIAS THROUGH EMPATHY ACROSS THE HEALTHCARE CONTINUUM

Jennifer Adams²; Colleen Gillespie¹; Renee Williams³; Maura Minsky⁴; Jonathan LaPook⁴; Richard E. Greene⁵; Joseph Ravenell⁶; Jessica Dennehy⁷; Cristina Gonzalez⁸

¹PrMEIR/IIME, NYU Grossman School of Medicine, New York, NY; ²Internal Medicine, NYU Langone Health, New York, NY; ³Medicine, NYU Langone Health, New York, NY; ⁴The Empathy Project, NYU Langone Health, New York, NY; ⁵Medicine, NYU Grossman School of Medicine, New York, NY; ⁶NYU Langone Health, New York, NY; ⁷Institute for Excellence in Health Equity, NYU Langone Health, New York, NY; ⁸Institute for Excellence in Health Equity, NYU Langone Health, New York, NY. (Control ID #3877101)

SETTING AND PARTICIPANTS: The curriculum (an animated film and facilitated discussion designed to engage health care professionals in reflecting on empathy as a tool for mitigating implicit bias) was delivered to 740 participants (medical students, residents/fellows, physicians, healthcare team members) via 30 sessions at two academic medical centers.

DESCRIPTION: We developed and delivered an innovative curriculum built around a high-quality animated film (“The Elephant in the Waiting Room”). The film portrays a clinical encounter between a young, Black woman and a white male physician. The well-intentioned physician’s relatable missteps and the patient’s prior experience with discrimination yield multiple opportunities to use empathy to restore the encounter after the patient perceives bias. Enter Denise the Empathy Elephant! She coaches the physician to use core communication and empathy skills to mitigate his anchoring bias and truly connect with the patient. The curriculum identifies multiple points for reflection and discussion to engage participants in recognizing the interplay between empathy and implicit bias recognition and management.

EVALUATION: Participants completed a brief, anonymous survey about their experience and the likely impact of the curriculum. At NYU Langone (the focus here), the curriculum was delivered to two consecutive medical school classes at orientation (n=215), 50 residents/fellows, 40 health care team members (nurses, assistants, social workers, etc), and 45 physicians. Survey data are available for 284 participants (80% response). Overall, the curriculum was experienced as engaging (95%), a safe environment (98%), and relevant to clinical practice (94%). The vast majority of participants somewhat or strongly agreed that watching and discussing the film would have an impact in terms of: recognizing implicit bias (96%), mitigating implicit bias (94%), recognizing opportunities for empathy (98%), practicing perspective-taking (94%), and being more empathic in clinical settings (95%). Responds did not differ by participant role. Half of participants (81/160) described how the curriculum helped them arrive at a more nuanced understanding of implicit bias and/or empathy; 42 (26%) wrote about how it translated abstract concepts into more compelling real world examples; 16 (20%) described specific ways in which they would change their health care practices; 8 responses (10%) were about coming to understand the power of implicit bias and/or empathy in influencing care/outcomes; and 10 (6%) said they now felt more confident in recognizing their own implicit bias.

DISCUSSION / REFLECTION / LESSONS LEARNED: The animated film combined with a structured curriculum engaging participants in a well-facilitated, small group discussion appears to be an effective way to engage a broad range of healthcare professionals in deepening their understanding of and commitment to strategies for mitigating implicit bias and enhancing empathy.

ONLINE RESOURCE URL: https://www.empathyproject.com/(https://www.empathyproject.com/denise)

WORDS MATTER: IMPLEMENTING AND EVALUATING A PATIENT-CENTERED DOCUMENTATION SMALL GROUP FOR MEDICAL STUDENTS

Zoe Kopp¹; Susannah Cornes³; Irina (Era) Kryzhanovskaya²

¹General Internal Medicine, University of California San Francisco, San Francisco, CA; ²Medicine, University of California San Francisco, San Francisco, CA; ³Neurology, University of California San Francisco, San Francisco, CA. (Control ID #3876158)

SETTING AND PARTICIPANTS: First year medical student (MS1) small group session.

DESCRIPTION: Stigmatizing documentation in patient notes is known to affect treatment decisions and perpetuate health disparities. Whether inclusion of anti-oppressive curriculum on note-writing can reduce bias and stigma in patient notes and ultimately improve patient care is unknown. As part of an anti-racist institution-wide effort, we created a 3-hour small group for 181 MS1s, facilitated by 27 faculty, in groups of 6. Prior to this session, MS1s examined documentation as a tool in medical decision making. This session followed the Sukerha and Watling 2018 framework for integrating implicit bias recognition and management into health professions education, introducing MS1s to 4 skills to improve their own documentation and decrease the effect of other’s documentation on their clinical care: word choice, questioning assumptions, deconstruction of dominant narrative, and emotional regulation. Groups discussed documentation as a tool that can improve or hinder patient care and examined patient note vignettes for differences in word choice and potential to impact clinician attitudes and behaviors. Informed by recent literature describing the biased use of stigmatizing language in medical documentation, facilitators contrasted examples of patient-centered word choice with phrasing that introduces doubt into the patient narrative. The second half of the session included MS1s examining their own previously written note for the presence of stigmatizing language, deconstructing the dominant narrative for 5 additional clinical scenarios, and applying self-monitoring and reflection skills to a non-medical experience.

EVALUATION: Thirty-three MS1s completed a post-session survey of Likert-scale and free response questions. All MS1s agreed that the session increased their awareness of the potential impact of biased language, 94% agreed that they learned new skills to recognize and reduce use of stigmatizing language, and all agreed they would apply these skills in the future. MS1s planned to increase their own awareness of biases and commit to telling the patient’s full story. MS1s noted conflicting priorities, burnout, and lack of knowledge as barriers to applying new skills. MS1s responded positively to the multiple aspects of the session and desired more chances to practice.

DISCUSSION / REFLECTION / LESSONS LEARNED: This session exposed MS1s to the negative consequences of biased medical documentation and provided skills to mitigate its effects. The combination of scrutinizing real-world notes and vignettes and practicing non-stigmatizing language and reframing questions, introduced the complexity of documentation to MS1s. Next steps include educating faculty and residents on these principles and increasing sense of autonomy within the curriculum to address barriers noted in the evaluation.

Innovation in Medical Education (IME) - Health Policy

A MODULE: THE HISTORY OF RACISM IN HEALTH & PUBLIC POLICY

Khaalisha Ajala

Hospital Medicine , Emory University, Atlanta , GA. (Control ID #3877038)

SETTING AND PARTICIPANTS: Recently, the need for health equity & social justice was an inconvenient truth with global impact. Despite varied opinions, it remains urgent. Health inequity is the culmination of historic and recent policy decisions. I sought to understand how the history of racism was interwoven in early and current U.S. public & health policies. I sought to trace the impact of how this work could inform health advocacy and explore it as a health policy case study. The intended participants are medical students, residents, and faculty physicians interested in health policy and advocacy.

DESCRIPTION: In this module, we examine 19th and 20th century public policies & health policies and their affect on health outcomes in Black, Brown and Indigenous communities. Next, we identify how these policies are connected to current health inequities. We ask how we can mitigate and advocate to change poor health outcomes these communities. Finally, we aim to llearn, identify, discuss and advocate on behalf of our patients for more equitable health from bedside, to the C-suite and Capitol Hill.

Some of the policies covered:

The Slave Health Subsystem 1619-1865

Post Civil War Reconstruction 1865-1877

Freedman’s Bureau 1865-1872

Black Codes 1865-1870’s

Jim Crow Laws 1877-1964

Black Midwives & Sheppard-Towner Maternity and Infancy Protection Act of 1921

The New Deal 1933-1939

The Hill Burton Act (Hospital Survey & Construction Act) 1946

Civil Rights Acts of 1964

Medicare & Medicaid 1965

Anti-Drug Abuse Act of 1986

The Violent Crime Control and Law Enforcement Act of 1994

Affordable Care Act 2011

EVALUATION: In separate sessions, learners and faculty will be engaged with various learning modalities such as journal club, workshops, didactics and documentary. They'll participate in breakout sessions and disucss the connection between health disparitied and historic policies. We'll note its impact upon at risk communities and map it's legacy in 2022. We'll document actionable items that will counteract the affect of some policies and ask how to strengthen others. Lastly,students and faculty will receive a survey. It will ask if our objectives were met by identifying health inequities or negatively impacted social determinants of health that are connected to historic policies.

DISCUSSION / REFLECTION / LESSONS LEARNED: Long have we accepted advanced pathology as baseline in black, brown and indigenous communities. One’s life expectancy can depend on the zip code and income. In many cases, this outcome started with a policy decision. Racism has informed or influenced the many federal and local policy decisions as well as their outcomes. There are developed curricula concerning DEI or antiracism exist in medical education, but none include the history of the public & health policies that've had a profound affect on black, brown and indigenous people. There is a need for an intentional antiracism framework to approach health policy. We would benefit from an antiracism informed approach to creation of future health policy.

ONLINE RESOURCE URL: Not available

INTEGRATING AN OP-ED WRITING OPPORTUNITY AND WORKSHOP INTO A REQUIRED HEALTH POLICY COURSE FOR MEDICAL STUDENTS RESULTED IN ENHANCED STUDENT ENGAGEMENT IN ADVOCACY WRITING, INCLUDING PUBLISHED OP-EDS.

Venkatesan R. Krishnamoorthi^1,2; Daniel Y. Johnson²; Spencer Asay²; Grace Keegan²; Maeson Zietowski³; Samuel Chen²; Vineet M. Arora^4,2; Shikha Jain⁵

¹Medicine, University of Chicago, Chicago, IL; ²University of Chicago Pritzker School of Medicine, Chicago, IL; ³Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; ⁴Medicine, University of Chicago Medical Center, Chicago, IL; ⁵Medicine, University of Illinois at Chicago, Chicago, IL. (Control ID #3877360)

SETTING AND PARTICIPANTS: All first-year medical students at University of Chicago Pritzker School of Medicine are required to take the course “The American Healthcare System.” For the final required writing assignment, students were given the option to 1) write an essay on one of the prompts provided by course directors or 2) write an op-ed advocating on a health-related issue of their choice. An optional op-ed writing workshop was provided, and additional editing and coaching was offered for students who wished to submit for publication.

DESCRIPTION: Medical schools have increasingly integrated advocacy training into their curricula. Op-ed writing can be a powerful and accessible advocacy tool for health professionals, but few opportunities and curricula exist in undergraduate medical education to train learners in this type of writing. We designed, implemented, and evaluated a workshop and training process to instruct and engage medical students in op-ed writing.

EVALUATION: Students were surveyed on their prior experience in advocacy, their background education about the healthcare system, whether they attended the workshop, and their confidence in op-ed writing skills before and after the workshop.

Results: Of 90 students, 48 (53.3%) chose the op-ed option. Students wrote to advocate on various topics, such as racial disparities in breast cancer survival and the ban on blood donation among men who have sex with men. Eight op-eds were published in major news outlets or physician blogs. Students’ decision to write an op-ed was not associated with prior advocacy experience (p = 0.17) prior education/experience in the healthcare system (p = 0.47). More than a third of students who took the post-course survey (N = 73) reported attending the op-ed writing workshop, and 88% of attendees found it helpful. Among students who wrote an op-ed, those who attended the workshop reported significantly increased confidence in their op-ed writing skills (p = 0.002) on a scale of 1-5 with the pre-course mean = 2.1 and a post-course mean = 3.5 compared to those who did not attend the workshop (pre-course 2.1 and post-course 2.3).

DISCUSSION / REFLECTION / LESSONS LEARNED: A workshop focused on op-ed writing can be integrated into an existing health policy course and result in demonstrable improvement in perceived confidence in advocacy writing skills among students and enhanced student engagement in advocacy writing, including publication of first-authored op-eds in major outlets. On reflection, simply providing the opportunity to write an op-ed in a required curricular framework engaged more than half of students to choose this format of writing. In addition, a training workshop and an additional peer-led coaching and editing process increased students' confidence in their writing skills. Finally, supporting and encouraging students to prepare their pieces for publication through this process resulted in a high number of first-time op- ed publications by medical students, demonstrating the potential for impact by medical students in health advocacy.

RECTIFYING THE ILLS OF POLICY PAST THROUGH MEDICAL EDUCATION

Marc Henry G. Estriplet¹; Louisa Holaday^2,1

¹Internal Medicine , Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, US, academic/medsch, New York, NY; ²Internal Medicine, Yale University School of Medicine, New York, NY. (Control ID #3877164)

SETTING AND PARTICIPANTS: Residents in a primary care residency program at an academic medical center in the northeast

DESCRIPTION: As the COVID-19 pandemic ravaged our country in early 2020, it unearthed health inequities hiding in plain sight. These disparities are part and parcel of the structural racism built into the U.S. healthcare system. While the past several years have led to a growing awareness in medicine of the social determinants of health and their role in driving health disparities, one topic continues to be lacking in these discussions- the role of health policy in codifying structural racism.

We propose an innovative educational curriculum targeted at medical residents to better understand the historical context of policies that have laid the foundation for current racial inequities in healthcare. This proposed curriculum seeks to provide the opportunity for residents to explore major health policy decisions- from the Hill-Burton Act to the formation of the ACA— and apply this knowledge to their clinical practice with patients. Ultimately, the goal is to educate our future healthcare leaders on the political determinants of health, providing them with the tools to advocate for racial equity via health policy and informed clinical practice.

EVALUATION: We will provide a lecture series to primary care residents, providing the historical context of the major health policy decisions and their role in upholding systems of structural racism. Prior to the didactic portion, we will assess their knowledge and confidence in interacting with health policy concepts and their role in health care. Following the implementation of the curriculum, we will measure their ability to operationalize this information and the role the political determinants of health plays in health.

This will include a 3-part lecture series to 20 primary care residents over the span of 3 months. The first two lectures will consist of didactics detailing specific policies and their health impacts from 1930-2020. The final lecture will use questions and cases to test retention and use those to re-present the material from the earlier lectures. The initial cohort of residents will be 85% female & 50% persons of color.

DISCUSSION / REFLECTION / LESSONS LEARNED: The purpose of this proposed curriculum is to empower providers by providing them with a richer and more nuanced understanding of health policy in relation to race-based patient outcomes. The field of medicine in recent years has increasingly worked to incorporate a social determinants of health lens towards patient health and well-being. However, not enough emphasis has been placed on the role that health policy has taken in ingraining these determinants within the very fabric of society. Furthermore, for many clinicians, there continue to be lingering gaps in comprehension of upstream drivers of racial disparities in healthcare. We will struggle to rectify the impact of structural racism without further focus on the political determinants of health.

Innovation in Medical Education (IME) - Interprofessional Education

A DAY IN THEIR SCRUBS: PIONEERING A NURSE AND RESPIRATORY THERAPIST PARTNERSHIP PROGRAM FOR FOURTH YEAR MEDICAL STUDENTS IN THE MEDICAL INTENSIVE CARE UNIT

Colleen A. O'Neill¹; Sherine Salib¹; Shailaja J. Hayden²

¹Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; ²Pulmonology and Critical Care Medicine, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #3873393)

SETTING AND PARTICIPANTS: Participants included fourth year medical students on a critical care elective as well as nurses and respiratory therapists (RTs) in the medical intensive care unit (MICU) at an academic medical center in the southern United States. Nurses and RTs volunteered and were then selected by the course director.

DESCRIPTION: Interprofessional collaboration is crucial to successful care in the ICU. There is limited literature on interprofessional education between medical students and ICU nurses, and, to our knowledge, none regarding RTs. In our pilot program, each medical student was provided a list of sample questions, and assigned 3 hours to shadow an ICU nurse and 3 hours with an ICU RT. Nurses and RTs received credit in our institution's professional development program for staff.

EVALUATION: Medical students completed pre- and post-program surveys, and nurses and RTs completed post-program surveys, all of which were anonymous. Our program is new, so the current sample size is small with 5 medical students, 3 RTs, and 2 nurses.

Medical students reported they gained a better understanding of the daily workflow and challenges faced by nurses and RTs. 80% felt better equipped to communicate with nurses and RTs about patient care. 80% reported a better understanding of the interprofesional cooperation required for ICU care. 80% rated both shadowing experiences as extremely valuable. Comments included: “I became aware of things I can do differently to work more effectively with nurses,” “I feel better prepared to work as an intern because of this experience,” and “it was empowering.”

Of nurses and RTs, 100% rated the value of this experience as a 4 or 5 on the Likert scale (5 being most valuable). One nurse commented: “By encouraging nurses and medical students to see each other, to interact beyond the established dynamic and roles, we encourage the hospital culture to trend toward empathy.”

On post-program surveys, 80% of medical students and 100% of nurses and RTs indicated that shadowing an ICU nurse and RT should be a necessary part of a medical school curriculum.

DISCUSSION / REFLECTION / LESSONS LEARNED: An interprofessional education program for medical students to learn about the roles of ICU nurses and RTs has been well received by all involved and can improve communication and collaboration between medical students and members of the healthcare team. We will continue to gather data about participants’ experiences. Other medical schools may benefit from initiating similar programs in their curricula.

BUILDING INTERPROFESSIONAL EDUCATION INTO THE CLINICAL LEARNING ENVIRONMENT

Jessica Donato¹; Bryce Montane²

¹Hospital Medicine, Cleveland Clinic, Cleveland, OH; ²Washington University in St Louis, St Louis, MO. (Control ID #3847826)

SETTING AND PARTICIPANTS: In our large academic internal medicine program, we developed a novel interprofessional education program involving 49 PGY1 residents.

DESCRIPTION: The educational experience involved a 2-day curriculum including experiential learning and a report out for peer education, which took place during the ambulatory “Y week” over five consecutive Y weeks. Each intern shadowed 1 of 5 healthcare professionals for 1.5-2.5 hours: Nursing, Physical therapy (PT), Occupational therapy (OT), Respiratory therapy (RT), and Speech and Language Pathology (SLP). Each intern was expected to complete a worksheet about the observed profession, which included education, workflow, responsibilities, and communication preferences. The majority of the information for the worksheet was to be obtained during the shadow experience, with additional research if needed. The following afternoon, the interns reported out, with a faculty guiding the discussion with use of a facilitator guide. Trainees were provided with a retrospective pre-post assessment instrument at the end of the session to assess knowledge and attitude changes, as well as a 1-page summary table on all five professions to consolidate learning points.

EVALUATION: There was 98% attendance at the shadowing experience and 100% at the report-out session.

100% of trainees completed the assessment instrument. Using a 5-point likert, trainees rated an increase in self-reported knowledge of the roles and responsibilities of each profession, with the lowest baseline knowledge and greatest increment in rating of self-reported knowledge for OT, followed by SLP (mean rating for PT 2.9 to 4.4, OT 2.4 to 4.4, SLP 2.6 to 4.4, RT 3 to 4.6, Nursing 3.5 to 4.7). Trainees also reported a high baseline rating of their value of non-physician team members on the inpatient medical team and value of an interprofessional team approach to inpatient medical care (mean rating 4.6 out of 5 for both). Trainees reported an increase in their self-reported ability to work on an interprofessional team (3.7 to 4.8), to effectively communicate with non-physician team members via a preferred communication strategy (3.6 to 4.8) and to be more effective in the physician role because of knowledge of non-physician team members (3.9 to 4.9).

DISCUSSION / REFLECTION / LESSONS LEARNED: This is a highly generalizable interprofessional education initiative, effectively built within the clinical learning environment and involving experiential learning. Our novel interprofessional educational experience was built upon high baseline trainee reports of valuing interprofessional teamwork and valuing the non-physician members of the team. Our curriculum enhanced trainee-reported knowledge of the roles and responsibilities of other professionals on the clinical team and also enhanced trainees’ ability to work on the interprofessional team more effectively and to more effectively communicate with non-physician professionals on the team.

C20 AS A NATIONWIDE PRACTICE-BASED LEARNING OPPORTUNITY

Michaela McCarthy¹; Katie Deal²; Grant Colbert²; Chad Kessler³

¹Denver/Seattle Center of Innovation, Veterans Health Administration, Washington, DC; ²Customer Value Partners, Fairfax, VA; ³Veterans Health Administration, Washington, DC. (Control ID #3876880)

SETTING AND PARTICIPANTS: C20 (Take Your 20 for Veteran Health) is a 20-minute live interactive biweekly webinar designed to educate, inform, and build community with multidisciplinary practitioners and staff across the Veterans Health Administration (VA). Participants ranged from primary care providers and emergency room providers to frontline staff across the VA. Presenters included frontline providers, VA leadership, and innovative practice providers across the nation.

DESCRIPTION: C20 was designed to share emerging practice-based learning with VA practitioners nationwide to improve Veteran care across the country. C20 originated in April 2020 and educated an inter- professional staff about the growing COVID-19 epidemic. Practitioners from earliest affected urban areas including New York City and New Orleans shared emerging practice-based learning with VA practitioners nationwide to improve Veteran care across the country. Currently C20 brings together the VA community through discussions about clinical and health care issues facing Veterans and topics related to VA employee wellness, growth, and retention. Continuing education credits are available across disciplines. EVALUATION: C20 has proven to be an enduring and effective innovative educational opportunity designed to reach providers and staff across the VA nationwide. To date C20 has had 549,914 total views over 2.5 years, with an average of 884 views per episode over the last 30 days. Educational topics include emerging pandemic and vaccination information, getting to know you segments with VA leadership, and wellness and resilience episodes to combat burnout among providers and staff.

DISCUSSION / REFLECTION / LESSONS LEARNED: C20 originated as an efficient platform to share emerging information with VA providers and staff nationwide. Best practices related to the emerging COVID-19 pandemic and subsequent efforts to vaccinate Veterans and staff comprised initial communication efforts. The critical infrastructure required to design, run, and market this effort will be discussed. Lessons learned including most viewed episodes, most requested topics, and the evolution of C20 as a nationwide communication platform will be shared.

EVALUATION OF FLOW: A RESIDENT PRIMARY CARE CLINIC WORKFLOW REDESIGN TARGETING RESIDENT AND MEDICAL ASSISTANT TEAMWORK

Mike K. Cheng¹; Sally Collins²; Mitchell D. Feldman¹; Christy K. Boscardin^1,3

¹Medicine, University of California San Francisco, Oakland, CA; ²University of California San Francisco School of Medicine, San Francisco, CA; ³Anesthesia, UCSF Medical Center, San Francisco, CA. (Control ID #3874939)

SETTING AND PARTICIPANTS: In 2020, 1 of the 3 resident primary care clinics in UCSF Health underwent Flow, a clinic workflow redesign. To evaluate, we surveyed 76% of the 55 residents, attendings, and medical assistants (MAs) in the Flow clinic compared to 42% of the 31 individuals belonging to one non- redesigned clinic in 2022. We interviewed 6 residents, 4 attendings, and 4 MAs in the Flow clinic.

DESCRIPTION: A difficult primary care clinic experience may be turning residents away from the career possibly due to dysfunction, inefficiency, and stress in clinic, exacerbating the national primary care shortage. In response, UCSF debuted the Flow redesign for resident primary care clinic. This adapted a redesign that occurred in the faculty practices in reaction to findings of a chaotic clinic environment, siloed workflows, and inefficient team communication. Flow involves more structured MA/resident communication (pre-clinic huddles, verbal hand-offs after rooming), an expanded MA role (order pending, detailed visit agenda-setting, more delegated tasks, patient coaching), and more consistent MA/resident pairing and co-localization in clinic. This evaluation assessed the current state of Flow implementation and its perceived effect on teamwork, patient care, and resident education. We surveyed residents, attendings, and MAs from the Flow clinic compared to a non-redesigned clinic and interviewed a Flow clinic subset. In surveys we assessed perception of teamwork through a novel 5-point teamwork score for teamwork-related questions and assessed clinic structure and satisfaction using a 5-point Likert agreement score for various statements. We performed scripted interviews and thematic analysis. Our understanding of the educational system of resident clinic is from the Cultural Historical Activity Theory; it informed our surveys/interviews.

EVALUATION: There was a significant increase in pre-clinic huddles in the Flow vs. non-redesigned clinic (79.3% vs. 44.2%, p=.001) and a non-significant increase in combined satisfaction scores (4.4 vs. 4.2, p=.325) but unchanged teamwork scores. Interviewees viewed Flow very positively and lauded the community and flattened hierarchy that resulted between residents and MAs. This brought joy and protected against burnout. They highlighted the value of the huddles to plan for efficiency, align perspectives, and encourage residents to delegate tasks. They explained the myriad benefits of the expanded MA role for efficiency and thoroughness of care; despite feeling burdened at times, MAs felt more empowered and engaged and enjoyed deeper patient relationships. The emphasis on team-based care allowed residents to see MAs as valuable sources of knowledge and as teachers, and learn delegation, anticipation of patient needs, and pursuit of efficiency.

DISCUSSION / REFLECTION / LESSONS LEARNED: The Flow redesign led to more community, flattened hierarchy, efficiency/throughness of care, and new avenues for resident education. It has promise to make clinic more engaging for MAs and less dysfunctional for residents.

EVALUATION OF THE EFFECTIVENESS OF AN INTERPROFESSIONAL HEALTHCARE EDUCATIONAL EVENT IN AN ADOLESCENT RURAL AMERICAN INDIAN AND ALASKA NATIVE POPULATION

Isra Sabir, Anita Yegappan

Medical School, University of Nevada Reno, Reno, NV. (Control ID #3875574)

SETTING AND PARTICIPANTS: Methods

Interprofessional students from various healthcare programs at a Southwestern medical school organized an interactive event included a general career presentation and eight interactive learning stations. This four-hour event was held at a rural high school of American Indian and Alaska Native students in the Mountain West on October 7, 2022. This population has decreased access to healthcare, healthcare workers, and counselors to guide students. We utilized current literature, similar events, and relevant summits to inform the conception of our event, bridge the gap in knowledge, and maintain cultural humility. Based on the studies, we ensured each part of our presentation was interactive and engaging.

DESCRIPTION: Background

Student exposure to medical career resources is important in creating interest and removing professional obstacles for American Indian and Alaska Native (AI/AN) students, considered an international community, living in rural communities. The primary objective of this study was to investigate the efficacy of an interprofessional healthcare event in educating high school students living on a Reservation in the Mountain West Region of the country. Learning objectives included the following: understanding roles and responsibilities of different healthcare professions, pathways from high school into professional programs, and basic clinical knowledge.

EVALUATION: Results/Findings

Students were given pre- and post- surveys containing six questions about their knowledge of various healthcare professions and their pathways rated on a five-point Likert scale. Students enrolled in 9th grade provided statistically significant lower scores overall than students enrolled in 10th, 11th, or 12th grades There were highly significant increases in scores for all six survey questions answered by 9th-12th graders with p-values <0.0001. Regardless of pre-event starting score for each grade and regardless of grade, all mean scores demonstrated statistically significant increases in post-event survey responses.

DISCUSSION / REFLECTION / LESSONS LEARNED: Interpretation & Conclusion The study revealed an increase in students’ knowledge of various healthcare careers, their roles and responsibilities, and route to each degree. The results are a strong indicator that continued interprofessional events held in schools will not only increase student knowledge, but also encourage a path into a medical career that may otherwise be elusive to students from rural American Indian and Alaska Native communities.

HEALTH COACHING SKILLS FOR CLINICIANS: A NEW APPROACH TO PARTNERING WITH PATIENTS

Theresa H. Liao^2,1; Mark Dreusicke³; Marc Castellani²

¹Portland VA Medical Center, Portland, OR; ²Office of Patient Centered Care & Cultural Transformation, Veterans Health Administration, Washington, DC; ³TechWerks LLC, Arlington Height, IL. (Control ID #3873421)

SETTING AND PARTICIPANTS: Veterans Health Administration

Clinicians interested in learning health coaching skills

DESCRIPTION: Health behaviors significantly impact health outcomes, yet clinicians receive little training to support behavior change. Health coaching (HC) is a collaborative process which begins with "what really matters to you in your life?" and empowers patients to make personally meaningful behavior changes. HC skills include co-creating goals, a collaborative approach to providing education, and exploring successes, barriers, and learnings. A Veterans Health Administration (VHA) priority is transforming to a Whole Health approach, aligning care with what really matters to patients, and empowering and equipping them to take charge of their own health and well-being to live their fullest lives. This approach also supports VHA’s goal of inclusive, equitable care by shifting power to patients, especially important for marginalized groups. To further clinicians' ability to support the Whole Health of veterans, we developed and piloted a synchronous experiential Whole Health Coaching Skills for Clinicians course (90-120 minutes/session x 4 weeks), focusing each week on one new skill, with debriefs of successes and challenges. Participants were VHA clinicians from all across the US. EVALUATION: Evaluation from 2 pilots (n=94) assessed satisfaction, application, and perceived impact of skills. 78% of participants completed the series. Surveys occurred pre-training, post- training, and 3 months later (60%, 64%, 28% response rates respectively). 92% strongly agreed/agreed that the training advanced their knowledge, attitudes, and skills to enhance interprofessional patient care. At 3-month follow-up, respondents reported success applying skills learned (mean 3.32 pre- training, 3.82 post-training, 5-point scale). 85% of respondents reported the interdisciplinary/interprofessional format helped them improve patient care. Participants valued practice time and the weekly format to support skill acquisition, with immediate impact on daily clinical work; they said “being coached” and feeling heard and connected in class motivated them to practice the same relational skills with patients. Challenges included breaking habits, such as “fixing problems” and “telling information.” 95% of attendees strongly agreed/agreed they would recommend the training to others.

DISCUSSION / REFLECTION / LESSONS LEARNED: VHA’s Whole Health Coaching Skills for Clinicians is a feasible, effective training for multidisciplinary clinicians to develop skills supportive of health behavior change and a collaborative approach to care. The first pilot used four 90-minute sessions; the second pilot was revised to 120-minute sessions for more practice time. Evaluation limitations include small sample size, lower response rates, and lack of linked surveys. Next steps include linked evaluations, statistical analysis, assessing additional impacts on clinicians, a train-the- trainer effort to help spread these skills across VHA, and evaluation of this dissemination approach.

IMPLEMENTATION OF AN INTERDISCIPLINARY CLINICAL SKILLS CURRICULAR THREAD: A NOVEL APPROACH TO GERIATRIC CARE EDUCATION FOR PRE-CLINICAL MEDICAL STUDENTS

Clara Riggle²; Melissa Allison²; Sarah L. Campbell³; Sonia Sehgal¹

¹Division of Geriatric Medicine and Gerontology, University of California Irvine School of Medicine, Irvine, CA; ²University of California Irvine School of Medicine, Irvine, CA; ³University of California Irvine Sue and Bill Gross School of Nursing, Irvine, CA. (Control ID #3876827)

SETTING AND PARTICIPANTS: As modern healthcare teams continue to advance, there is a growing push to incorporate interdisciplinary education into medical educational curriculum, to better prepare student physicians for the workforce. Given the complexities of older adult medical care, the field of geriatrics provides an outstanding model to improve interdisciplinary medical education curriculum. The following outlines the results of an interprofessional pilot program for pre-clinical medical students, pre-licensure nursing students, and doctor of pharmacy students, to prepare students for team-based care delivery utilized in older adult care.

DESCRIPTION: We designed a three- part clinical skills curriculum to take place sequentially within one academic year, the first of which has been completed. During these clinical skills sessions, medical students are paired with pre-licensure nursing and pharmacy students to form teams to collaborate on the care of a geriatric Standardized Patient. Students of each discipline rotate through speaking with the patient, while collaborating with one another between patient interactions. Sessions focus on developing and building interprofessional communication skills, with themes progressing from history taking, to physical exam and assessments, to eventually working with the entire team to develop a care plan. We utilized a 5-point Likert scale survey to assess attitudes on working on an interprofessional care team and understanding the individual's role in that team, using Wilcoxon signed-rank test to analyze changes in responses. Additionally, students' perceived value of the experience was evaluated.

EVALUATION: 11 students participated and 100% completed post-session surveys. Questions assessed abilities in domains of interprofessional communication, interprofessional teamwork, and motivational

interviewing, as well as feedback on perceived value of the experience. Students displayed significant improvements in self-rated evaluation of interprofessional communication (P=.012), interprofessional teamwork (P<.001), and motivational interviewing (P<.001). 100% of students reported they would recommend the session to students in their profession.

DISCUSSION / REFLECTION / LESSONS LEARNED: A primary focus of this session was fostering an awareness of the differences in responsibilities and scope of students in the different medical disciplines, and a comprehensive understanding of their functions as a team. Interprofessional communication and teamwork skills are vital to a student doctor’s success through training and later in their career, and this session showed promising results in improving those skills. Students reported increased confidence in interprofessional skills, even after only one session. Providing interdisciplinary clinical skill education for medical, nursing, and pharmacy students presents an opportunity for broadening medical student’s patient care skills, and should be considered as a method to prepare students for their roles in the hospital during clinical rotations and beyond.

INTERDISCIPLINARY APPROACH IN A DIABETES CLINIC IN AN URBAN SETTING

Priya Sharma¹; Jennifer Mendez²; Neelima Thati³

¹Medicine, Wayne State University School of Medicine, Detroit, MI; ²Medical Education, Wayne State University School of Medicine, Detroit, MI; ³Internal Medicine, Wayne State University, Detroit, MI. (Control ID #3876304)

SETTING AND PARTICIPANTS: Currently in 2022, almost 24% of Detroit’s population aged 65 or older have diabetes and that number is increasing. Hence, the Diabetes Education and Wellness Clinic (DEW), a student-run free clinic, was created to provide resources for those with diabetes in Detroit. Unlike other clinics, DEW is interdisciplinary and focuses on teaching students and patients alike. Additionally, as a result of the COVID-19 pandemic, DEW can provide telehealth sessions in addition to in-person clinics. During the session, students assist patients with many aspects of their diabetes. Assessments are provided by students from 8 disciplines: medicine, pharmacy, dietetics, physical therapy, occupational therapy, social work, law, and public health. The goal is to help patients learn and manage their diabetes under a Chronic Care Model, and also to offer students the opportunity of working in an interdisciplinary setting, providing representation of what occurs in regular clinics. Under DEW’s model, patients are allowed to collaborate with various disciplines to fulfill their needs and feel empowered to take control of their health.

DESCRIPTION: Patients are recruited through flyers distributed at various locations in Detroit. Three students from each discipline volunteer at the monthly clinic. The clinic sessions on-site are split into three parts: intake, interview, and debrief. The intake involves students checking vitals and past medical history. The interview involves the patient talking to students from each discipline about their diabetic concerns. Once the interview is completed, the patient completes a satisfaction survey. During the debrief session, students and faculty from each discipline discuss the encounters in an interprofessional discussion. Recommendations from all the disciplines are emailed to the patient after the clinic session.

EVALUATION: Of the 18 patients in 2022, 16 have identified as female and 2 have identified as male. 72% of these patients have been older than 65, and 28% have been younger than 65. Patients often found all the disciplines helpful in their visit, though dietetics, physical therapy, and occupational therapy were noted to be the most helpful. Patients also often request to see all the disciplines in future visits but note to have the most interest in speaking to pharmacy and dietetics.

DISCUSSION / REFLECTION / LESSONS LEARNED: Implementing a free clinic is beneficial in an urban setting, where people often lack resources. Moreover, many are not aware of community resources and self-management strategies to prevent the complications of diabetes, making this resource extremely vital. With this project, it is possible to acknowledge what disciplines impact patient experience the most when using an interdisciplinary approach. It also shows the importance of implementing an interdisciplinary diabetes clinic so that patients have an opportunity to receive well-rounded diabetes care. Additionally, DEW explores providing diabetic care both through telehealth and in-person opportunities.

SUBSTANCE USE RESEARCH EDUCATION AND TRAINING PROGRAM (SARET)

Mia Malone¹; Kathleen Hanley¹; Jennifer McNeely¹; Danielle Ompad²; Selena A. Gilles²; Lance Keene²; Lukasz Witek²; Marc Gourevitch¹

¹Population Health, NYU Langone Health, New York, NY; ²New York University, New York, NY. (Control ID #3875785)

SETTING AND PARTICIPANTS: The inter-professional SubstAnce use Research Education and Training (SARET) program, now in its 15^th year, is an educational initiative to build the ranks of health professionals engaged in substance use (SU) research. Each year, SARET trains 15 graduate-level students from the NYU Schools of Medicine, Nursing, Social Work, Dentistry, and Global Public Health and accepts up to 10 visiting faculty into the Visiting Mentor Development Program (VMDP).

DESCRIPTION: SARET is a NIDA-funded program to stimulate students’ interest and pursuit of careers in SU research through exposure to its two main components: participation in stipend-supported mentored research, and a curriculum of seven web-based learning modules. In 2019, SARET added the VMDP with a goal of fostering similar programs across the U.S.

EVALUATION: SARET’s impact is evaluated with a survey of all student participants every five years, and annual bibliometric analyses. The survey assesses involvement in SU research and the influence of SARET on expanding knowledge of SU etiology, screening, and treatment. The bibliometric analysis tracks presentations and publications. Quarterly phone calls with VMDP participants assess their progress in developing and implementing SU research programs. We track local and national/international completions of SARET’s curriculum modules. Results: Students: Since 2007, 166 students have participated in SARET and have published 99 peer-reviewed SUD-related articles and 49 presentations at national meetings. Visiting mentors: The VMDP program has hosted 20 visiting mentors, of which three (15%) have implemented pilot interdisciplinary SU mentored research programs at their home institutions. Two VMDP participants developed a SUD research course and are creating a SUD research minor. Modules: Total module completions are over 36,000; 23,000 at NYU and over 13,000 elsewhere. Of note, in 2020 and 2021 our SARET and VMDP programs successfully transitioned to a virtual platform in response to the COVID-19 pandemic, and in 2022 our programs returned to in-person learning with the use of a hybrid model as needed. Participants appreciated the flexibility of the virtual format but also noted the loss of interdisciplinary informal interaction.

DISCUSSION / REFLECTION / LESSONS LEARNED: SARET participants demonstrate enduring SU research interest and research successes. The VMDP can be a model for advancing the development of interdisciplinary SU mentored research programs, and SARET’s free online modular curriculum increases access to high-quality educational materials that can be readily adopted particularly at institutions with fewer resources. The modules are continuously updated, and we are currently developing a new online module focused on issues of health equity and racial justice in substance use research and treatment that will be available in 2023.

ONLINE RESOURCE URL: https://gsomxcc.brightspace.com/

TEACHING A WHOLE HEALTH APPROACH TO CARE DURING WIDESPREAD SHORT- STAFFING: SURPRISING EXPERIENCE WITH A NATIONALLY MANDATED TRAINING FOR PRIMARY CARE IN VETERANS HEALTH ADMINISTRATION

Theresa H. Liao^1,2; Elizabeth Recupero^1,3; Jill Antonishak⁴

¹Office of Patient Centered Care & Cultural Transformation, Veterans Health Administration, Washington, DC; ²Portland VA Medical Center, Portland, OR; ³New Orleans VA Medical Center, New Orleans, LA; ⁴TechWerks LLC, Arlington Height, IL. (Control ID #3874095)

SETTING AND PARTICIPANTS: Veterans Health Administration (VHA)

Primary Care (PC) teams (Providers, RNs, LPNs, administrative staff); Additional disciplines working closely with PC

DESCRIPTION: A VHA national strategic priority is transforming to a Whole Health approach- care that aligns with what really matters to a person and empowers and equips them to take charge of their own health and well-being. This also supports VHA’s goal of inclusive, equitable care by asking clinicians to partner and co-create care with patients, especially important for marginalized groups. VHA is mandating all Primary

Care (PC) teams complete Whole Health training by 2024. These teams have recently experienced high levels of short-staffing and burnout, so mandated training encouraging a potentially different approach to care could be unwelcome and ineffective. We developed a synchronous accredited 2-hour experiential course for multidisciplinary PC teams to learn about incorporating a whole health approach into clinical work. Pedagogically, our focus was on interweaving opportunities for human connection, self-reflection,

application, discussion with peers, and brief moments of self-care.

EVALUATION: 383 participants responded to pre- and 45-day post-training follow-up surveys (42%

response). Both asked about confidence and use of Whole Health strategies, including 1) asking Veterans about what matters most to them, 2) setting shared goals with Veterans, 3) using what matters most to Veterans to guide discussion, 4) asking Veterans about their areas of strength. Participants reported significant increases in confidence using these strategies, with large effect sizes across metrics. Significant increase was also seen in adoption of all strategies. For example, clinicians’ report of setting shared goals with Veterans increased (M=3.82, SD=.94) compared to pre-training (M=2.93, SD=.98, t(380)=13.47), p<.001, Cohen’s D ES=1.29). Qualitative responses noted appreciation of the interactive format, variety of activities, support for clinician self-care, specific case studies, and examples shared. 85% were very satisfied/satisfied with the training; 83% would recommend the course to others.

DISCUSSION / REFLECTION / LESSONS LEARNED: This mandatory 2-hour training for VHA PC teams was feasible and effective in improving confidence and integration of a whole health approach into care, with increased self-reported adoption of whole health strategies at 45-day follow-up. Centering the values and humanity of clinicians through different activities, while simultaneously encouraging a change in how to care for patients, was well-received despite being mandatory against a backdrop of significant short- staffing and burnout. Limitations include low survey response rates, shorter follow-up interval and possible confounders as Whole Health spreads across VHA. To train all VHA PC teams, regional training teams are being employed. Ongoing evaluation will include efficacy of these decentralized trainings, as well as possible longer follow up to assess durability of impact.

THE USE OF MULTIMEDIA IN RESIDENT TEACHING: LEARNING KEY EDUCATIONAL THEORIES AND OPTIMIZING ONE'S ROLE AS A TEACHER

Sahana Venkatesh, Kathryn Burtson, Ronald J. Markert

Internal Medicine, Wright State University, Dayton, OH. (Control ID #3875181)

SETTING AND PARTICIPANTS: Subjects (n=27) are first- through third-year Internal Medicine residents from a single university-affiliated medical center.

DESCRIPTION: Medical residency serves as an educational platform to develop skills in sharing complex information with a professional audience. Multimedia platforms (such as Microsoft PowerPoint) are frequently used by medical residents to augment their voice. However, improper use of multimedia can result in decreased information transfer to the audience. Resident physicians may not have training in the educational theories involved in information delivery and retention, such as the limited-capacity assumption, dual-channel theory, and active processing. We seek to assess resident knowledge and perceptions in the use of multimedia before and after an educational intervention.

Subjects initially completed a pre-survey which assessed their baseline knowledge and perceptions of multimedia use. They received a twenty-minute presentation on educational theories in information processing and implementable tactics in audiovisual learning. This was followed by a small group session for subjects to develop short multimedia presentations applying these theories. A post-survey was then distributed to assess resident confidence and knowledge. No identifiers were collected. Data was interpreted utilizing Statistical Package for the Social Sciences (SPSS) by International Business Machines (IBM) using the Related-Samples Wilcoxon Signed Rank Test.

EVALUATION: Data from this study demonstrated that 81% of residents had no previous training in multimedia use. Mean resident confidence in the use of multimedia, as demonstrated by a five-point Likert scale assessment (1= not at all confident, 5= extremely confident), improved from 3.5 to 4.2 (p=<.001, 95% CI) from pre- to post-test assessment, respectively. Resident impression of the importance of optimal multimedia use, also demonstrated by a five-point Likert scale assessment (1=not at all important, 5=extremely important), demonstrated a significant increase from 3.9 to 4.5 (p=0.003, 95% CI) from pre- to post-test, respectively. Residents demonstrated improvement in identifying key theories involved in audio- visual presentations such as the dual-channel theory and limited-capacity assumption as assessed by multiple choice questions. Active participation in small group sessions demonstrated the subjects’ efforts to reduce audio-visual redundancy, utilize signaling, and limit extraneous material.

DISCUSSION / REFLECTION / LESSONS LEARNED: Our investigation demonstrated that residents are rarely educated on the optimal use of multimedia platforms despite frequent utilization. After our intervention, residents were found to associate greater importance with the multimedia component of presentations. Resident confidence in their future use of multimedia improved when taught about key learning theories and implementable tactics. Further research seeks to investigate the longitudinal quality of medical presentations after this didactic intervention.

TRAINING WITH INTERPRETERS AND LIMITED-ENGLISH PROFICIENCY PATIENTS IS VALUABLE TO DEVELOPING MEDICAL AND PHYSICIAN ASSISTANT STUDENTS’ COMMUNICATION SKILLS

Quennie Q. Nguyen²; Julia L. Flora²; Jeff Chi¹; Jason Hom¹; John Kugler³; Madika Bryant⁶; Poonam Hosamani²; Jerri Westphal⁵; Preetha Basaviah⁴; Alicia A. DiGiammarino⁶; Johanna Parker⁵

¹Internal Medicine, Stanford Health Care, Stanford, CA; ²Stanford University, Stanford, CA; ³General Medical Disciplines, Stanford University, Menlo Park, CA; ⁴Internal Medicine, Stanford University, Stanford, CA; ⁵Stanford Medicine, Stanford, CA; ⁶Stanford University School of Medicine, Stanford, CA. (Control ID #3873127)

SETTING AND PARTICIPANTS: Setting - Medical school in the California-Hawaii region Participants - 43 medical and PA students, 15 faculty preceptors, and 6 interpreters participated in the Fall Quarter of 2022 and were sent a post-session survey about their experiences.

DESCRIPTION: Patients with limited-English proficiency (LEP) are particularly vulnerable to disparities in healthcare. To address this issue and improve patient satisfaction and outcomes, language barriers between physician and patient must be considered. However, the current state of U.S. medical school curricula on working with LEP patients is underdeveloped. Opportunities to both work with and learn from medical interpreters in pre-clerkship medical education are especially scarce. Thus, this study aims to assess a new educational initiative at our medical school—namely, incorporation of LEP patients and pedagogical interpreters in clinical practicum sessions for second-year medical and physician assistant (PA) students. These sessions are part of a year-long required bedside medicine curriculum where students interview and examine hospitalized patients and learn to present their findings through oral presentations and write-ups.

Our pilot includes enhanced didactics about best practices for working with interpreters in patient encounters and built-in opportunities for students to receive real-time structured feedback from interpreters. EVALUATION: There were 29 respondents to the survey (13 students, 11 preceptors, and 5 interpreters), reflecting a 30%, 73% and 83% completion rate, respectively; responses are ongoing as the quarter is not yet complete. Most preceptors (90.9%) stated that the interpreter provided recommendations to the student prior to seeing the patient, with 93% of all respondents indicating that such recommendations were incorporated in the students’ interviews. 89.7% of those surveyed (including 76.9% of students) felt that the student benefitted from the interpreter’s feedback after each session. 76.9% of students felt more confident working with interpreters after the experience. Ultimately, 96.6% of all respondents recommended that LEP patients and medical interpreters continue being integrated in pre-clerkship clinical curriculum; they appreciated that the practical experience directly prepared students for future interactions as clinicians.

DISCUSSION / REFLECTION / LESSONS LEARNED: Clinical sessions with interpreters and LEP patients proved to be an effective curricular intervention for increasing self-reported measures of value to medical education by students, preceptors, and interpreters. Our data suggests that further training with interpreters should be integrated into pre-clerkship medical education to develop cultural competence in medical and physician assistant students and strengthen communication with linguistically-diverse populations. Students can especially benefit when interpreters are actively involved in their training by answering questions, providing recommendations, and fostering a collaborative clinical environment.

USING LEADERSHIP TRAINING AS A WAY OF BUILDING COMMUNITY IN AN INTERPROFESSIONAL TRAINING PROGRAM

Madelyn Alvarez¹; Katelyn West¹; Christine J. Kolehmainen⁴; Anne Stahr²; Melissa McNeil^3,4

¹GRECC, William S Middleton Memorial VA Hospital, Madison, WI; ²Office for Faculty Affairs and Development, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI; ³Medicine, University of Pittsburgh, Pittsburgh, PA; ⁴Office of Women's Health, Veterans Health Administration, Washington, DC. (Control ID #3875545)

SETTING AND PARTICIPANTS: The VA Advanced Fellowship in Women’s Health is an interprofessional training program that provides opportunities for post-residency physicians and postdoctoral allied health professionals to develop academic careers in women’s health. The fellowship exists at 8 VA training sites. It has had physicians (internal medicine, family medicine, gynecology, and endocrinology), psychologists, postdoctoral nurses and midwives, and speech language pathologists (SLP). Current fellows include 5 physicians, 12 psychologists, 2 SLPs, and 1 RN PhD. One challenge was how to develop community across both geographic and interprofessional differences. In response to this, the National Coordinating Center (NCC) for the fellowship developed a Fellow's Forum designed to create community and encourage collaboration. We report now on the outcomes of our forum on creating an interprofessional community.

DESCRIPTION: We focused on leadership training as this material is applicable to trainees across all disciplines. We created a quarterly virtual forum for the fellows to present on leadership topics with site directors as mentors. To enhance collaboration across the sites, the NCC creates a sign up for fellows to work with others in the fellowship. Topics include identifying a leadership style, negotiation, creating a sustainable career, and self-awareness. This strategy creates an opportunity for fellows of different professions to collaborate on a topic that is useful for all of them as they become leaders, educators, and researchers in women’s health. A strength of the forum is leveraging the expertise and perspective of multiple professions in a setting that does not typically happen in practice.

EVALUATION: From the past 3 years of forums, we have had increasing participation from 33% in 2020 to 63-76% in 2022. Over the past year, we collected surveys to gauge satisfaction and feedback. Out of 17 total responses, 82% were very satisfied, 12% were somewhat satisfied and 6% were neutral. From comments, fellows felt it “provoked really thoughtful interaction across fellows” and thought it was helpful to “interact and learn as a group” and receive “validation from others”. Other fellows thought that the forums provide a “great balance of discussion and presentation of information” and “concrete strategies” to implement in real life.

DISCUSSION / REFLECTION / LESSONS LEARNED: The interprofessional forum met the goal of enhancing collaboration and community. The increased attendance over the last 3 years speaks to the perceived value of the seminar, and the qualitative comments support that conclusion. Strategies that enhanced our success include 1) making this a high priority activity and sharing the expectation of attendance with fellows and site directors and 2) choosing topics that are important, relevant to all career trajectories, and are unlikely to be covered elsewhere. A major challenge for the forum is finding a time that spans 4 time zones and accommodates fellows with busy clinic and research/academic schedules.

Innovation in Medical Education (IME) - Medical Ethics and Humanities

CULTIVATING COMPASSION IN MEDICINE: A TOOLKIT FOR MEDICAL STUDENTS TO IMPROVE SELF-KINDNESS AND ENHANCE CLINICAL CARE

Krisha K. Mehta¹; Shafkat Salam²; Austin Hake²; Rebecca Jennings²; Afra Rahman²; Stephen Post²

¹Medicine, Stony Brook University Hospital, Stony Brook, NY; ²Stony Brook University Renaissance School of Medicine, Stony Brook, NY. (Control ID #3869017)

SETTING AND PARTICIPANTS: Compassionate care lies at the foundation of good patient care and is a quality that patients and providers continue to value in the fast-paced setting of contemporary medicine. The authors present a 8-session curriculum for teaching compassion that addresses the need for this form of education in medical training. The compassion curriculum was delivered to fourth- year medical students at Renaissance School of Medicine at Stony Brook University who had just completed their clerkship year.

DESCRIPTION: In this curriculum, students were taught evidence-based cognitive exercises followed by group discussions and written reflections based on compassion-focused thematic questions. Sessions were strategically built to teach mindfulness, emotional regulation, common needs, interconnectedness, and shared common humanity. All students completed a pre- and post-Self-Compassion Scale, Compassion Scale, and Toronto Mindfulness Scale. Students in this course were compared with students in different courses about non-clinical topics delivered at the same time. Paired t-tests were used to assess potential associations between pre- and post survey responses for the validated scales

and subscales.

EVALUATION: 17 fourth-year medical students completed pre- and post-course tests, 11 participated in the compassion curriculum while 6 participated from the other courses. Prior to any of the courses beginning, all students performed similarly on the pre-test across all scales. The students in the compassion curriculum demonstrated a significant increase in their total Self-Compassion score by 8.7 [95% CI 4.3 to 13.2] points (p=0.001), total Compassion score by 6.0 [95% CI 1.4 to 10.6] points (p=0.015), and the curiosity component of the Toronto Mindfulness Scale by 4.4 [95% CI 1.0 to 7.7] points (p=0.015). There was no statistically significant difference between pre- and post-tests among the non-compassion curriculum students in the aforementioned scales (p=0.45, p=0.069, p=0.092, respectively).

DISCUSSION / REFLECTION / LESSONS LEARNED: Our results indicate that the students in our course developed an enhanced ability to engage in self-compassion, to understand the shared human experience, and to be motivated to act to alleviate suffering. Specifically, our study demonstrates that this curriculum can enhance attentional stability, allow students to develop better mental representations of another’s emotional experience, connect with another’s distress and engage in actionable change. Regardless of a program's existing compassion education, this customizable model allows for easy integration into a medical student’s crowded curriculum and could be delivered in various ways. Furthermore, although teaching compassion early and often in a clinician’s training is desirable, our study that targeted fourth-year medical students suggests an additional benefit of rekindling the loss of compassion well described in a medical student’s clinical years.

ONLINE RESOURCE URL: https://www.stonybrook.edu/commcms/bioethics/education/compassion_research_committee.php

LOOKING, SEEING, AND FEELING: THE USE OF ART DURING ROUNDS TO PROMOTE TRAINEE WELLNESS ON THE WARDS

Nayelah Sultan

Hospital Medicine, University of Florida, Gainesville, FL. (Control ID #3876978)

SETTING AND PARTICIPANTS: Attending physician sits down with their inpatient team at the start of rounds to discuss art for 10-15 minutes. The art can be digital or printed depending on setting.

DESCRIPTION: The 2022 CLER report found the "pandemic has adversely affected clinical care team well being." Promoting wellness, therefore, is tantamount but we need to find practical and consistent ways to do it. The uniqueness of this intervention is it's done daily inside the hospital as part of rounds. Using social constructivist theory to facilitate discussions, the goal of this intervention is to promote wellness through the medium of art. Following are examples that have been used:

* The Castle is a mixed media sculpture by Jorge Mendes Blake. He constructed a brick wall that sits atop "The Castle," a book by Franz Kafka. As you zoom out, you see how this seemingly inconsequently object has changed the entire facade of the wall. Once team members discuss what they see, the facilitator asks, "One single thing can change the entire facade of the wall, so what is the one thing each team member is going to work on this week?" It's a great way to focus a trainee on a specific skill set rather than them feeling overwhelmed by all the things they need to work on.

* A Twilight poster is used to discuss the concept of a “human minute.” For the uninitiated, Edward is a vampire and Bella is a human. This means Edward is much stronger and faster, and at some point, Bells says, "I need a human minute." This art works very well on a call day when you know the team is going to be extremely busy. The facilitator asks the team what each member will do to take a "human minute" for themselves (i.e. a Starbucks break, hydrate, attend conference, etc). This allows trainees to reframe their day to incorporate wellness despite the chaos.

* Lucian Freud's "Fat Sue," a painting of a morbidly obese woman lying naked on a couch is shown side by side with the "Naked Maja" by Goya, a painting of a thin woman lying similarly on a couch. Trainees are asked to discuss differences, and the facilitator uses this to elicit "uncomfortable truths" in medicine. Prior discussions focused on chronic pain management, end of life conversations, discharging patients with poor support systems.

EVALUATION: Trainees evaluated "Art of the Day" segment in their end of rotation evaluation. Next round will use a pre and post Likert Scale filled out by trainees to evaluate the intervention's effectiveness in promoting wellness.

DISCUSSION / REFLECTION / LESSONS LEARNED: Medical training regardless of stage is very stressful, and wellness can feel like a mirage despite our best intentions. We need to recognize that wellness is multi-faceted, and includes promoting connectedness, self reflection/introspection, self-care, and resilience. Trainees consistently said that "Art of the Day" segment was an easy and accessible way to initiate open dialogue on all those fronts and bring wellness to the forefront despite the stress of their daily working environment.

REKINDLING THE PROVIDER-PATIENT RELATIONSHIP THROUGH WOMEN VETERANS’ STORIES: A REFLECTION ON THE PERSON BEHIND THE PATIENT

Brianna Rossiter^1,2; Gaetan Sgro¹; Amy H. Farkas³; Melissa McNeil⁴; Sarah B. Merriam⁵; Christine J. Kolehmainen⁶

¹Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²VA Pittsburgh Healthcare System, Pittsburgh, PA; ³General Internal Medicine, Medical College of Wiscponsin, Milwaukee, WI; ⁴Medicine, University of Pittsburgh, Pittsburgh, PA; ⁵Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh , PA; ⁶Office of Women's Health, Veterans Health Administration, Washington, DC. (Control ID #3876434)

SETTING AND PARTICIPANTS: 876 VA providers

DESCRIPTION: Women Veterans (WVs) are the fastest growing group in VHA and present unique healthcare challenges for PCPs, including high rates of mental health disorders. Deployment and reintegration for WVs present stressors common to all Veterans, such as separation from family, but also gender-specific factors such as sexual harassment and lack of recognition for service. Burnout is high in VA primary care, affecting 45-55% of providers overall, and women’s health PCPs are more burned out and have higher attrition (14%/year) than general PCPs. Narrative medicine interventions are associated with enhancing patient-centered care and provider empathy while decreasing burnout. We hypothesized that depersonalization and burnout among VA providers would be improved with a medical humanities session that utilized stories to explore the unique deployment/reintegration experiences WV face.

During November 2022, we delivered a 3-hour virtual, interprofessional medical humanities session which aimed to increase healthcare professionals’ awareness of the 1) unique challenges faced by WVs during deployment, 2) culture shock associated with reintegration, and 3) how these experiences shape the patient- provider relationship. We utilized 2 forms of narrative media – the documentary film Journey to Normal, that follows the reintegration stories of several WVs, and a WV story from the educational initiative, My Life, My Story.

EVALUATION: We assessed the emotional impact of the program as a primary outcome. During the live session, we invited participants to answer prompts designed to promote reflection on WV deployment and reintegration experiences. Using the chat feature, we created participant-generated “word clouds” as a visual representation of these reflections. We ended the session with an open-ended writing prompt asking about the most impactful aspects of the session. Analysis is ongoing but initial data indicates that participants were highly engaged: 700 participants used the chat and posted 1770 messages. 264 responses to open-ended prompts largely centered around gratitude for WV service and a changing perspective about patients through storytelling. One such response: “As a clinician, who feels burned out often… it is training like this that reminds me why I work for the VA…I’ve always been in awe of female Veterans … My favorite part of working for the VA is hearing a Veteran's story, and this reminded me again how gratifying [that] is.”

DISCUSSION / REFLECTION / LESSONS LEARNED: A medical humanities session for VHA providers exploring and reflecting on WVs’ stories showed high attendance and engagement. Initial qualitative analysis on reflective, chat responses and an open-ended writing prompt includes the following themes: changing appreciation of and perspective on WVs, the importance of stories in understanding patients, and the impact of medical media on professional empathy.

SUSTAINING A PHYSICIAN CREATIVE WRITING COMMUNITY: CORE CREATIVE WRITING COMPETENCIES AND LESSONS LEARNED FROM 15 YEARS OF THE PEGASUS PHYSICIAN WRITERS PROGRAM AT STANFORD

JENNIFER PIEN¹; Sofia Schlozman²; Tayyeba K. Ali³; Armaal Jamaal⁴; Matthew Bucknor⁵; Malathi Srinivasan⁶

¹Department of Psychiatry, Stanford University School of Medicine, Stanford, CA; ²Columbia University, New York, NY; ³Department of Ophthalmology, Sutter Health, Sunnyvale, CA; ⁴Stanford Center for Asian Health Research and Education, Stanford University School of Medicine, Stanford, CA; ⁵Department of Radiology, University of California San Francisco School of Medicine, San Francisco, CA; ⁶Medicine, Stanford University School of Medicine, Palo Alto, CA. (Control ID #3874555)

SETTING AND PARTICIPANTS: Setting: Medical Humanities and creative writing programs may improve wellness in medical practitioners. Building and sustaining writing programs for busy medical professionals can be challenging and may be aided by identifying core creative writing competencies and foundational program elements. We developed the Pegasus Physician Writers at Stanford (Pegasus) over 15 years, to promote creative writing and build community for medical professionals.

Participants: Practicing physicians and premedical/medical learners who have worked/trained at our academic medical center.

DESCRIPTION: Pegasus is a community of physician writers who participate in monthly workshops and sessions on advanced writing and publication skills, within an international program of partnerships and collaboration.

We collaborated with national experts in creative writing and medical humanities to develop competencies for writers and program directors to support program development and evaluation.

The Pegasus creative writing model includes four competency domains: Creative Expression (self- expression and the craft of creative writing), Creative Communication (development of writer identity and coaching/mentoring with others), Creative Publication (publishing skills, including working with agents/publishers), and Creative Wellness (deeper connection with self to improve wellness).

Two program director domains include sustaining communities and building partnerships. We surveyed participants about program utility and impact, including creative publications since joining Pegasus.

EVALUATION: Results: Of 383 current (180) and past (203) Pegasus members surveyed, 81 (24%) responded. 75% of physicians and 50% of medical learners reported publishing their creative work, with 287 total creative publications since joining Pegasus. Participants reported improvement in all four creative writing competencies. For Creative Expression, most participants felt that Pegaus participation improved their ability to translate experiences into stories (77%). For Creative Communication, most participants felt a greater sense of community (91%) and enhanced confidence as a writer (81%). Most participants also improved their ability to plan and produce creative works (78%) and analyze literature and provide feedback (74%). For Creative Publication, most reported improved experimentation in their creative work (89%), although only half reported better understanding of the publication process (51%). For Creative Wellness, most participants felt that Pegasus participation increased their personal/professional wellness (81%).

DISCUSSION / REFLECTION / LESSONS LEARNED: Creating and sustaining a creative writing ecosystem for physicians may be enhanced by considering core writing competencies. Our flexible framework encouraged participation from physicians and medical learners and our partnerships extended program reach. Pegasus participants published hundreds of creative writing pieces and felt increased wellness through participation.

Innovation in Medical Education (IME) - Quality Improvement and Patient Safety

A NOVEL APPROACH TO TRANSITIONS OF CARE EDUCATION: INTERN DISCHARGE DOCUMENTATION AUDITS AND FEEDBACK

Jessica Donato

Hospital Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #3872603)

SETTING AND PARTICIPANTS: Effective discharge summaries and discharge instructions are essential for a safe discharge from the hospital; however, many training programs do not provide formal training and feedback on these important documents. In our large academic internal medicine program, we designed a new educational initiative for first year (PGY1) residents starting in 2019, which included a 1-hour didactic followed by individual feedback meetings for review of audited discharge documentation. This educational experience takes place six months into intern year and involves 49-54 PGY1 learners per year.

DESCRIPTION: A one-hour interactive didactic focused on discharge safety is delivered annually during our internal medicine training program academic half day for PGY1 residents between January and February. The session is intended to reinforce knowledge and skills related to discharge documentation that is taught early in intern year, and provide new knowledge related to optimizing discharge safety including patient, provider and systems factors to consider. Over the subsequent 3 months following this session, a discharge summary and discharge instructions for one patient, which was completed by each intern, is reviewed by a senior resident, chief resident or faculty reviewer. These documentation audits are meant to be random to avoid the Hawthorne effect. The documentation review is guided by instructions and reviewers are also provided with model discharge paperwork for reference. An audit rubric for documentation review was created to guide and standardize reviews in the third curricular iteration. A 1-on-1 feedback meeting is then completed to provide feedback to the PGY1 on the discharge documentation reviewed.

EVALUATION: During the pilot of this educational experience in 2019, 54 PGY1 residents were included in the experience. Ten senior residents, 5 chief residents and 3 faculty completed the documentation audits and feedback sessions with 96% (52 of 54) of interns completing the experience. In 2020, 49 PGY1 residents were included in the experience with 17 senior residents, 2 chief residents, and 4 faculty reviewers. 63% of interns completed the experience. The curriculum was paused due to COVID in 2021 and 2022. Audit and feedback completion rates will be tracked with the experience in 2023 and the audit rubric will be collected for evaluation.

DISCUSSION / REFLECTION / LESSONS LEARNED: We describe a novel transitions of care curriculum for PGY1 medicine residents, which includes an interactive didactic session and review of discharge documentation with individual feedback meetings. By incorporating individualized feedback on random discharge documentation audits, we believe this curriculum is effectively built into the clinical learning environment, allowing greatest impact on learners. Formalizing the documentation review with an audit rubric will allow for better program evaluation and measurement of impact over time.

CULTIVATING A CULTURE OF SAFETY: AN ONLINE CURRICULUM FOR INTERNAL MEDICINE RESIDENTS ON PATIENT SAFETY EVENTS AND ROOT CAUSE ANALYSIS Kathryn Leyens¹; Allison Dekosky¹; John Szymusiak¹; Melinda Hamilton⁴; Andrew Buchert⁵; Benjamin

Sprague²; Dylan Yang³; Neha B. Etherington¹

¹Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ²Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ³Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; ⁴Pediatric CCM, UPMC, Pittsburgh, PA; ⁵Pediatric Hospital Medicine, UPMC, Pittsburgh, PA. (Control ID #3877093)

SETTING AND PARTICIPANTS: Our curriculum was provided to UPMC internal medicine (IM) resident physicians with the overall aim to develop the confidence, knowledge, and skills to accurately recognize in- hospital patient safety events (PSE), improve quality of reporting of PSE, and evaluate these events through understanding of root cause analysis (RCA). Our curriculum, including pre- and post- surveys, was administered to these learners prior to resident outpatient clinics in Summer 2022.

DESCRIPTION: In-hospital adverse events (AEs) are a leading source of patient morbidity and mortality, with approximately half of these cases being preventable. The Accreditation Council for Graduate Medical Education (ACGME) has emphasized the importance of identifying, reporting, and evaluating PSE. RCA is the standardized method of evaluation of PSE with a variety of implementations across facilities. Our targeted needs assessment comes from our local ACGME Clinical Learning Environment Review (CLER) visit, demonstrating the need for a standardized curriculum on patient safety and RCA. This sentiment is echoed with the national ACGME CLER report. Our curriculum aims to help residents develop the knowledge, skills, and confidence to accurately recognize PSE, create quality reports of PSE, and to understand the ideal process of RCA. It consists of two online interactive modules that introduce and detail the topics of PSE, PSE reporting, and RCA. It concludes with a third module of a video-simulated ideal RCA based on an AE from our hospital system.

EVALUATION: Resident attitudes, knowledge, and skills were assessed using pre- and post-surveys with response rates of 60.3% (n=85) and 40.4% (n=57), respectively. Surveys were paired using a unique identifier. Analysis of attitudinal data using paired t-tests demonstrates a statistically significant increase in confidence (p<0.001) for all topics including PSE identification and reporting, as well as components of RCA. These surveys also include knowledge questions and a case for which the learner will have to write an associated PSE report. The PSE reports will be graded for quality of content based on a modified validated rubric. We plan for a secondary post-survey to be sent out six months following implementation of the curriculum to evaluate for retention. The analysis of knowledge, skill, and secondary post-survey data is ongoing and will be available at the time of the conference.

DISCUSSION / REFLECTION / LESSONS LEARNED: This curriculum fulfills a local and national need for education on patient safety event identification, reporting, and evaluation through RCA. The importance of this topic is further emphasized through ACGME recommendations and requirements for IM residents. There is also a larger opportunity to help the GME community in education within this subject matter. The implementation of this curriculum for UPMC IM residents has demonstrated significant improvements in confidence surrounding these topics. We plan to extend this curriculum to other departments within the UPMC system and beyond.

DEVELOPING A ROOT-CAUSE ANALYSIS WORKSHOP PROTOCOL IN A MULTI-SYSTEM ACADEMIC HEALTH CENTER

Saahil A. Jumkhawala, Krittika Pant, Jared P. Walsh, Neil Kothari

Medicine, Rutgers New Jersey Medical School, Newark, NJ. (Control ID #3875511)

SETTING AND PARTICIPANTS: The Office of Graduate Medical Education (GME) based at Rutgers New Jersey Medical School sponsors 48 residency and fellowship programs, including the development of educational interventions. In this report we pilot tested a Root Cause Analysis (RCA) workshop with all Internal Medicine (IM) residents with expansion to additional programs within the system.

DESCRIPTION: Promotion of Patient Safety (PS) is a key aspect of residency training programs and an ACGME requirement. Reports have described a key barrier to successful resident education in PS being a lack of connection to meaningful work. To address this, we developed a RCA workshop with contemporary, specialty-specific cases, delivered to 5 cohorts over ten weeks within an IM residency followed by expansion to three other programs across the system. The workshop was developed by the GME Committee on PS and Quality, an interdisciplinary committee comprised of members of various training programs at our institution. The workshop comprised of a didactic session followed by case-based small group activities exploring key concepts such as definitions of medical errors, fishbone diagrams, and process flow mapping.

EVALUATION: 138 anonymous pre-workshop and 118 post-workshop surveys were completed, covering knowledge recall, trainee experience with RCA, and trainee application of RCA methodology. 78.2% of respondents had not received any formal RCA training and 87.7% had never participated in an institutional RCA. Only 34.1% of participants had previously reported a PS issue at their institution and 18.1% had received feedback regarding a reported issue. Analysis of responses with Likert-scale data before and after sessions using the Kruskal-Wallis test showed statistically significant improvements (p<0.001) in: understanding the difference between M&M and RCA; interest in the RCA approach as a supplement to original M&M conferences; understanding of terminology in quality improvement (ex. active error, latent error); understanding and likelihood of using the adverse event reporting systems. 06.5% and 50.8% of respondents strongly agreed they were comfortable with the RCA process before and after the workshop, respectively, with 73.7% strongly agreeing that the workshop improved their understanding of the RCA method.

DISCUSSION / REFLECTION / LESSONS LEARNED: This workshop was designed to be portable to other training specialties with minimal changes as guided by site-specific quality offices, currently being disseminated to the other sponsored programs at our institution. We identified 1 hour to be the optimal time for this workshop, developing an accompanying protocol adoptable by any program across a heterogeneous system, with the only required changes being (1) case relevant to trainees' field of study; and (2) two informational slides guided by the hospitals' quality offices. With the proliferation of multisystem educational institutions, this project established a model to standardize and implement an effective workshop which could be scaled up successfully.

ECONOMIC IMPACT OF INSUFFICIENT MEDICAL DOCUMENTATION: A RETROSPECTIVE STUDY OF INPATIENT ENCOUNTERS IN AN INTERNAL MEDICINE RESIDENCY

Sumender Sharma¹; Keir MacKay²; Devon Fetters¹; Niranjan Thothala¹; Jay Patel¹

¹Internal Medicine , Indiana University School of Medicine, Evansville , IN; ²Internal Medicine, Indiana University School of Medicine, Indianapolis, IN. (Control ID #3840389)

SETTING AND PARTICIPANTS: A 158 bed rural hospital in Indiana with a newly accredited academic internal medicine residency program established in July 2020. We identified patients admitted to the hospital from July 2021 to June 2022 to figure out the total revenue lost due to errors made by resident in their medical documentation. Inclusion criteria included patients ≥ 18 years old on teaching services (ICU and general medical floor).

DESCRIPTION: Regular monthly billing audits by clinical coders were conducted on 5% of randomly selected patient encounters. CPT code 99223, 99222 and 99221 represent H&P encounter Level 3, 2 and 1 respectively. CPT code 99233, 99232 and 99231 represent follow up encounter Level 3, 2 and 1 respectively. CPT code 99239 and 99238 represent discharge time >30 minutes and time <30 minutes respectively. The encounters were downgraded to lower CPT codes (based on CMS guidelines of billing) if any deficiency in documentation was identified. Total revenue loss was estimated based on the number of wRVUs lost due to each CPT code downgrade. We used $42 and $46 as base value for each wRVU at our institution and national average respectively.

EVALUATION: 511 of 10231 total charges were audited. 82 charges were found to be deficient, representing a 16% error rate. Some of the errors that resulted in billing downgrades were insufficient documentation of review of systems; past medical, social or family history; medications, physical exam and missing chief complaint. We noted incidents of downgrades 99223 to 99221 – 51 (62%); 99239 to 99238 - 20 (24%); 99223 to 99222- 4 (4.9%), 99233 to 99232 - 4 (4.9%) and 99222 to 99221- 2 (2.4%). The revenue loss within the sample due to CPT code downgrade was $5,043.36 - $5,523.68. The total revenue lost across all encounters was estimated at $101,379.60 - $111,026.80.

DISCUSSION / REFLECTION / LESSONS LEARNED: The importance of accurate patient care records for effective communication and medical education is well documented. However, medical documentation as a tool for financial compensation is not emphasized in graduate medical education. This study demonstrates that basic medical billing and coding education in graduate medical education may reduce billing errors, improve clinical documentation, and have a positive economic impact on local healthcare systems.

Resident education teaching aides including noon didactics, pamphlets demonstrating the essential components of documents and ongoing process monitoring were implemented to improve accurate documentation practices. A follow up retrospective study will be conducted next year to evaluate the impact of these intervention.

ONLINE RESOURCE URL: 1. Chen L, Guo U, Illipparambil LC, Netherton MD. Racing Against the Clock: Internal Medicine Residents' Time Spent On Electronic Health Records. J Grad Med Educ. 2016 Feb;8(1):39-44. doi: 10.4300/JGME-D-15-00240.1. PMID: 26913101; PMCID: PMC4763387.

2. Billing and Coding: Acute Care: Inpatient, Observation and Treatment Room Services. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52985.

EXPANDING THE TENT: INCREASED ACADEMIC SIMULATION CENTER USAGE THROUGH A MULTIFACETED STRATEGY

Brielle Blatt¹; Katie E. Tame¹; Kathleen Allen¹; Ryan C. Zurich¹; Pablo Heredia¹; Deepak Pradhan¹; Joanne Agnant¹; Sondra Zabar¹; Donna Phillips^1,2

¹NYSIM, NYU Langone Health, New York, NY; ²Orthopedic Surgery, NYU Langone Health, New York, NY. (Control ID #3874509)

SETTING AND PARTICIPANTS: The New York Simulation Center for the Health Sciences (NYSIM) is a public/private partnership between NYU Grossman School of Medicine and the City University of New York supporting healthcare professional (HCP) training. NYSIM serves as an institutional resource for providing experiential education across the health system to raise quality of care, outcomes, and patient safety.

NYSIM utilization decreased during the COVID-19 pandemic. In 2020 we set a goal to expand utilization, particularly for constituents with lower utilization. We wanted to address stakeholders' barriers and demystify the perception that simulation is costly or difficult to execute. We aimed to increase the number of sessions (each instance of a program), learners, and hours of instruction without expanding operating hours or increasing staffing.

DESCRIPTION: NYSIM leadership devised a strategic plan to increase utilization and increase accessibility.

Outreach: NYSIM directors met with previous users who had not returned and programs that had not used simulation. We disseminated monthly newsletters to our learning community promoting educational consultations (EC) and new equipment.

Faculty development: Directors conducted ECs with faculty across institutions to develop or enhance programs, provide scholarship mentoring, and offer cases and assessments. We ran a three-day course, offered five times annually for faculty, focused on simulation case design, management, and debriefing. We hosted a yearly Simulation Education Symposium and offered faculty education on how to operate simulators.

Operations: We created standardized protocols, cross trained staff, streamlined intakes and scheduling, leveraged group OSCEs to increase learner capacity, improved user experience on website, and offered remote programs to expand accessibility. We helped programs minimize costs by educating faculty on which supplies can be re-used and how to design programs within budget, and without compromising learning objectives or education integrity.

Utilization Monitoring: We are developing an internal dashboard, published annual reports, and reported to our steering committee each quarter. We used our learning management system to track programs and disciplines and user center sign-in.

EVALUATION: Between fiscal year (FY) 21 and FY22, the number of sessions increased from 977 to

1,065, the number of learners increased from 12,171 to 14,638, and the number of hours of instruction increased from 5,467 to 5,980.

Our directors conducted 53 and 70 ECs in FY21 and FY21, respectively. 39 ECs led to new reservations.

DISCUSSION / REFLECTION / LESSONS LEARNED: We achieved our goal of increasing utilization across programs and disciplines, while operating hours and staffing remained unchanged. Sustaining and building upon these interventions will enable us to expand our reach further and maintain partnerships with constituents. As a result, NYSIM provides ongoing education and research that fosters quality care, patient safety, and effective communication with patients and HCPs.

HOW TO SAVE A LIFE: A QUALITY IMPROVEMENT PROJECT ON IMPROVING HEPATITIS C SCREENING AND LINKAGE TO CARE IN AN URBAN AMBULATORY ACADEMIC CENTER Einat Kadar-Kricheli²; Carolina Villarroel²; Anna Mageras¹; Silpa Yarra²; Rebecca Roediger¹; Desiree Chow²

¹Liver, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY; ²Internal Medicine, Mount Sinai Beth Israel Hospital, New York, NY. (Control ID #3875262)

SETTING AND PARTICIPANTS: Urban ambulatory clinic at an academic center with a diverse patient population with complex chronic diseases. Participants were internal medicine residents at a primary care clinic, General Medical Associates (GMA), located at Mount Sinai Beth Israel.

DESCRIPTION: Hepatitis C virus (HCV) infection can lead to cirrhosis, hepatocellular carcinoma, or death. In NYC, two out of five residents with HCV remain undiagnosed. In 2020, the Centers for Disease Control and Prevention (CDC) and the United States Preventive Services Task Force (USPSTF) expanded previous guidelines to recommend universal HCV screening in adults ages 18+ (CDC) or 18-79 (USPSTF). Baseline data of screening rates Q2-Q3 2021 at General Medical Associates were 14%, well below the NYC Department of Health goal of 42%. We aimed to understand the drivers of low screening rates and increase screening rates to 20% in 6 months.

EVALUATION: Using Plan-Do-Study-Act (PDSA) quality improvement methodology, an interdisciplinary team including a Hepatologist and the Liver Department’s viral hepatitis program manager was created to

address HCV screening. In January 2022, this interdisciplinary team initiated a campaign for HCV screening with four prongs: 1) patient-facing signage in the clinic, 2) a Best Practice Alert (BPA) for HCV screening via Epic, an electronic medical records system, 3) printed weekly lists for each primary care physician (PCP) of patients eligible for screening, and 4) a short oral educational presentation to GMA providers. In addition to these efforts, baseline data was collected by providing a survey to providers regarding HCV screening guidelines immediately before and 4-6 weeks after the educational session to assess for retention of knowledge. The survey had two components: knowledge-based questions and questions about PCP-level barriers to HCV screening.

DISCUSSION / REFLECTION / LESSONS LEARNED: A multi-pronged approach increased the screening rate from 13% to 35% in Q1 2022 and 32% by Q3 2022, exceeding the goal of 20%. However, it is difficult to ascertain which intervention(s) contributed to this change. The rates of patients found to have hepatitis C at the GMA clinic were lower than expected, thus leading to a small sample size from which to monitor referrals to the Liver Department. Furthermore, as there was no significant difference in retained knowledge based on pre and post-surveys, we attribute increased HCV screening rates to awareness of the importance of HCV screening as well as the impact of the automated BPA alert.

IMPLEMENTING A LONGITUDINAL INTERN QUALITY IMPROVEMENT CURRICULUM WITHIN AN INTERNAL MEDICINE RESIDENCY PROGRAM

Alicia H. Bowles^3,2; Sarah K. Hall^1,2; Taryn Young²

¹Primary Care, VA Salt Lake City Health Care System, Salt Lake City, UT; ²Internal Medicine, University of Utah Health, Salt Lake City, UT; ³VA Salt Lake City Health Care System, Salt Lake City, UT. (Control ID #3876801)

SETTING AND PARTICIPANTS: Setting is an urban, university-based internal medicine (IM) residency program. Educational content creation and delivery are performed by two dedicated Quality Improvement (QI) chief residents appointed at the program's affiliated Veterans Affairs (VA) hospital and three QI specific faculty mentors. Participants include 32 categorical PGY1 IM residents.

DESCRIPTION: QI education is one of the Accreditation Council for Graduate Medical Education (ACGME) objectives within IM residency training. Guidance provided by the ACGME however is generalized and vague. Currently, there is no standardized approach to meeting ACGME’s outlined QI education criteria. Our objective in this study is to evaluate the implementation of a comprehensive, longitudinal QI curriculum created with the intention to meet and exceed ACGME’s requirements. Our QI curriculum content is delivered over the course of 1 year to learners. The participants’ schedules are based on a “X+Y” or 4+1 system where each resident rotates between 4 weeks of inpatient followed by 1 week of outpatient. During the outpatient week, the QI curriculum content is delivered during a required 1-hour session. Each session begins with a didactic portion. Didactic content begins with Plan, do, study, act (PDSA), followed by quality metrics, SMART aim statements, process mapping, hierarchy of interventions, impact-effort matrix, run charts, and mock root cause analysis (RCA). Each didactic is followed by an interactive activity directly applicable to the didactic. The activity is also tied to a longitudinal, intern QI project at the VA hospital. This structure is the fifth iteration of our curriculum.

EVALUATION: Efficacy of curriculum delivery was assessed by a pre- and post-course survey completed by participants.

DISCUSSION / REFLECTION / LESSONS LEARNED: Prior to participating in our QI curriculum, 64% of surveyed participants reported never having past QI experience. 58% of participants reported feeling uncomfortable with describing how to apply the plan, do, study, act (PDSA) QI tool, 80% reported feeling uncomfortable with process mapping, and 83% reported discomfort with run charts. Following participation in the curriculum, only 8% of participants felt uncomfortable with the PDSA method, 0% felt uncomfortable with process mapping, and 23% felt uncomfortable with run charts. Based on these results, our current longitudinal intern QI curriculum is meeting the ACGME QI milestones for education in basic QI methodologies, quality metrics, and engagement in QI activities. This education can be incorporated in a longitudinal fashion with a X+Y schedule system, which is a common scheduling format for IM residency programs.

IMPROVING CLINIC HANDOFF IN ACADEMIC RESIDENT GENERAL MEDICINE CONTINUITY CLINICS AT THE UNIVERSITY OF CALIFORNIA SAN DIEGO

Ruth Abeles¹; Namita Sachdev¹; Amara Seng¹; Elena Heide¹; Stacy T. Charat²; Unna Albers¹; Deanna Hill³; Melissa A. Wong¹; Jennifer DeConde¹; Simerjot K. Jassal⁴; Dhwanil Vyas¹; nivedita restaino¹

¹Internal Medicine, University of California San Diego, La Jolla, CA; ²Medicine, University of California San Diego, Rancho Santa Fe, CA; ³Internal Medicine, University of California San Diego, La Jolla, CA; ⁴Medicine, UCSD & VASD, San Diego, CA. (Control ID #3874865)

SETTING AND PARTICIPANTS: There are limited data on handoffs of continuity patients in internal medicine residency programs. In a study by Phillips et al, only 34% of programs reported having an ambulatory handoff system. Our aim is to assess a new handoff process for graduating resident patients at the University of California San Diego (UCSD) Internal Medicine resident clinics.

DESCRIPTION: In March 2022, graduating residents in the University Pacific Clinic (UPC) and Lewis Clinic (LC) sites identified 5 patients who would benefit from direct handoff to an intern. Each resident received one-hour of protected time during clinic to add a “handoff note” in the electronic medical record. It included a brief summary of active problems and a 3-item task list (i.e. labs, test results or referrals that require follow-up). All patients were called by clinic staff and offered to schedule with an incoming intern at the same clinic site.

EVALUATION: Pre-intervention and post-intervention surveys were sent to all graduating third year residents to assess attitudes and confidence in performing hand-off processes in their continuity clinic in April and June 2022. A chart review conducted from July to September 2022 assessed what percentage of patients had a hand-off note completed, a follow up appointment scheduled, and percentage of tasks completed at the follow up appointment.

A total of 54 patients were identified by graduating residents at UPC and 43 patients at LC. At UPC site, 35 patients were reached and scheduled (64%). 21 patients were seen by residents within 3 months (July to Sept) and 12 of these patients had completed handoff notes (57%). For these patients, 25 out of 36 tasks were completed (69%). At LC site, 29 patients were reached and scheduled (66%). 20 patients were seen by residents within 3 months (July to Sept) and 9 of these patients had completed handoff notes (45%). For these patients, 20 out of 27 tasks were completed (74%). A total of 17 graduating residents completed the pre- intervention survey. Only 4 (24%) residents reporting feeling somewhat confident/confident in the outpatient setting. A total of 13 graduating residents completed the post-intervention survey. There was an increase to 11 (85%) residents reported feeling somewhat confident/confident in the outpatient setting.

DISCUSSION / REFLECTION / LESSONS LEARNED: In this study approximately two thirds of patients from both clinics were scheduled v. 43% in a previous study by Garment et al. When a handoff note was present, residents had a high rate of task completion of 74% and 69% respectively LC and UPC. Residents also noted an overall improvement in confidence in outpatient handoffs after completion of this process. These data suggest our handoff process and identification of tasks was useful in the transfer of care of graduating resident patients. In the future, we aim to evaluate barriers to handoff note completion and to clarify the types of tasks identified by residents to further improve the outpatient handoff process.

IMPROVING PATIENT CONTINUITY IN RESIDENT CLINIC FOLLOWING THE COVID-19 PANDEMIC

Taylor Adams, Margaret Nulton, Jane Broxterman

Internal Medicine, University of Kansas, Kansas City, KS. (Control ID #3846191)

SETTING AND PARTICIPANTS: Internal Medicine continuity clinic at a Midwest academic institution including 65 resident physician panels over a 3 month period.

DESCRIPTION: Our ambulatory practice includes faculty and resident patient panels. We monitor monthly

continuity rates for each physician, as defined as: the number of PCP’s assigned panel patients seen by PCP over total number of PCP panel patients seen in clinic by any provider during that month. Prior to the COVID-19 pandemic, our resident continuity rate was between 70-75%. Despite increased telehealth access, our clinic saw a decline in continuity during the COVID-19 pandemic. However, continuity did not recover to pre-pandemic rates once pandemic restrictions were lifted.

EVALUATION: Using automated monthly continuity reports at the department level, we analyzed continuity rates in resident clinic from July 1 - September 30, 2022. Average continuity for all PGY levels was 59%, with PGY1 continuity significantly lower than PGY2 and PGY3 resident panels at 49% versus 63% respectively (p=0.00001837). Between June and July 2022, the PGY3 to PGY1 transition period, continuity decreased from 60% to 54%.

We performed a fishbone analysis to identify targeted areas of improvement. One of the largest concerns is clinic scheduling factors. Provider factors such as vacation, PGY3 to PGY1 transition, panel size, and PGY level were also of concern. It was assumed that resident scheduling factors, such as vacation or backup, negatively impacted continuity however this was disproven in data review. Finally, patient factors such as age, gender, insurance, transportation, and no-show rate may also be contributing to decreased continuity.

DISCUSSION / REFLECTION / LESSONS LEARNED: We will target several components to assess improvement in continuity. Given a dramatic continuity decline during resident PGY3 to PGY1 panel transition, we will implement dedicated coaching for PGY3 residents regarding targeted follow up for July- based appointments to 10-12 of the panel’s most complex patients. We will increase July access to PGY1 residents from 2 patient appointments per session to 3 appointments per session (7/2023). We will streamline hospital follow up (HFU) appointments with a staff-ran HFU clinic (9/2022), as well as limiting the absolute number of HFU slots per resident, per week (7/2023). From a multi-disciplinary perspective, we will engage our advanced practice providers to link continuity-teams for resident empaneled patients (12/2022). Lastly, we focus on individualized resident availability by limiting ‘new patient’ slots to residents based on time-to- third return and time-to-third new duration (12/2022). We will analyze data monthly following each of these implementations to determine changes in continuity and plan to present timely accurate data Spring 2023.

IMPROVING WRITTEN HANDOFF ON INPATIENT MEDICINE RESIDENT SERVICES FOR PATIENT SAFETY

Veena Janardan, Ola Al-Sous, Ethan Bowlin, James Haubert

Internal Medicine, St Joseph Mercy Health System, Ann Arbor, MI. (Control ID #3873787)

SETTING AND PARTICIPANTS: The transition of care is a time of vulnerability for patient safety. Different handoff methods for improving patient safety have been studied, but the “I-PASS” method has shown to be the most effective tool. Thus, it has adapted in our hospital by using an EMR smart phrase for written patient handoff on inpatient medical resident services. Our initial PDSA cycle focused on educating residents about I-PASS through two conferences, but this did not increase compliance of using the smart phrase. Through root cause analysis, we found lack of standardization of the handoff process to be a major contributor to lack of compliance, paving the way for our current project. Our goal for this new PDSA cycle was to increase the percentage of written handoffs completed for all new patients on our four teaching services by 50% in eight weeks.

DESCRIPTION: We designed a program-approved template for night to day team handoff, which included the I-PASS smart phrases and verbal handoff instructions, in which verbal communications were reserved for only highly clinically relevant information, naturally increasing the compliance with written communications. All residents involved received these templates with in-person education of them just prior to starting their rotations.

EVALUATION: Baseline data on percentage of written handoffs completed on new patients were already available from our earlier PDSA cycle. In this PDSA cycle, data were also collected on verbal handoff metrics such as the time taken for night residents to present new admits and cross-cover events to day resident teams. Subjective feedback was invited from residents/faculty. Measures were tracked daily and uploaded biweekly on run charts during July-September 2022. Applying run chart rules for QI interpretation, we noted an upward trend in the percentage of written handoffs completed on admissions post-intervention, with the median pre-intervention rate of 31% and the median post-intervention rate of 89% at eight weeks, currently sustaining at the four month mark. While it was not the primary goal, we also noted a downward trend in admission presentation time with the median pre-intervention time 4.5 minutes, and the median post- intervention time 1.7 minutes. Faculty and residents also noted improvement in coverage of overnight events and residents’ presentations, efficiency, education, and wellness.

DISCUSSION / REFLECTION / LESSONS LEARNED: PDSA cycle 1 and 2 demonstrated that in- person instruction along with creating a standardized template for night to day team handoff can increase the usage of the I-PASS smart phrase, which has the potential to improve patient safety. Currently, data collection is ongoing to assess for sustainability. We are also planning subsequent PDSA cycles to tackle other handoff related issues as this will ultimately improve patient safety, and residents’ wellness and educational experience.

ONLINE RESOURCE URL: https://docs.google.com/document/d/1a64ZNjAYqu5xVAtiHhimXkF9LJeFTnItg2MgsSadsRo/edit?usp=sharing

INCREASING HOUSESTAFF ENGAGEMENT IN SAFETY EVENT REPORTING

Cecelia N. Theobald¹; Blake Funke¹; Neeraja B. Peterson²; Jennifer Green³

¹Internal Medicine, Vanderbilt University, Nashville, TN; ²Medicine, Vanderbilt University, Nashville, TN; ³Vanderbilt University Medical Center, Nashville, TN. (Control ID #3872065)

SETTING AND PARTICIPANTS: Internal medicine and medicine-pediatric residents & fellows at a large quaternary academic medical center

DESCRIPTION: Residents and fellows are uniquely positioned to be sentinel reporters of patient safety events (PSEs), but tend to do so infrequently, citing lack of feedback on incident follow-up and resolution. We sought to (1) measure frequency of housestaff reporting of PSEs, (2) implement a real-time feedback program for housestaff-initiated PSEs, (3) describe characteristics of housestaff reported PSEs; and (4) describe the impact of a feedback program on housestaff event reporting rates.

EVALUATION: We reviewed all new safety reports submitted by internal medicine residents and fellows over a thirty-month period and provided individualized feedback to all non-anonymous reporters. The feedback email included four standard components: (1) brief details of the report to ensure the recipient knew it was not an automated acknowledgement of receipt; (2) explicit thanks for their engagement in systems improvement, including notification of the program director to highlight appreciation; (3) specific information on expected next steps to address the concern; and (4) a request for their continued engagement in event analysis (as applicable). We analyzed deidentified details of all submissions to describe characteristics of the reporters, content, and trends in reporting volumes over the study period. 240 unique reports were submitted by at least 130 different housestaff, with 7.5% of all reports submitted anonymously.

36% of non-anonymous reporters filed more than one report over the study period. Each report was assigned one primary thematic category, with the most frequent content categories for reports being nursing (17.9%); communication (15.8%); occupational injury (12.5%); admissions (9.6%); diagnostic error (8.3%); radiology (8.3%); medication errors (6.7%); and professionalism (5.4%). The frequency of reports increased significantly over the study period, from an average of 2.67 reports per month in the baseline period to 9.65 per month following the intervention.

DISCUSSION / REFLECTION / LESSONS LEARNED: We demonstrated that a brief, personal follow- up message to housestaff who submit reports on medical errors can improve trainee engagement with and trust in quality systems at a large academic medical center. This contributed to a greater number of housestaff reports over time and increased opportunities for systems improvement. The impact on the clinical environment at the institution was so positive that this pilot project has now become a required component across all clinical departments.

LONGITUDINAL QUALITY IMPROVEMENT PROJECTS TO AUGMENT THE INTERN QUALITY IMPROVEMENT CURRICULUM

Taryn Young^2,1; Sarah K. Hall^2,1

¹Internal Medicine, University of Utah Health, Salt Lake City, UT; ²VA Salt Lake City Health Care System, Salt Lake City, UT. (Control ID #3876520)

SETTING AND PARTICIPANTS: The setting is an academic-affiliated Veterans Affairs (VA) Medical Center. Projects are overseen by two Chief Residents in Quality and Patient Safety (CRQS) and three faculty mentors. Thirty-two PGY1 Internal Medicine (IM) residents develop and implement the quality improvement (QI) projects over the academic year.

DESCRIPTION: Systems-based practice is an integral component of IM training. To achieve this milestone, the Accreditation Council for Graduate Medical Education (ACGME) requires IM residents to demonstrate competency in patient safety and QI through reviewing metrics related to their patient populations and gaining experience in QI implementation. Our IM residency program has created a QI curriculum that is taught to PGY1 categorical interns during their ambulatory blocks by two CRQS positions and three faculty mentors. To provide further experience and insight into these QI topics, we have implemented longitudinal projects that the interns develop and execute.

The format of the longitudinal project has evolved from year to year. During Year 1, projects were limited to metrics that were already available on one of the Electronic Health Record (EHR) primary care dashboards. During Year 2, the topic selection was unconstrained and data could be obtained through any manner. During Year 3, the topic selection was unconstrained, but the data needed to be obtained through chart review or the EHR dashboard. During Year 4, an outpatient order set was created to provide clinical guidance on diabetes and hypertension. This year (Year 5), we are implementing a single inpatient project to improve smoking cessation medication prescriptions and counseling at hospital discharge for patients who use tobacco. EVALUATION: The success of the longitudinal QI projects has been measured by (1) outcomes of the QI projects, (2) ACGME survey results, and 3) Resident feedback.

DISCUSSION / REFLECTION / LESSONS LEARNED: By developing longitudinal intern projects, categorical PGY1 residents participate in experiential learning as a supplement to QI concepts that are taught in a traditional format. While there are numerous ways that a project can be structured, we have found that there are four main components that promote success. First, there needs to be adequate faculty support. Although the PGY1 residents are given ownership of project ideas, they have clinical duties outside of the ambulatory blocks that limit the amount of time they can dedicate to collaboration. Therefore, it is vital that faculty support is available for developing lectures, project planning, intervention implementation, and data collection. Second, the scope of the project should be narrow enough that it is attainable in a single academic year. Third, by using metrics from preexisting EHR dashboards residents are familiarized with metrics that are important to the healthcare facility and data is more easily obtained. Finally, when metrics are chosen so that residents can observe how their care directly affects the data, greater buy-in is achieved.

MIND THE GAP; IMPROVING CKD KNOWLEDGE GAPS IN RESIDENTS DURING PRECLINIC HUDDLES

Lina Daoud¹; Mina Rasheed¹; Fawas Shaman¹; Ihab Abd Ali¹; Alhussain Saeed¹; Diane L. Levine²; Ahmid Al-Shawk¹

¹Internal Medicine, Wayne State University, Detroit, MI; ²Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #3876469)

SETTING AND PARTICIPANTS: It is estimated that more than 1 in 7 US adults or 37 million Americans suffer from CKD(1). These patients are at high risk for end-stage kidney disease, cardiovascular diseases, and death. We are a participating patient site for the Controlling Hypertension through Education and Coaching in Kidney Disease (CHECK-D) study and recruit/enroll patients with CKD into the study. During this process, we recognized that our internal medicine (IM) residents have a knowledge gap related to CKD workup and management. To improve the knowledge we integrated short high-impact educational sessions into our pre- clinic huddle.

DESCRIPTION: After reviewing current KDIGO guidelines and current recommendations for the management of CKD and Diabetes, we created four PowerPoint presentations consisting of 4-5 slides each; topics included:

1-How to diagnose CKD & who to screen

2-CKD management goals

3-Metabolic bone disease in CKD

4-Anemia workup and management in CKD

Presentations were delivered to residents at the beginning of each clinic week during the huddle. Residents were asked to answer a 2-question pre-presentation survey at the beginning of the week & a post-presentation survey at the end of the week for each topic. A text box for responses was provided. Answers were based on the material provided; partial credit was not given. A coffee gift card was sent to residents who correctly answered all questions on each survey.

EVALUATION: Session 1 addressed CKD screening, diagnosis, and management; 54 residents completed the pre-presentation survey, and 25 (46%) completed the post-presentation survey. For question 1: “How to diagnose CKD”, 60% correctly answered on the post-survey compared to 19% on the pre-survey. For question 2: “Who to screen for CKD”, 24% answered correctly on the post-test and 2% on the pretest.

Session 2 covered CKD progression prevention; 47 residents completed the pre-survey; 31 (66%) completed the post-survey. “Blood pressure goal in CKD patients” was answered correctly by 94% on the post-test compared to 45% on the pre-test, “First line treatment for Diabetes Mellitus in CKD patients” was answered correctly by 90% on the post-test compared to 54% on the pre-test.

Session 3 on metabolic bone disease (MBD) management in CKD is currently being delivered. Session 4 will take place in January. Results will be available by mid-February.

DISCUSSION / REFLECTION / LESSONS LEARNED: Identifying knowledge gaps provides an opportunity to intervene. Preliminary results suggest that short educational presentations integrated into the pre-clinic huddle were effective in increasing resident knowledge about CKD diagnosis and management. The next steps are to see if this positively impacts patient care.

ONLINE RESOURCE URL: (1) https://www.cdc.gov/kidneydisease/publications-resources/ckd-national- facts.html

NOVEL QUALITY IMPROVEMENT/PATIENT SAFETY (QIPS) PROBLEM-BASED CURRICULUM

Susan Barba^1,2; Kerry Benton³; Kathleen C. Abalos³; Zaeema Zafar⁴

¹Internal Medicine, Washington DC VA Medical Center, Washington, DC; ²Uniformed Services University of the Health Sciences, Bethesda, MD; ³Hospital Medicine, MedStar Georgetown University Hospital, Washington, DC; ⁴Division of General Internal Medicine, University of Washington, Seattle, WA. (Control ID #3873018)

SETTING AND PARTICIPANTS: This curriculum was given at a Mid-Atlantic academic medical center to internal medicine interns.

DESCRIPTION: This novel curriculum is a problem-based small-group QIPS curriculum that centers on a recent patient safety event (PSE). Delivered in four 1-hour didactics, the learner employs root cause analysis (RCA) tools on a PSE, applying their own clinical experiences, and then uses that RCA to create a QI project addressing the event. Each QIPS principle introduced is immediately practiced in a problem-based format and then built upon during the next session.

In the first didactic, preceptors review a recent PSE case with the trainees along with principles of RCA. The trainees break down the case through flow-mapping and create a fishbone diagram of the contributing causes. The 5-Why’s are applied to some of the identified causes to generate root causes.

In the second didactic, the group chooses a previously identified root cause and generates a QI project by crafting an aim statement, relevant measures, and constructing a current state process map addressing that cause.

In the third didactic, the group uses their current state map to make a target state map and a key driver diagram, rating potential interventions proposed through an impact-effort matrix.

In the fourth didactic, QI concepts are solidified via a journal club comparing strong and weak publications. Additionally, the group learns how to analyze data: constructing run charts and evaluating for special cause variation.

EVALUATION: The curriculum and QI theory were assessed via a before and after survey and quiz. When asked to rate the statement “I feel comfortable developing a QI project,” 6% of initial respondents agreed (n=31); in the post-survey, 73% of the respondents agreed (n=22). In the QI Theory test, percent correct increased 26% after the curriculum. Further deliverables from this curriculum include the root cause analysis of the PSE as well as a fully formed QI project.

DISCUSSION / REFLECTION / LESSONS LEARNED: QIPS curricula have become commonplace given their requirement as an ACGME core competency for all residencies. However, trainee learning and engagement in QIPS can be limited when these curricula are disconnected from the realities of clinical medicine. This novel curriculum capitalizes on the patient care that the trainee is invested in by using a relevant PSE; thus, the curriculum is adaptable to virtually any specialty or post-graduate training level.

By limiting QIPS concepts to 2-3 per session, the cognitive load of new material is manageable and solidified by actively practicing each concept that is introduced. The learner will finish the curriculum with concrete tools to develop and implement their own projects. The curriculum encourages trainee engagement in QIPS at a residency and hospital level: employing RCA tools in morbidity and mortality conferences, engaging in QI councils, and accomplishing their own quality work. In conclusion, this novel curriculum is adaptable, approachable, and energizing for trainee-driven QI work.

ONE SIZE DOES NOT FIT ALL: UNDERSTANDING VARIABILITY IN RESIDENT CLINIC CONTINUITY RATES

Hadas Reich¹; Melissa Chiang²

¹Internal Medicine, NYU, New York, NY; ²Internal Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #3848145)

SETTING AND PARTICIPANTS: Continuity of care in primary care is known to improve outcomes. Better rates of continuity in resident primary care clinics positively impact residents' clinic experience and may affect career trajectory. Achieving continuity in resident clinic presents unique challenges, and average rates of continuity are typically worse for residents than for attending physicians. Improving continuity rates in resident clinic is an essential step to increase both resident satisfaction and primary care as a career choice. This initial exploratory study attempts to determine variability of continuity for residents. Understanding such differences can lead to improved continuity overall.

DESCRIPTION: The NYU Internal Medicine Primary Care Track has 8-10 residents per class year. Residents rotate through 2 continuity clinics. We observed data from their time at Gouverneur Health, an FQHC safety net clinic in New York City. Residents rotate on a “4+2” schedule: 4 weeks in the inpatient setting, then 2 weeks in the primary care clinic.

Residents are the primary care physican for their patients. They are listed as the PCP in the electronic medical record, with an attending listed as the supervising PCP. Appointments for residents are opened on a 3 months rolling basis. When patients request appointments, they are scheduled with their resident PCP. If no slots are available, patients can be scheduled with another resident or provider (NP, PA, attending). When visits are completed, follow up appointments are also scheduled with the resident PCP, with alternatives being the resident’s waitlist or another provider, depending on urgency.

EVALUATION: Using the EMR, we created reports of all appointments scheduled with each current resident, and the listed PCP for each patient scheduled. We measured continuity by calculating the percentage of appointments scheduled for each resident with their own patients. We used 2 sided T-tests to compare average class year data.

DISCUSSION / REFLECTION / LESSONS LEARNED: On average, continuity improved yearly throughout residency from 63.25% in PGY1 to 66.19% in PGY2 to 73.35% in PGY3. Continuity varied tremendously among residents, evidenced by large standard deviations (up to 14.07%). For example, within one class year, one resident had continuity of 89.83%, while another only 45.31%.

Our study shows the experience of individual residents with continuity differs greatly. Further research is needed to determine what factors improve resident continuity and whether education about continuity may have an impact. In future studies, we will examine the effects of continuity clinic session timing, language concordance, and communication skills on continuity rates. We will also obtain qualitative data from interviews with residents about their continuity experience, both to help assess reasons for the large variability and to understand the impact of continuity on their education. Developing a precision approach to resident continuity may help tailor approaches to improve continuity for each resident.

PLAN FOR THE BAD BEFORE IT GETS BAD

Chelsey Bertrand-Hemmings¹; Jalisa Carvalho¹; Sharde Mcleish¹; Chadane Thompson¹; Dipal R. Patel²

¹Department of Medicine, Englewood Hospital and Medical Center, Englewood, NJ; ²Dept of Medicine, Englewood Health, Englewood, NJ. (Control ID #3876955)

SETTING AND PARTICIPANTS: This project was conducted among the an Internal Medicine residency clinic, located in a federally qualified health care facility( FQHC) and provides care for a diverse undeserved population in North New Jersey.

DESCRIPTION: Advanced Care Planning (ACP) is a patient- centred communication focused on patient’s values and preferences as it related to medical care in the event of severe illness. ACP is an ongoing

conversation between patients, their loved ones and care team. It is a conversation that needs to be finessed, with the understanding that each patient and family is unique. As a result, advanced care planning is still not common practice in primary care.

EVALUATION: Internal Medicine residents were surveyed on the frequency of ACP conversations in the clinic. Of 42 residents, 36 responded. Based on the results, a curriculum consisting of a one hour podcast, and 90-minute workshop on ACP conversations in the primary care setting was developed.

DISCUSSION / REFLECTION / LESSONS LEARNED: In the Survey, 69.1 % of residents rated advanced care planning in the primary care setting as important to very important. Despite this, 62.9% reported rarely or never holding ACP conversation. Two questions were asked as a comparison of perceived comfort level of ACP in the primary care setting versus the inpatient setting. In the primary care setting, 17.1% reported very good skills with none reporting expert skills, compared to 24.8% reporting very good to expert skill in the inpatient setting. Physician-barriers identified were: lack of knowledge of POLST form location 66.8%, uncertainty of how to initiate ACP conversations 38.9%, 33.3% believed the patient should initiate the conversations in the primary care setting and 27.8% reported not having enough time. Patient- related factors barriers were: language barrier 57.1%, ACP not indicated due to good health 31.4%; Concern that ACP too complex for patient participation 17.1%. Statistical analysis of the rate of ACP conversation in the primary care setting was out of the purview of this study. Post intervention survey however, showed increased perceived comfort with ACP conversations in the primary care setting to 94.1%. This underscores the potential benefit of increased physician exposure and education in increasing ACP conversations. Earlier introduction in medical training,such as medical school,of ACP may decrease physician anxiety and bias regarding these conversations. This will hopefully allow ACP to be practiced, earlier and more frequently in the primary care setting.

RAPID FIRE QI: TEACH SKILLS AND ADVANCE PATIENT CARE QUICKLY

Jess Dreicer, Amber Inofuentes

Medicine, University of Virginia, Charlottesville, VA. (Control ID #3877319)

SETTING AND PARTICIPANTS: In the fall of 2020, a multidisciplinary team leading a longitudinal quality improvement (QI) project to reduce medication errors at hospital discharge to facilities identified the need to improve admission medication reconciliation (med rec). This coincided with an opportunity to teach QI skills to internal medicine resident physicians.

DESCRIPTION: One fourth of the residents participate in a single “QI hour” per month. We designed four consecutive “problem analysis” sessions in which the prior session’s work would be expanded upon the subsequent week. To emphasize the importance of multidisciplinary involvement in QI, we invited health system QI coaches and pharmacists to participate.

The first week’s session began with the problem statement: “Incomplete and inaccurate medication histories obtained on admission lead to errors in medication prescribing at discharge.” Week one residents completed process maps and identified opportunities for improvement. Week two residents performed root cause analyses on four problems using the “5 Whys” framework. Week three residents described the ideal state and planned countermeasures to address the root causes. Week four residents completed effort-impact analyses of these countermeasures and identified which countermeasures truly addressed the identified root causes, eliminating those that did not.

A valuable countermeasure identified was a “pharmacy consult” for difficult admission medication histories. The “pharmacy consult” was piloted in a similar block utilzing “Plan/Do/Study/Act” framework. This pilot underwent further improvement and remains in use.

EVALUATION: Overall reception of the sessions was positive and 91% of residents who completed

post-session surveys indicated that this experience was useful to their training. A free text survey response that mirrored in person feedback was “...it was good to have a session on the basics while also attempting to help solve a problem that our hospital is currently facing.”

DISCUSSION / REFLECTION / LESSONS LEARNED:

This curriculum advanced an active QI project while imparting QI skills to resident physicians. Starting with a problem statement, limited classroom work resulted in identifying and testing a countermeasure that became an enduring improvement to our local system of healthcare delivery.

This curriculum was well received by resident physicians. Based on informal and formal feedback we believe that in part this was due to the fact that learning QI skills was done in the context of solving a problem that the residents encountered frequently and that they themselves had significant experience and insight to share.

We have successfully repeated the “problem analysis” sessions exploring how to improve care to hospitalized patients with diabetic ketoacidosis and also used this structure to work through a second PDSA cycle starting with analysis for two QI projects. This structure could be easily adapted for a variety of active QI projects for learners at different stages.

RESIDENT HUDDLE ON THE VA WARDS

Scott Warner^1,3; Ramya Prasad^3,1; Bryn McGhee^3,1; Matthew DiVeronica^3,1; Andrea Smeraglio^2,3

¹Internal Medicine, Oregon Health & Science University, Portland, OR; ²Internal medicine, Oregon Health & Science University, Portland, OR; ³Division of Hospital & Subspecialty Medicine, Portland VA Medical Center, Portland, OR. (Control ID #3876243)

SETTING AND PARTICIPANTS: Internal medicine residents on inpatient wards rotation at an academic Northwest VA medical center.

DESCRIPTION: Despite representing a significant portion of the physician workforce at teaching hospitals, communication between administrators and trainees about organizational change is often lacking. This can lead to underutilization of a vital resource and frustration amongst trainees. Huddles have been shown to be an effective means for bi-directional communication and performance improvement in the outpatient setting but are rarely described on inpatient resident teams. We set out to create an inpatient huddle to better orient internal medicine residents to the VA wards rotation, ensure that the residents are abreast of updates happening in the VA, and improve their understanding and performance on VA wards.

EVALUATION: In 2019, we introduced 15-minute weekly inpatient resident huddle run by a Health Systems Science expert and the VA site director to VA inpatient wards. The huddle topics cycled every 3-weeks to match the resident rotation schedules. The six regularly covered domains included: systems updates, rotation updates, process reminders, COVID updates, performance/error reporting feedback, and ending with a listening session for residents to provide administrators feedback about issues they are encountering on wards. Examples of these domains can be seen in Figure 1 which can be accessed through the URL provided below.

DISCUSSION / REFLECTION / LESSONS LEARNED: Resident huddle became a staple bidirectional information sharing modality, which was increasingly crucial during the COVID-19 pandemic. It helped organizational leaders at the VA communicate changes to the residency program and allowed for dissemination of rapidly evolving standards of care during the COVID-19 pandemic. This forum also successfully served as an accessible medium for residents to provide VA administrators feedback, troubleshoot logistical concerns, and amplifying voices within the internal medicine residency program.

ONLINE RESOURCE URL: https://www.teachis.org/resident-huddle

SEE SOMETHING, SAY SOMETHING, DO SOMETHING: EMPOWERING RESIDENTS TO BE CHANGE AGENTS IN HEALTHCARE THROUGH A MULTIDIMENSIONAL, LONGITUDINAL, AND ADAPTABLE PATIENT SAFETY CURRICULUM

Samantha J. Magier^2,1; Naseema B. Merchant^2,1

¹Internal Medicine, Yale New Haven Health System, New Haven, CT; ²Internal Medicine, VA Connecticut Healthcare System West Haven VA Medical Center, West Haven, CT. (Control ID #3873766)

SETTING AND PARTICIPANTS: Classroom based workshops supplemented with regular “just-in-time,” direct learning huddles designed for Internal Medicine residents at an academic institution.

DESCRIPTION: Per the Accreditation Council for Graduate Medical Education’s Systems Based Practice (SBP), residents should demonstrate knowledge and participate in the reporting, analysis, and management of patient safety events (SE). Residency programs often face challenges in safety education, which tends to be offered inconsistently, limited to the classroom, and not weaved into the clinical learning environment (CLE). Initiatives may lack core content, focus only on the human aspect of medical errors, and not include experiential learning in psychologically safe spaces. We present a novel, multipronged curriculum guided by data to addresses recommendations and challenges listed above.

Learning platforms:

●Resident-only morbidity and mortality conferences

●Patient safety core didactic series with high reliability organization concepts

●Facilitated analysis and follow-up of SE

●Just-in-time safety huddles

●Safety award program to recognize residents

Strengths:

●Traditional classroom teaching on core safety topics supplemented with an experiential component offered within the CLE at the point of care

●Spiral approach and longitudinal format

●Resident participation as peer teachers

●Dedicated and skilled chief resident educator

EVALUATION: We used the Safety Attitudes Questionnaire-Short Form (SAQ-SF), a validated survey, which analyzes different domains of safety attitudes pre and post intervention. At baseline, residents overwhelmingly did not feel hospital leadership supported their daily efforts to provide a safe patient care. Between 2018 and 2021, a total of 2722 SEs were reported by all staff; only 2.8% (26/2722) were reported by residents and fellows, of which 42% were near misses and 48% were SEs which reached the patient. Only 10 SEs were submitted by residents between July 2022 and October 2022. The number (#) of SEs reported and # of residents as safety co-teachers per academic year is used as a surrogate for resident engagement in safety culture. Since the curriculum launch, there has been an increase resident engagement and more than five-fold increase in the # of resident attendees at didactic sessions from baseline. The SE reporting has already increased from an average of 3 SEs per month at baseline to an average of 10 SEs per month. Regular, informal feedback served as additional assessment.

DISCUSSION / REFLECTION / LESSONS LEARNED: Resident participation with safety initiatives in the CLE was low. Our curriculum can improve resident learning and engagement with patient safety as already observed from our initial data. It is adaptable to any training program and supports the meeting theme due to its novel, data-driven, educational approach and impact on safety culture in the CLE. Future iterations will include involvement of interprofessional staff in shared learning spaces within the CLE.

TELL US ABOUT YOUR MOST CHALLENGING CASE FROM CLINIC: ENGAGING RESIDENTS IN QUALITY AND SAFETY THROUGH AN AMBULATORY MORBIDITY AND MORTALITY CONFERENCE

Stephanie M. Hastings¹; Rebecca Rogers¹; Lorraine E. Murphy²; Richard Pels³

¹Graduate Medical Education, Cambridge Health Alliance, Cambridge, MA; ²Ambulatory Clinical Risk and Patient Safety Manager, Cambridge Health Alliance, Cambridge, MA; ³Medicine, Cambridge Health Alliance, Cambridge, MA. (Control ID #3874755)

SETTING AND PARTICIPANTS: We sought to bring a traditional morbidity and mortality (M&M) analysis to the outpatient setting at a primary care internal medicine residency in a community academic center. The conference is resident led. The Chief of Medicine serves as the advisor and a risk manager participates.

DESCRIPTION: In 2006 Bingham at al. developed a HealthCare Matrix that juxtaposes Institute of Medicine quality aims and ACGME competencies to help residents analyze experiences of care within the learning environment. We adapted this matrix as a tool to facilitate planning, discussion and inquiry during the conference. Residents analyze an episode of care exploring domains of population health, patient and provider experience of care and reducing cost/waste.

Attendees are led through the chronology of the case followed by discussion, utilizing our adapted matrix to explore the following questions: Was the care of this patient safe, timely, effective, efficient, equitable, patient centered and satisfying for all members of the healthcare team?

EVALUATION: Since 2019, 24 cases have been presented, topics include delayed diagnosis, transitions of care, engaging with consultants, care coordination, medical error, ineffective care, provider experience and care equity.

Attendees provide evaluative feedback (score 1-5) based upon their confidence in the following skills: 1) Understand how to analyze an adverse event in the ambulatory setting & identify systems errors, 2) Identify areas where systems can be improved based on this case and 3) Have an idea for how to prevent a similar situation in the future. 28 evaluations have been submitted with average scores 4, 4.7 and 4.4 for questions 1, 2 and 3. The faculty member evaluates the presenting resident with attention to the ACGME systems based practice competency.

We have observed improved rates of resident safety event reporting system (SERS) submissions. Before the conference began, 12 residents filed 31 SERS. After the conference, reports increased with 16-19 residents filing 46-50 SERS annually.

DISCUSSION / REFLECTION / LESSONS LEARNED: Unlike inpatient based M&M conferences, the ambulatory M&M probes learners to analyze an episode of outpatient care, providing a deeper understanding of processes relevant to ambulatory practice. The interdisciplinary design allows residents to achieve and be evaluated on competency in quality and safety in the ambulatory setting. The conference provides opportunities to engage with institutional quality initiatives. A recent conference reviewed a medication error; the case contributed to a project related to electronic medical record safety warnings and alert fatigue. While many factors may have contributed to improved SERS reporting, our participating risk manager routinely highlighted the potential positive impact of reporting in relation to the M&M conference. The conference model can be modified to meet specific aims for a particular program or institution.

ONLINE RESOURCE URL: https://docs.google.com/spreadsheets/d/1M-c97ofvoLvsHMyWb9xp4Q3l7KDAxuDQnHxvlLfkOk8/edit#gid=0

THE CHICAGOLAND FREE CLINICS CONSORTIUM: A MODEL FOR COLLABORATION TO IMPROVE CARE ACROSS CHICAGO’S STUDENT RUN FREE CLINICS

Amani Allen¹; Grace Keegan¹; Santiago Avila¹; Jordan Millhollin¹; Teresa Xiao¹; James N. Woodruff²; Wei Wei Lee²

¹Pritzker School of Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; ²Medicine, The University of Chicago, Chicago, IL. (Control ID #3875359)

SETTING AND PARTICIPANTS: Medical student-run free clinics (SRFCs) are prevalent at US medical schools. While SRFC leaders face similar challenges in caring for underserved patients in under-resourced environments, few opportunities for collaboration and dissemination of innovation across institutions exist. In 2018, Pritzker School of Medicine students formed the Chicagoland Free Clinics Consortium (CFCC) to provide a forum to foster collaboration and innovation across 23 free clinics at the 6 Chicago medical schools.

DESCRIPTION: The CFCC aimed to: 1) engage clinics from all six Chicago schools to join the consortium and executive board, 2) provide innovation grant funding for member clinics 3) host an annual CFCC conference, and 4) provide a platform for longitudinal collaboration. In 2019-2022, innovation grant awardees were selected by the CFCC executive board based on potential to address identified community needs, feasibility and sustainability. In October 2022, two surveys were emailed to student attendees of the 2018-2022 conferences and 2019-2022 grant recipients to assess impact of the CFCC programming.

EVALUATION: In 2022, CFCC has engaged with all 23 Chicagoland clinics (17 free clinics, 4 street- medicine groups, and 2 mobile units) from all 6 medical schools. The CFCC executive board has representation from 5 of the 6 schools. Between 2019-2022, $15,423 in grant funding was awarded to 19 projects at 14 clinics from 5 schools, of which 4 were inter-institutional collaborations. One virtual and 3 in- person conferences were held between 2019-2022, with a total of 215 student attendees (range 27-72). The grant survey response rate was 55% (16/29), representing 84% (16/19) of grants distributed. Overall, 87% (14/16) of respondents agreed the grant “allowed them to implement a project that would not have otherwise been accomplished”, 79% (12/15), “directly benefited patients served by their clinic”, and 73% (12/16) were satisfied with the grant process. Almost all (92%, 14/16) projects continued beyond the funding period. Data collection from the conference survey is ongoing, but initial analysis found that 78% (36/46) of conference attendees felt more prepared to address common challenges in free clinics, and 82% (38/46) were more likely to collaborate with other free-clinic leaders after attending the conference.

DISCUSSION / REFLECTION / LESSONS LEARNED: To our knowledge, CFCC is the first student-led organization to promote collaboration across student-run free clinics in a large metropolitan area and provide grant grant funding for innovative projects. Future work will focus on developing other networking opportunities to foster connections between schools, assessing the impact of grants on patients and their communities, and dissemination of the CFCC model to medical schools in other cities.

THE CLEVELAND VA QUALITY SCHOLARS QUALITY IMPROVEMENT COACHING TOOLKIT: PREPARING INTERPROFESSIONAL QUALITY IMPROVEMENT TEAMS IN A CLINICAL LEARNING ENVIRONMENT.

Melissa D. Klein^2,1; Elizabeth A. Edmiston^2,3; Emily Tsivitse^2,3; Mary Ann Lawlor^2,3; Mary A. Dolansky^1,2; Mamta K. Singh^2,1

¹Case Western Reserve University School of Medicine, Cleveland, OH; ²Louis Stokes Cleveland VA Medical Center, Cleveland, OH; ³Case Western Reserve University, Cleveland, OH. (Control ID #3874381)

SETTING AND PARTICIPANTS: At the VA Center for Outpatient Education, interprofessional residents develop and lead a quality improvement (QI) project as part of the experiential learning phase of a longitudinal QI curriculum. Coaches from our VA Quality Scholars (VAQS) program site guide learners through a QI project using a step approach to project planning and guidance around team building, stakeholder engagement and approaches to common challenges. The VAQS begin coaching early in their fellowship experience and require mentorship of their QI coaching skills to step into their role as a coach with confidence.

DESCRIPTION: Healthcare systems have embraced the need for QI strategies to achieve the Institute for Healthcare Improvement’s (IHI) quintuple aim. Similarly, health professions education is striving to develop competency-based QI education using both didactic and experiential learning. Learners require guidance as they embark on their first experiences in QI planning and leadership. Coaches are instrumental in guiding teams through this process. The skills required for QI coaching are different than those required for designing and leading a project. Our VAQS QI Coaching Toolkit was developed to support new QI coaches with the necessary mentorship, skills, and tools to successfully coach interprofessional learner teams. The toolkit is based on the VAQS QI Coaching Model. Core components of the toolkit guide coaches through the IHI Model for Improvement with paired facilitation pearls outlined by the VAQS Coaching Model. The toolkit provides coaches with learner competencies and expectations for project completion as well as guidance on the knowledge, skills and behaviors required to succeed in the QI coaching role with an emphasis on the role of mentorship in becoming an effective QI coach. The toolkit contains: VAQS QI Coach Model Worksheet & Coaching Video; Core Coaching Principles, Coach Competencies and Qualities; Coach Role and Expectations; Coach Self Evaluation Form; Mentoring Structure Guidance; Model for Improvement Project Worksheet; Learner QI Competencies and Project Evaluation Rubric.

EVALUATION: Impact of the coaching toolkit will be evaluated using a questionnaire and semi-structured interviews of coaches to assess coaching confidence and toolkit usefulness following utilization of the toolkit. Additionally, learners are asked to rate their satisfaction with faculty coaching to apply QI principles and complete their project.

DISCUSSION / REFLECTION / LESSONS LEARNED: The development and recent piloting of the QI Coaching Toolkit has been instrumental in our growth as QI coaches. The toolkit and mentoring structure allow QI faculty and fellows to pass along fundamental coaching knowledge and experience to new coaches. Lessons learned in coaching are shared between coaches and with learner teams to disseminate knowledge of common pitfalls and share stories of success and failures. We expect that our toolkit will serve as a platform to build and continually improve upon the training of QI coaches.

UTILIZING ATTENDING PHYSICIANS MENTORS AND QUALITY PERFORMANCE COACHES TO FOSTER SUCCESSFUL RESIDENT QI PROJECTS

Jess Dreicer

Medicine, University of Virginia, Charlottesville, VA. (Control ID #3875353)

SETTING AND PARTICIPANTS: The internal medicine residents at our program participate in one “Quality Improvement (QI) hour” per month with the same residents present during a recurring week in each month-long block. Each week was split into two QI group projects for a total of eight groups. Attending physicians and quality performance improvement (QPI) coaches were recruited to serve as project facilitators.

DESCRIPTION: Project topics, selected by residents, included improving patient safety (e.g., enhancing treatment of patients admitted with diabetic ketoacidosis) as well as improving resident workflow (e.g., updating patient guidance on how to use the after hours resident clinic phone coverage line). Guidance on the goals for each meeting were provided as well as one page hand-outs with the specific QI skills for that session to be used at the beginning of each session. In addition to work completed during that hour, senior residents were identified to complete project tasks between meetings (e.g., contacting stakeholders, obtaining data).

All groups presented their work to their peers and faculty at end-of-the-year oral presentations. The work resulted in an order set, an update to the general medicine discharge summary, a revised policy to reduce unnecessary screening by access team members, an update to the after hours’ voicemail message to patients, and an update to the after visit summary wording for general medicine clinic patients.

EVALUATION: 87% of residents (N=56) responded positively to the statement “I understand the basics of how to define and scope a QI project.” 80% responded positively to “I understand how to use tools such as ‘5 Whys’ or a fishbone diagram to assess the root cause of a problem.” 77% of residents (N=55) responded positively to “I recommend resident group projects as a valuable way to learn QI skills” in end-of-the-year surveys. Representative comments included, “Excellent way to incorporate QI into the curriculum. From start to finish I learned new techniques on how to approach and work through QI.” and “I very much appreciated gaining exposure to the [plan, do, study, act] cycle, and this experience has increased my readiness to pursue future QI projects.”

DISCUSSION / REFLECTION / LESSONS LEARNED: Based on corrective feedback, the next iteration of projects will include a clearer delineation of responsibilities of the senior resident leader each week and residents will be given more autonomy in choosing project topics.

Designing resident group QI projects with an attending physician mentor and QPI coach supporting each group was overall well received by resident physicians and correlated with a large majority of residents reporting understanding of how to define and scope a QI project as well as utilize QI tools. This structure supported the output of tangible countermeasures including changes to documentation, creation of new order sets in the electronic medical record, and updates to ineffective access team member protocols.

Innovation in Medical Education (IME) - Women’s Health, Sex, and Gender-Informed Medicine

BETTER THAN THEY THINK: RESIDENTS UNDERESTIMATE THEIR SKILLS AND LACK CONFIDENCE WHEN CARING FOR TRANSGENDER PATIENTS IN OSCES

Christine P. Beltran¹; Jeffrey A. Wilhite¹; Rachael Hayes¹; Caleb LoSchiavo²; Jennifer Adams³; Kathleen Hanley¹; Kevin Hauck⁴; Colleen Gillespie⁵; Sondra R. Zabar¹; Richard E. Greene⁶

¹Medicine, New York University Grossman School of Medicine, New York, NY; ²Rutgers School of Public Health, Piscataway, NJ; ³Internal Medicine, NYU Langone Health, New York, NY; ⁴Medicine, NYU Langone Health, New York, NY; ⁵PrMEIR/IIME, NYU Grossman School of Medicine, New York, NY; ⁶Medicine, NYU Grossman School of Medicine, New York, NY. (Control ID #3876752)

SETTING AND PARTICIPANTS: Medicine residents in a single internal medicine track at an urban Mid- Atlantic academic medical center.

DESCRIPTION: As part of their annual OSCE assessment in 2022, residents participated in an OSCE station where they evaluated a transgender standardized patient (SP) complaining of abdominal pain. Residents had 10 minutes address the SP’s abdominal pain, evaluate testing needs, ask about the SP’s pronouns and organs, and complete a comprehensive sexual history. To ensure the perspectives of transgender individuals were included in the case, the SP was played by an individual who identifies as transgender and was trained to be a SP.

EVALUATION: The SP evaluated resident performance across five domains [information gathering (5 items), relationship development (5 items), education and counseling (3 items), time management (2 items), and LGBTQ health (6 items)], using a “not”, “partially” or “well done” (WD) scale. Summary scores (mean % WD) were calculated for each domain. The SP also rated each resident on the extent to which they would recommend the resident to a loved one and their overall professionalism, using 4-point scales. Residents completed post-OSCE evaluations to rate the extent to which residency training prepared them for the case, how much supervision they would need to handle the case in actual practice, and the educational value of the case, along with open-ended feedback.

Residents (n=30) scored the lowest on the LGBTQ health domain (73% WD), while scoring above 80% WD on all other domains. Of 26 residents who completed a post-OSCE evaluation, 65% of residents reported that residency somewhat prepared them for the case. 58% of residents reported that they would require indirect supervision in actual practice, while only 35% of residents felt they were ready for unsupervised practice and 8% felt that they could supervise others. The SP recommended 87% of the residents, and rated residents as mostly professional (13%) or completely professional (87%).

Many residents in the post-OSCE evaluations reported feeling “nervous” or “anxious” due to little prior training and experience caring for transgender patients. All residents rated the case as very valuable. Many attributed this value to the opportunity to practice language to use with transgender patients in a safe space. Residents described feeling more confident, comfortable, and prepared to care for future transgender patients because of their participation.

DISCUSSION / REFLECTION / LESSONS LEARNED: Despite our residents’ concerns for preparedness and supervision, the SP rated them as professional and would recommend their care to others. Our findings suggests that residents are more skilled at providing gender affirming care than they think, and there is a confidence gap that must be overcome. OSCEs with SPs who have lived experiences as transgender individuals are valuable opportunities for residents to gain practice, feedback, and comfort with caring for transgender patients in actual practice.

NATIONAL SEX AND GENDER EDUCATION INITIATIVE: A STUDENT-LED MODEL OF MEDICAL EDUCATION, MENTORSHIP, AND ADVOCACY

Brooke Hartenstein¹; Sneha Chaturvedi²; Jeanna Qiu³; Shayna Levine⁴; Nora Galoustian⁷; Jan Werbinski⁵; Deborah Kwolek⁶

¹Medical Education, Florida State University College of Medicine, Tallahassee, FL; ²Washington University in St Louis School of Medicine, St Louis, MO; ³Harvard Medical School, Boston, MA; ⁴Brigham and Women's Hospital, Boston, MA; ⁵Western Michigan University, Kalamazoo, MI; ⁶Medicine, Harvard Medical School, Boston, MA; ⁷University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #3877014)

SETTING AND PARTICIPANTS: The American Medical Women’s Association’s Sex and Gender Health Collaborative (SGHC) sponsors a National Student Sex and Gender Education Initiative, with the aim of transforming medical education through the development, evaluation, and dissemination of innovative SGBM educational materials by student volunteers in its chapters nationwide. Participants include faculty mentors and over 200 pre-medical and medical student volunteers from across the US.

DESCRIPTION: The project aims to bridge gaps in traditional medical curricula through the creation of educational material highlighting SGBM.The first pilot phase created ten SGBM fact sheets and toolkits. In the second phase, over 200 students were recruited and placed into seventy-five teams, creating SGBM factsheets for various medical conditions. Student-led support committees were also formed: fundraising, implementation and dissemination, social media, and evaluation/ scholarship. Fact sheet information to other educational materials in media: slide decks and video modules.

EVALUATION: The project aims to bridge gaps in traditional medical curricula through the creation of educational material highlighting SGBM.The first pilot phase created ten SGBM fact sheets and toolkits. In the second phase, over 200 students were recruited and placed into seventy-five teams, creating SGBM factsheets for various medical conditions. Student-led support committees were also formed: fundraising, implementation and dissemination, social media, and evaluation/ scholarship. Fact sheet information to other educational materials in media: slide decks and video modules.

DISCUSSION / REFLECTION / LESSONS LEARNED: Sex and gender differences have profound impacts on clinical disease presentation, treatment response and management, and clinical outcomes. Despite the growing recognition of the importance of SGBM, surveys of U.S. and Canadian medical schools found that 70% lack a formal SGBM curriculum. Ninety-four percent of medical students surveyed agree that knowledge of SGBM improves patient management and only 25% of medical students report feeling prepared to manage sex and gender differences in practice. In our initiative, students were enthusiastic about SGBM and were eager to disseminate knowledge of SGBM into their medical and premedical educational environments. Engaging students in SGBM national initiatives and advocacy for SGBM education and training appears valuable and well-received. The SGHC initiative hopes to serve as a framework for encouraging SGBM awareness and education implementation at all levels of medical training and clinical practice.

PARENTING IN FELLOWSHIP TRAINING

Ashley N. Youngs¹; Paige Langhals-Totino¹; Molly A. Fisher¹; Erica Riddick^1,2

¹Internal Medicine, Allegheny General Hospital - Western Pennsylvania Hospital Medical Education Consortium, Pittsburgh, PA; ²Drexel University College of Medicine, Philadelphia, PA. (Control ID #3876694)

SETTING AND PARTICIPANTS: It is well known how rigorous of a process it is to become a physician. From the onset of undergraduate education to medical school and lastly graduate medical education (GME), doctors spend well over a decade of their lives training. Due to this, many trainees choose to delay their childbearing due to fear of increased risk of adverse pregnancy outcomes, negative impact on career, or prolonging training. These fears are accompanied by lack of guidance and understanding of the implications and accommodations for pregnancy, childbirth, and parenting.

DESCRIPTION: To better understand the perspectives of fellowship directors, we created a survey assessing demographics of fellows, knowledge of parental leave policies, experiences with these policies, and perceptions of family planning in training. We sent the survey to 49 program directors across multiple fellowship specialties at three large institutions in the Mid-Atlantic and Mid-West regions.

EVALUATION: Out of the 49 surveys sent, there were 19 responses, which was a 39% response rate. Within the current fellowship classes, 123 fellows identified as male and 86 identified as female. For those who identified as male, 21 welcomed a child into their family during fellowship. 11 out of the 21 (58%) did not take any parental leave, while 3 out of the 21 (14%) took 4-6 weeks. Of those who identified as female, 10 welcomed a child into their family during fellowship. 3 out of the 10 did not take time off for maternity leave (30%) and 1 out of the 10 (10%) took more than 6 weeks off for maternity leave. All 19 programs that responded indicated they have a formal leave of absence policy, with the majority being institutional based versus program specific. Program directors varied with the degree of knowledge they had regarding specific details of these parental leave policies and the majority indicated they had very little knowledge of the policy overall. 94% of program directors, in all fields, were either not at all likely or not very likely to recommend disclosing pregnancy plans and leave of absence policies during fellowship interviews.

DISCUSSION / REFLECTION / LESSONS LEARNED: Fellowship training is part of peak childbearing age, especially for fellows the trainees who identify as female Fellowship training overlaps with women's peak childbearing age. Women make up almost half of fellows. We demonstrate how trainees who have a child during fellowship, regardless of identified gender, decide not to take reasonable time for parental leave. While we are not surprised to see these results, our survey responses highlighted an area for continued research and meaningful improvement. Further efforts are needed to understand how fellows who have childbearing plans can be supported without jeopardizing their training and career goals.

TEACHING POLITICALLY CHARGED, CONTROVERSIAL TOPICS: THE CHALLENGE FOR WOMEN’S AND GENDER HEALTH

Janet Henrich¹; Joseph Canarie¹; Mukta Dhond¹; Katherine Gielissen²; Allister Hirschman³; Cynthia F. McNamara¹; Shefali Pathy⁴; Tracy Rabin¹; Ilana Richman¹; Luz S. Vasquez⁵

¹Yale University Department of Internal Medicine, New Haven, CT; ²Internal Medicine, Yale University School of Medicine, New Haven, CT; ³Yale New Haven Hospital, New Haven, CT; ⁴Yale University Department of Obstetrics Gynecology and Reproductive Sciences, New Haven, CT; ⁵General Internal Medicine, Yale Medical School, North Branford, CT. (Control ID #3871761)

SETTING AND PARTICIPANTS: The curriculum was implemented at a large, urban, academic medical center. Participants included three nurse practitioner and 164 internal medicine resident trainees in the Traditional, Primary Care and Med-Peds Programs. Sessions took place over four-hour, required ambulatory half days. The curriculum was developed and taught by core faculty from general medicine, surgery, and Ob/Gyn, in consultation with a legal expert in reproductive health. Trainees provided their reactions to the curriculum via anonymous survey immediately following participation.

DESCRIPTION: In the current political environment, aspects of patient care become polarized. Teaching these topics requires deliberate creation of a respectful learning climate. We designed this curricular module to teach content related to controversial health care topics using an interdisciplinary approach. Core to this initiative was fostering an objective, evidence-based, open learning environment. The module, Hormones Across the Gender Spectrum, included three topics: Gender Affirming Medical Care (GAMC), Contraception, and Medication Abortion (MA). At the start of each session, faculty acknowledged the spectrum of personal beliefs and values and articulated the obligation of physicians to understand these topics to provide equitable care to patients. GAMC focused on gender-affirming care, with emphasis on the lived experience of gender- diverse individuals. Contraception covered contraceptive options in gender-diverse people and patients with medical comorbidities. MA provided information on abortion care medications and laws regulating their use. All topics were presented via interactive, case-based format by expert faculty.

EVALUATION: Of the 167 trainees who attended the module, 132 (79%) completed the survey. For GAMC, trainees (somewhat or strongly) “agreed” they could describe basic steps of starting gender-affirming hormonal therapy (95%), know its expected side effects (92%), and counsel on primary preventive care (88%) in gender-diverse patients. For Contraception, trainees felt prepared to discuss (94%), incorporate patient preference (96%), and recommend (94%) contraceptive options. For MA, trainees agreed they could describe the basic steps (92%), provide information about (94%), and recognize complications (92%) of medication abortion. Trainees noted case-based discussions and discussions of real-life scenarios were highly effective and expressed a desire to learn more about the legal landscape surrounding these topics.

DISCUSSION / REFLECTION / LESSONS LEARNED: An interdisciplinary team approach and consensus on educational philosophy regarding controversial topics were key to this module’s success. Specifically, this format facilitated a collaborative approach to learning that leveraged local resources and was objective, yet patient centered. Importantly, our module modeled the importance of acquiring knowledge in a safe, respectful setting. This module provides a template for teaching controversial topics that can be adapted to other settings.